A Single Preoperative Dose of Tranexamic Acid Reduces Perioperative Blood Loss: A Meta-analysis.

OBJECTIVE: To review the efficacy and safety of a single dose of intravenous tranexamic acid (TXA) given preoperatively. SUMMARY BACKGROUND DATA: TXA is a synthetic antifibrinolytic that has been used in various surgical disciplines to reduce blood loss, blood transfusions, ecchymosis, and hematoma formation. However, there is no universal standard on the most effective dose and route of TXA administration, limiting its routine use in many centers. This study evaluates the current evidence for the efficacy and safety of a single preoperative dose of TXA on surgical blood loss in all surgical disciplines. METHODS: With the guidance of a research librarian, in accordance with the Cochrane Handbook Medline, Cochrane Central and Embase were searched in November 2018. Search terms included "Tranexamic Acid" AND "Intravenous," with studies limited to randomized controlled trails in adult humans. Two independent reviewers and an arbitrator assessed articles for inclusion. Criteria included a single preoperative bolus dose of intravenous TXA, surgical patients, and intraoperative blood loss measurement or perioperative blood loss up to 24 hours postsurgery. Quality assessment was done using the Cochrane Collaboration risk-of-bias tool by 2 reviewers. Statistical analysis was carried out using Cochrane Review Manager 5.3. The primary outcome was surgical blood loss. Secondary outcomes included venous thromboembolic complications, transfusion requirements, and dosing. RESULTS: A total of 1906 articles were screened, 57 met inclusion criteria. The majority of included studies were orthopedic (27), followed by obstetric and gynecological (16), oral maxillofacial and otolaryngology (10), cardiac (3), and 1 plastic surgery study focusing on acute burn reconstruction. Across all surgical specialties (n = 5698), the perioperative estimated blood loss was lower in patients receiving TXA, with a standard mean difference of -153.33 mL (95% CI = -187.79 to -118.87). Overall, surgical patients with TXA had a 72% reduced odds of transfusion (odds ratio = 0.28 [95% CI = 0.22-0.36]). The most frequently used dose of TXA was 15 mg/kg. There was no difference in the incidence of venous thromboembolic events between TXA and control groups. CONCLUSIONS: While there is a growing body of evidence to support benefits of perioperative TXA use, this is the first meta-analysis to identify the efficacy and safety of a single preoperative dose of IV TXA. The potential implications for expanding the use of preoperative TXA for elective day surgery procedures is substantial. Preoperative intravenous TXA reduced perioperative blood loss and transfusion requirements in a variety of surgical disciplines without increasing the risk of thromboembolic events. Therefore, it should be considered for prophylactic use in surgery to reduce operative bleeding.

Perichondrial Arthroplasty Revisited: Technical Pearls.

Articular cartilage damage has been a longstanding challenge in hand surgery. Because of its limited ability to heal on its own and its predictable impact on bone resulting in degenerative osteoarthritis, surgical intervention is often mandated, through arthrodesis or implant arthroplasty. In this article, we revisit the perichondrial arthroplasty, a two-stage joint resurfacing technique using autologous rib perichondrium. It is indicated for posttraumatic osteoarthritic changes with or without stiffness and deviation, rheumatoid arthritis, and congenital joint malformation and/or ankylosis. This long-lasting method allows for a functional, pain-free joint that avoids both the immobility of arthrodesis and the long-term complications associated with implants.

A Multidisciplinary Hand Clinic Using Physiatrists for the Evaluation of Non-Operative Pathologies.

PURPOSE: The purpose of this study was to describe the impact of using a multidisciplinary hand clinic on (1) hand clinic waitlists for urgent operative pathologies and (2) the volume of urgent operative referrals seen by plastic surgery. METHODS: A retrospective data analysis of all new referrals to the Peter Lougheed Centre hand clinic in Calgary, Alberta, was performed. Data were collected from 6 months before and after the introduction of the multidisciplinary model (ie, between January 2017 and January 2018). Demographics for all new referrals were collected from the clinic database, including wait times, triage type, and volume of referrals triaged to each discipline. RESULTS: Prior to using a multidisciplinary model, 81% (n = 591) of new patient referrals were triaged directly to plastic surgery, 4% (n = 28) to physiotherapy, and 6% (n = 43) to minor surgery (N = 728). However, following the addition of physiatry to the clinic, 62% (n = 451) of new patient referrals were triaged directly to plastic surgery, 24% (n = 173) to physiatry, 2% (n = 17) to physiotherapy, and 4% (n = 31) to minor surgery (N = 730). Overall, the number of urgent operative referrals triaged to plastic surgery proportionally increased by 7%, from 67% to 74%. Mean wait times for urgent referrals to plastic surgery decreased by 1.7 ± 1.0 months (P = .09). CONCLUSION: Applying a multidisciplinary model to a hand clinic can allow non-operative cases to be triaged directly to physiotherapy and physiatry, allowing plastic surgeons to manage a higher volume of urgent and operative referrals. Implementing a multidisciplinary hand clinic can, therefore, decrease waitlist volumes and shorten the time to assessment by a plastic surgeon. TYPE OF STUDY: Level II Prognostic Study.

OBJECTIF: La présente étude vise à décrire les répercussions d'une clinique multidisciplinaire de la main sur 1) la liste d'attente de pathologies devant être opérées d'urgence dans les cliniques de la main; 2) le volume de patients dirigés d'urgence vers la plasturgie. MÉTHODOLOGIE: Des chercheurs ont procédé à l'analyse rétrospective des données de tous les patients dirigés vers la clinique de la main du Peter Lougheed Centre de Calgary, en Alberta. Ils ont recueilli les données entre six mois avant et six mois après l'adoption du modèle multidisciplinaire (entre janvier 2017 et 2018). Ils ont extrait tous les nouveaux patients dirigés vers le centre figurant dans la base de données de la clinique, y compris les temps d'attente, le type de triage et le volume de triage vers chaque discipline. RÉSULTATS: Avant d'utiliser un modèle multidisciplinaire, 81 % (n=591) des nouveaux patients étaient triés directement vers la plasturgie, 4 % (n=28) vers la physiothérapie et 6 % (n=43), vers des interventions chirurgicales mineures (n=728). Cependant, après l'ajout de la physiatrie à la clinique, 62 % (n=451) des nouveaux patients étaient triés directement vers la plasturgie, 24 % (n=173), vers la physiatrie, 2 % (n=17), vers la physiothérapie et 4 % (n=31), vers des interventions chirurgicales mineures (n=730). Dans l'ensemble, la proportion de tris vers une opération d'urgence en plasturgie a augmenté de 7 %, passant de 67 % à 74 %. Les temps d'attente moyens des patients dirigés d'urgence vers la plasturgie ont diminué de 1,7±1,0 mois (p=0,09). CONCLUSION: Le recours à un modèle multidisciplinaire dans une clinique de la main permet de trier directement les cas n'ayant pas à être opérés vers la physiothérapie et la physiatrie. Les plasticiens peuvent ainsi prendre en charge un plus fort volume de patients qui leur ont été dirigés pour une urgence ou une opération. La création d'une clinique multidisciplinaire de la main peut donc réduire le volume de temps d'attente et l'attente avant l'évaluation par un plasticien. TYPE D'ÉTUDE: Étude pronostique de niveau II.

"You Helped Create This, Help Me Now": A Qualitative Analysis of Patients' Concerns about Breast Implants and a Proposed Strategy for Moving Forward.

BACKGROUND: Some women with breast implants express concern about the safety of implants, fearing the possibility of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant-related illness. METHODS: A qualitative analysis was performed to examine the perceived challenges, barriers, and worries experienced by these women. Convenience sampling was used to elicit responses from members of Canadian BIA-ALCL Facebook advocacy groups. Three independent coders read and reread the transcripts, using thematic analysis to identify emerging themes. RESULTS: Sixty-four women answered questions posed by the president of the Canadian Society of Plastic Surgeons regarding concerns about their breast implants. Five themes were identified: informing, listening, acknowledging, clarifying, and moving forward. Patients desire improved communication about possible risks before implantation and as new information becomes available (informing), sincere listening to their concerns (listening), acknowledgement that these disease entities may be real and have psychosocial/physical impact on patients (acknowledging), clarification of implant-related problems and their treatment (clarifying), and improved processes for monitoring and treatment of patients with identified problems (moving forward). Consideration of these themes in the context of the five domains of trust theory (i.e., fidelity, competence, honesty, confidentiality, and global trust) suggests significant breakdown in the doctor-patient relationship for a subset of concerned women. CONCLUSIONS: Concerns related to BIA-ALCL and breast implant-related illnesses have undermined some women's trust in plastic surgeons. Consideration of these five themes and their impact on the five domains of trust can guide strategies for reestablishing patients' trust in the plastic surgery community.

Evidence-based microsurgical skills acquisition series part 2: validated assessment instruments--a systematic review.

OBJECTIVES: To systematically review literature pertaining to microsurgical skill assessment tools to determine those specific to, and validated for, microsurgery training. DESIGN: Multiple databases were searched with preset terms. The search dates included all years up to May 2014. The eligibility criteria included the presence of statistical comparison with a control group and the presence of a measure of validation. The articles and their references were independently reviewed by 2 assessors. Each assessment tool was evaluated for content, construct, face, and criterion validities as well observation/expectant bias and interrater/intrarater reliability. For individual studies, we screened for expectant and selection bias. RESULTS: Of the 261 articles reviewed, 10 articles and 1 abstract were included. Those excluded were predominantly assessment tools that did not evaluate microsurgical skill or articles where no assessment tool was described. The assessment tools identified in this review include a self-assessment tool where trainees rate their skill confidence from 1 to 5, stereoscopic visual acuity as a predictor for microsurgical performance, an objective motion-tracking electronic device--the Imperial College of Surgical Assessment Device, and 6 global rating scales. Content, construct, and face validities were consistently demonstrated in addition to observation/expectant bias and interrater reliability. Criterion validity was only demonstrated for half of the instruments and intrarater reliability for only 1. CONCLUSIONS: Overall, 10 articles and 1 abstract described validated methods. Reliability and validity were demonstrated by 6 global rating scales (University of Western Ontario microsurgical skills acquisition, structured assessment of microsurgery skills, and video-based objective structured assessment of technical skill). Motion analysis using the Imperial College of Surgical Assessment Device is a valid objective measure of skill.

Evidence-based microsurgical skill-acquisition series part 1: validated microsurgical models--a systematic review.

OBJECTIVES: The purpose of this study is to (1) systematically review all the literature pertaining to microsurgical training models and to (2) determine which of these are specific to and validated for microsurgery training. DESIGN: PubMed, MEDLINE (OVID/EBSCO), Google Scholar, and Cochrane Central Register of Controlled Trials were searched using preset terms. The last search date was in July 2012. Articles of all languages, years of publication, sample sizes, and model types pertaining to microsurgery were included. The eligibility criteria included the use of a microsurgical training model on a subject group with statistical analysis and measures of validation. Two assessors independently reviewed the articles and their references. RESULTS: Of the 238 articles reviewed, 9 articles met the criteria. Those excluded were predominantly model descriptions that had not been validated in a set of learners. The 9 models whose performances were assessed in a group of learners included an online curriculum, nonliving prosthetics and biologics, and the live rat femoral artery model. Each model was evaluated for content, construct, face, and criterion (concurrent and predictive) validity, as well as selection and observation/expectant bias. Content, construct, concurrent, and face validities were consistently demonstrated for all 9 models. Selection bias was also reliably well controlled with random allocation of participants to each study group. Observation/expectant bias was controlled in 6 of the 8 papers. Predictive validity, an arguably more difficult factor to measure, was only present in 1 article. CONCLUSIONS: Despite a plethora of papers describing microsurgical learning tools, only 9 were discovered that provided validation of the proposed method of microsurgical skills acquisition. This review depicts the need for basic, yet well-designed studies that substantiate the effectiveness of microsurgical training models by using a subject group and demonstrating a statistical improvement with employment of the model. Ease of access, cost, and assessment tools used also require attention.

Reduction of pulmonary complications and hospital length of stay with a clinical care pathway after head and neck reconstruction.

BACKGROUND: Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidence-based tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction. METHODS: Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups. RESULTS: Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days' shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation. CONCLUSIONS: A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complications and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A survey of current practices in the diagnosis of and interventions for inhalational injuries in Canadian burn centres.

OBJECTIVE: To summarize current Canadian practice patterns in the diagnosis of and interventions for inhalation injuries (INHI). METHODS: A 10-question survey regarding the diagnosis of and interventions for INHI was sent to the medical directors of all 16 burn centres across Canada. RESULTS: The response rate to the survey was 50%. Fibreoptic bronchoscopy is required for the diagnosis of INHI in only four centres (50%). The departments of intensive care, plastic surgery, otolaryngology and respirology are involved in performing fibreoptic bronchoscopy in 87.5%, 37.5%, 12.5% and 12.5% of Canadian burn centres, respectively. Intubation for INHI is most often based on physical examination results (87.5%) and clinical history (75%). The most common physical features believed to be most consistent with INHI are dyspnea (87.5%) and hoarseness (87.5%). Common treatments include intubation (87.5%), routine ventilatory support (87.5%) and chest physiotherapy (75%). None of the centres used nebulized heparin. A total of five centres (62.5%) routinely changed the fluid resuscitation protocol when INHI was diagnosed. Only two centres (25%) routinely used prophylactic antibiotics for INHI. CONCLUSION: Prospective, multicentre trials are needed to generate evidence-based consensus in the areas of diagnosis, grading and treatment for INHI in Canada.

OBJECTIF: Résumer les profils de pratique actuels quant au diagnostic et aux interventions relatifs aux lésions par inhalation (LINH). MÉTHODOLOGIE: Les directeurs médicaux des 16 centres de brûlés du Canada ont reçu un sondage de dix questions sur le diagnostic et les interventions relatifs aux LINH. RÉSULTATS: Le taux de réponse au sondage s'élevait à 50 %. La bronchoscopie par fibres optiques est obligatoire dans seulement quatre centres pour diagnostiquer les LINH (50 %). Les départements de soins intensifs, de chirurgie plastique, d'otorhinolaryngologie et de pneumologie participent à la bronchoscopie par fibres optiques dans 87,5 %, 37,5 %, 12,5 % et 12,5 % des centres de brûlés du Canada, respectivement. L'intubation découlant de LINH dépend surtout des résultats de l'examen médical (87,5 %) et des antécédents cliniques (75 %). La dyspnée (87,5 %) et la raucité (87,5 %) sont les principales caractéristiques cliniques perçues comme les plus évocatrices de LINH. Les traitements fréquents incluent l'intubation (87,5 %), le soutien ventilatoire systématique (87,5 %) et la physiothérapie pulmonaire (75 %). Aucun des centres ne faisait appel à la nébulisation d'héparine. Au total, cinq centres (62,5 %) changeaient systématiquement le protocole de réanimation liquidienne au diagnostic de LINH. Seulement deux centres (25 %) utilisaient systématiquement des antibiotiques en prophylaxie dans ce contexte. CONCLUSION: Il faudra mener des essais rétrospectifs multicentriques pour parvenir à un consensus fondé sur des données probantes au sujet du diagnostic, du classement et du traitement des LINH au Canada.

Delayed mobilization after microsurgical reconstruction: an independent risk factor for pneumonia.

OBJECTIVES/HYPOTHESIS: Large defects secondary to oral cancer resection are reconstructed with microsurgical free flaps. Pulmonary complications in these patients are common. Postoperative mobilization is recommended to decrease respiratory complications; however, many microsurgeons are reluctant to adopt early mobilization protocols due to the perceived risk of flap compromise. The purpose of this study was to determine the incidence of pneumonia among patients undergoing oral cancer resection and immediate free flap reconstruction and to compare the incidence of this complication between patients mobilized early (<4 days postoperative) versus later. A secondary goal was to determine whether early postoperative mobilization affected microvascular flap outcome. STUDY DESIGN: Retrospective cohort study. METHODS: Sixty-two consecutive patients treated between 2005 and 2009 with oral carcinoma resection and free flap reconstruction were studied. Information pertaining to comorbidities, postoperative care, and complications were collected. Risk factors for development of pulmonary and flap complications were analyzed. RESULTS: The incidence of pneumonia was 30.6%. Longer intensive care unit stay (P = 0.01), tracheostomy decannulation later than 10 days (P = 0.04), and longer operative times (P = 0.04) were significantly associated with pneumonia. Delayed mobilization (after day 4 postoperative) was an independent risk factor for pneumonia (OR = 4.2, 95% CI: 1.1, 17.1). Early mobilization (before day 4 postoperative) was not associated with an increased incidence of secondary flap procedures or flap failure. CONCLUSION: Late mobilization of free flap patients is an independent risk factor for developing postoperative pneumonia. Earlier mobilization does not increase flap failure rates, is safe, and should be strongly considered in all free flap patients to reduce pulmonary complications.