The Utility of Smartphone-Based Thermal Imaging in the Management and Monitoring of Microvascular Flap Procedures: A Systematic Review and Meta-Analysis.

BACKGROUND: Smartphone-based thermal imaging (SBTI) has been reported in the literature to be an easy-to-use, contactless, cost-friendly alternative to standard imaging modalities in identifying flap perforators, monitoring flap perfusion, and detecting flap failure. Our systematic review and meta-analysis aimed to evaluate SBTI's accuracy in perforator identification and secondarily evaluate SBTI's utility in flap perfusion monitoring as well as ability to predict flap compromise, failure, and survival. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was performed using PubMed from inception to 2021. Articles were uploaded into Covidence and, following duplicate deletion, were initially screened for use of SBTI in flap procedures through title and abstract screening followed by full-text review. The following data points, if provided, were extracted from each included study: study design, number of patients, patient demographics, perforator number and location, flap number and location, room temperature, cooling method, imaging distance, time from cloth removal, primary (SBTI's accuracy in perforator identification), and secondary outcomes (prediction of flap compromise/failure/survival and cost analysis). Meta-analysis was performed using RevMan v.5. RESULTS: The initial search yielded 153 articles. Eleven applicable studies with a total of 430 flaps from 416 patients were ultimately included. The SBTI device assessed in all included studies was FLIR ONE. Four studies assessed the SBTI's perforated detection ability and were included in meta-analysis. Smartphone-based thermal imaging correctly identified 378 (93.3%; n = 405) perforators, and computed tomography angiography (CTA) correctly identified 402 (99.2%; n = 402), although in one study SBTI found additional perforators not detected on CTA. A random-effects model was used (I2 = 65%), and no significant difference in perforator detection ability was found between SBTI and CTA (P = 0.27). CONCLUSIONS: This systematic review and meta-analysis supports SBTI as user- and cost-friendly ($229.99), contactless imaging modality with perforator detection ability comparable to current criterion-standard CTA. Postoperatively, SBTI outperformed Doppler ultrasound in early detection of microvascular changes causing flap compromise, allowing for prompt tissue salvage. With a minimal learning curve, SBTI seems to be a promising method of postoperative flap perfusion monitoring able to be used by all hospital ranks. Smartphone-based thermal imaging could thus increase flap monitoring frequency and lower complication rates, although further study is warranted.

Risk factors associated with 30-day complications following lower extremity sarcoma surgery: A national surgical quality improvement project analysis.

BACKGROUND: Our study aims to identify risk factors associated with complications in lower extremity (LE) sarcoma surgery, as well as the prevalence and complications associated with concurrent plastic surgery procedures (CPSP). METHODS: ACS-NSQIP database was accessed to identify patients treated for LE sarcoma (2010-2019). Patient demographics, preoperative lab, comorbidities, tumor type, location, principle procedure, and presence/characteristics of CPSPs were recorded. Thirty-day soft tissue complications were analyzed. Bivariate and multivariate logistic regression was performed on IBM SPSS.™ RESULTS: Nine hundred eighteen patients were included (483 males and 435 females), average age and body mass index (BMI) of 57 and 27.4 kg/m,2 respectively. Comorbidities included smoking (13.9%, 128), hypertension (37.3%, 342), and insulin-dependent diabetes (3.7%, 34). Preoperative lab values included albumin <3.5 (6.8%, 63), hematocrit <30% (8.2%, 75), and platelet count <150 000 (5.9%, 54). Thirty-day soft tissue complication rate was 5.7% (52 of 918). On multivariate logistic regression, increased age (p = 0.039), higher BMI (p = 0.017), and longer operative times (p = 0.002) were significant risk factors independently associated with soft tissue complications. CONCLUSIONS: Soft tissue complications within 30 days occur in 6% of patients. Graft procedures carry a 20% risk of complications. Risk factors independently associated with complications include increased age, increased BMI, and longer operative times.

Color Doppler Ultrasound versus Computed Tomography Angiography for Preoperative Anterolateral Thigh Flap Perforator Imaging: A Systematic Review and Meta-Analysis.

BACKGROUND: The anterolateral thigh (ALT) perforator flap is a commonly used flap with a predictable, though often variable, perforator anatomy. Preoperative imaging with color Doppler ultrasound (CDU) and computed tomography angiography (CTA) of ALT flap perforators can be a useful tool for flap planning. This study provides a complete review and analysis of the relevant preoperative ALT imaging literature. METHODS: Studies related to preoperative CDU and CTA imaging were reviewed, and information related to imaging method, sensitivity, false-positive rates, and perforator course identification (musculocutaneous vs. septocutaneous) were analyzed. RESULTS: A total of 23 studies related to preoperative ALT flap CDU and CTA imaging were included for review and analysis. Intraoperative perforator identification was compared with those found preoperatively using CDU (n = 672) and CTA (n = 531). Perforator identification sensitivity for CDU was 95.3% (95% CI: 90.9-97.6%) compared with the CTA sensitivity of 90.4% (95% confidence interval [CI]: 74.4-96.9%). The false-positive rate for CDU was 2.8% (95% CI: 1.1-4.5%) compared with 2.4% (95% CI: 0.7-4.1%) for CTA. Accuracy of perforator course identification was 95.5% (95% CI: 93.6-99.2%) for CDU and 96.9% (95% CI: 92.7-100.1%) for CTA. CONCLUSION: CDU provides the reconstructive surgeon with greater preoperative perforator imaging sensitivity compared with CTA; however, false-positive rates are marginally higher with preoperative CDU. Preoperative imaging for ALT flap design is an effective tool, and the reconstructive surgeon should consider the data presented here when selecting a flap imaging modality.

Resident-Driven Wellness Initiatives Improve Resident Wellness and Perception of Work Environment.

BACKGROUND: Resident burnout is associated with increased adverse patient events and increased incidence of resident depression and suicide when compared to the general population. We hypothesized that resident-driven assessment and implementation of wellness measures would allow implementation of desired interventions and facilitate improvement in wellness. METHODS: A wellness intervention team was established to address resident wellness and job satisfaction. A needs assessment to determine desired interventions as well as a three-part anonymous 5-point Likert scale survey was developed and distributed to general surgery residents. Following implementation of three measures, a postintervention survey was administered at 6 and 15 mo to the same cohort. Analysis of variance test was used to evaluate for significant difference between preintervention and postintervention surveys. RESULTS: Three interventions were implemented: two protected weekday personal days per year, modernization of resident workspace, and additional meal funds. There were statistically significant changes in perceptions of wellness opportunities (3.14 versus 3.88 and 3.7; P < 0.05), time for wellness (2.53 versus 3.42 and 3.2; P < 0.05), work/life balance satisfaction (2.86 versus 3.71 and 3.41; P < 0.05), and improved quality of life (2.67 versus 3.3 and 3.0; P < 0.05) in both 6-mo and 15-mo postintervention responses. CONCLUSIONS: Implementation of resident-selected wellness measures was found to influence overall resident satisfaction and improved perception of the working environment. Several scores of wellness items showed sustained improvement at 15 mo. These results suggest that resident-driven wellness interventions can positively affect working conditions for residents.

Remote Injuries and Outcomes After Distal Radius Fracture Management.

BACKGROUND: Distal radius fracture (DRF) is a common fracture of the upper extremity. The role of concurrent injuries in patients treated for DRFs is poorly elucidated. The authors sought to determine whether remote injuries were associated with worse outcomes after management of DRFs. METHODS: A retrospective cohort study including all consecutively seen patients by a university hospital hand service between 2010 and 2015. Preoperative radiographs were analyzed, and patients were managed by surgeon preference and evaluated postoperatively using pain scores. Remote injury was defined as any other injury sustained at the time of fracture not localized to affected extremity. Univariate analysis was performed to identify factors associated with risk of complication. A multivariate logistic regression analysis was performed, controlling for confounding factors. RESULTS: A total of 181 DRFs in 176 patients were treated over the 5-year period of the study. Forty-eight (26.5%) of the fractures were managed nonoperatively with casting, 12 (6.6%) with closed reduction and pinning, and 119 (65.7%) with open reduction and plating. The mean follow-up was 5.2 months. The complication rate was 18.2%. The most common complication was persistent pain in 5 patients, followed by median neuropathy, loss of reduction, arthritis, and distal radioulnar joint instability. After controlling for age, body mass index, hand surgeon, and other confounders, remote injury was associated with a significantly increased risk of complications ( P = .04, odds ratio: 6.03, 95% confidence interval: 1.05-34.70). CONCLUSIONS: Patients with remote injuries have a 6-fold increased risk of complications after DRF treatment. The additional risk in these patients should be considered during patient/family counseling and clinical decision-making in DRF management.