Preoperative Angiography for Free Fibula Flap Harvest: A Meta-Analysis.

BACKGROUND: The necessity for routine preoperative imaging for free fibula harvest is controversial. The primary objective of this meta-analysis is to determine if lower extremity angiography is necessary to detect abnormalities that may alter flap selection. The secondary objective is to determine if physical examination alone is sufficient to predict these abnormalities. METHODS: A literature search was performed using Cochrane, CENTRAL, MEDLINE, CINAHL, and EMBASE. Studies were selected for inclusion if they included patients undergoing free fibula flap harvest with preoperative imaging, with or without physical examination findings. Data extraction was performed independently and in duplicate, including a change in flap selection and the level of agreement between physical examination and imaging. Pooled proportions were calculated using a random-effects model and 95% confidence intervals (CI). RESULTS: Sixteen studies were included for analysis. Mean sample size was 42 patients (range: 5-123). Included studies were of low methodologic quality. Pooled proportion of patients who had flap selection change secondary to abnormalities identified on preoperative angiography was 20.1% (95% CI: 9.6-33.2%). A pooled proportion of 71.5% (95% CI: 5-88.7%) of cases requiring change in flap selection was missed by physical examination findings alone. CONCLUSION: There is low-quality evidence suggesting a necessity for routine preoperative angiography for all patients undergoing free fibula flap harvest. Physical examination alone is insufficient in detecting vascular abnormalities that may result in limb compromise or an inability to successfully harvest a free fibula. Further investigation is warranted for cost-effectiveness of preoperative imaging protocols.

Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet.

BACKGROUND: In our experience, for all surgeries in the hand, the optimal epinephrine effect from local anesthesia-producing maximal vasoconstriction and visualization-is achieved by waiting significantly longer than the traditionally quoted 7 min from the time of injection. METHODS: In this prospective comparative study, healthy patients undergoing unilateral carpal tunnel surgery waited either 7 min or roughly 30 min, between the time of injection of 1 % lidocaine with 1:100,000 epinephrine and the time of incision. A standardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60 s of measuring the quantity of blood loss using sterile micropipettes. RESULTS: There was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30 min after injection and before incision compared to the group that waited only 7 min (95 % confidence intervals of 0.06 + -0.03 ml/cm of incision, compared to 0.17 + -0.08 ml/cm, respectively) (P = 0.03). CONCLUSIONS: Waiting roughly 30 min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min, achieves an optimal epinephrine effect and vasoconstriction. In the hand, this will result in roughly a threefold reduction in bleeding-making wide awake local anesthesia without tourniquet (WALANT) possible. This knowledge has allowed our team to expand the hand procedures that we can offer using WALANT. The benefits of WALANT hand surgery include reduced cost and waste, improved patient safety, and the ability to perform active intraoperative movement examinations.

Osteotomy for sigmoid notch obliquity and ulnar positive variance.

Background Several causes of ulnar wrist pain have been described. One uncommon cause is ulnar carpal abutment associated with a notable distally facing sigmoid notch (reverse obliquity). Such an abnormality cannot be treated with ulnar shortening alone because it will result in incongruity of the distal radioulnar joint (DRUJ). Case Description A 23-year-old woman presented with ulnar wrist pain aggravated by forearm rotation. Ten years earlier she had sustained a distal radius fracture that was conservatively treated. Examination revealed mild tenderness at the DRUJ and decreased wrist flexion and grip strength on the affected side. Radiographic examination demonstrated 1 cm ulnar positive variance, ulnar styloid nonunion, and a 37° reverse obliquity of the sigmoid notch. The patient was treated with ulnar shortening and rotation sigmoid notch osteotomy to realign the sigmoid notch with the ulnar head. Literature Review Sigmoid notch incongruity is one of several causes of wrist pain after distal radius fracture. Traditional salvage options for DRUJ arthritis may result in loss of grip strength, painful ulnar shaft instability, or reossification and are not acceptable options in the young patient. Sigmoid notch osteotomy or osteoplasty have been described to correct the shape of the sigmoid notch in the axial plane. Clinical Relevance We report a coronal plane osteotomy of the sigmoid notch to treat reverse obliquity of the sigmoid notch associated with ulnar carpal abutment. The rotation osteotomy described is particularly useful for patients in whom a salvage procedure is not warranted.

A systematic review of power and sample size reporting in randomized controlled trials within plastic surgery.

BACKGROUND: The randomized controlled trial is a reliable study design for assessing the effectiveness of a surgical intervention, provided it is adequately powered. This systematic review examines the appropriateness of reporting of power and sample size in randomized controlled trials within the plastic surgery literature. METHODS: Original randomized controlled trials published from January of 1990 to December of 2010 in nine high-impact plastic surgery journals were appraised. The data extracted from each study included calculation of power and sample size, number of patients, and effect size. A Jadad score was calculated, providing a quality assessment of the randomized controlled trial. RESULTS: : Of the 736 original articles, 463 met the inclusion criteria; 88 (19.0 percent) of these 463 reported performing a priori power analysis or sample size calculation. Of these 88 studies, 68 (77.3 percent) had an adequate sample size. In most studies, a standard of 0.05 for the type I error and 0.20 for type II error was used. There has been some improvement in the reporting of power and sample size in the decades from 1990 to 2010. CONCLUSIONS: Nineteen percent of 463 randomized controlled trials in the plastic surgery literature reported performing an a priori power analysis or sample size calculation. The implication is that when we read the results of a published randomized controlled trial in plastic surgery, in 81 percent of cases we cannot trust the findings. Although the reporting of power and sample size has improved in the last decade, it is still inadequate. Lack of such reporting casts doubt on the validity (truthfulness) of the study's findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.