Users' guide to the surgical literature: how to assess an article about harm in surgery.

CLINICALSCENARIO: You are a new plastic surgeon in the community and you are referred a patient interested in breast reconstruction. The patient is a 35-year-old female school teacher who had a bilateral prophylactic mastectomy 2 years earlier, as she was a BRCA gene carrier. Since she is of a petite build with very little subcutaneous tissue or extra skin in the lower abdomen, you decide that she is not a suitable candidate for an abdomen-based autologous tissue reconstruction. You recommend the technique of tissue expansion and silicone gel implants. She is concerned, however, about the possibility of anaplastic large cell lymphoma (ALCL) developing in her breasts. She read in a magazine recently that ALCL, an unusual form of breast cancer, has been occurring in patients who have breast implants. She is very concerned that she might be at risk and asks for your opinion as to whether she should proceed with the procedure or not.

Users' guide to the surgical literature: how to perform a high-quality literature search.

The article "Users" guide to the surgical literature: how to perform a "literature search" was published in 2003, but the continuing technological developments in databases and search filters have rendered that guide out of date. The present guide fills an existing gap in this area; it provides the reader with strategies for developing a searchable clinical question, creating an efficient search strategy,accessing appropriate databases, and skillfully retrieving the best evidence to address the research question.

Measuring utilities of severe facial disfigurement and composite tissue allotransplantation of the face in patients with severe face and neck burns from the perspectives of the general public, medical experts and patients.

PURPOSE: In an otherwise healthy patient with severe facial disfigurement secondary to burns, composite tissue allotransplantation (CTA) results in life-long immunosuppressive therapy and its associated risk. In this study, we assess the net gain of CTA of face (in terms of utilities) from the perspectives of patient, general public and medical expert, in comparison to the risks. METHODS: Using the standard gamble (SG) and time-trade off (TTO) techniques, utilities were obtained from members of general public, patients with facial burns, and medical experts (n=25 for each group). The gain (or loss) in utility and quality adjusted life years (QALY) were estimated using face-to-face interviews. A sensitivity analysis using variable life expectancy was conducted. RESULTS: From the patient perspective, severe facial burn was associated with a health utility value of 0.53, and 27.1 QALYs as calculated by SG, and a health utility value of 0.57, and 28.9 QALYs as calculated by TTO. In comparison, CTA of the face was associated with a health utility value of 0.64, and 32.3 QALYs (or 18.2 QALYs years per sensitivity analysis) as calculated by SG, and a health utility value of 0.67, and 34.1 QALYs (or 19.2QALYs per sensitivity analysis) as calculated by TTO. However, a loss of 8.9 QALYs (by SG method) to 9.5 QALYs (by TTO method) was observed when the life expectancy was decreased in the sensitivity analysis. Similar results were obtained from the general population and medical experts perspectives. CONCLUSION: We found that severe facial disfigurement is associated with a significant reduction in the health-related quality of life, and CTA has the potential to improve this. Further, we found that a trade-off exists between the life expectancy and gain in the QALYs, i.e. if life expectancy following CTA of face is reduced, the gain in QALY is also diminished. This trade-off needs to be validated in future studies.

Accuracy and completeness of electronic medical records obtained from referring physicians in a Hamilton, Ontario, plastic surgery practice: A prospective feasibility study.

OBJECTIVE: To assess the feasibility of auditing electronic medical records (EMRs) in plastic surgery for future large-scale research studies. The secondary objective was to ascertain the accuracy and completeness of EMRs accompanying referral requests by physicians for plastic surgery consultation between July and December 2013. METHODS: EMRs of 30 patients were reviewed and crosschecked independently by two reviewers and subsequently verified by a third reviewer using predefined criteria to determine whether they were accurate and/or complete. Descriptive analysis was performed to calculate the frequency of inaccuracies and incompleteness for each EMR information field. Information fields were compared to assess whether the frequency of inaccuracies and incompleteness varied. RESULTS: Of the 270 information fields reviewed, four (1.48%) were inaccurate and 66 (24.4%) were incomplete. The most common field of inaccuracy was current medications, followed by medical history and medical allergies. The most common field of incompleteness was history of presenting illness followed by surgical history. CONCLUSION: Despite their purported benefits, inaccuracies and incompleteness are a frequently occurring problem in EMRs. A large-scale study may be beneficial in determining the efficacy of EMRs in the future.

OBJECTIF: Évaluer la faisabilité de vérifier les dossiers médicaux électroniques (DMÉ) en chirurgie plastique en vue de futurs projets de recherche à grande échelle. L'objectif secondaire visait à établir l'exactitude et l'exhaustivité des DMÉ accompagnant les demandes d'aiguillage de médecins vers une consultation en chirurgie plastique entre juillet et décembre 2013. MÉTHODOLOGIE: Deux réviseurs, suivis d'un troisième, ont examiné et contre-vérifié les DMÉ de 30 patients de manière indépendante au moyen de critères prédéfinis pour déterminer s'ils étaient exacts ou complets. Ils ont effectué une analyse descriptive pour calculer la fréquence d'inexactitudes et d'omissions dans chaque champ d'information des DMÉ. Ils ont comparé les champs d'information pour évaluer la variation de la fréquence d'inexactitudes et d'omissions. RÉSULTATS: Sur les 270 champs d'information examinés, quatre (1,48 %) étaient inexacts et 66 (24,4 %), incomplets. Le champ grevé du plus d'inexactitudes était les médicaments actuels, suivi des antécédents médicaux et des allergies médicales. Le champ le plus souvent incomplet était l'histoire des symptômes initiaux, suivi des antécédents chirurgicaux. CONCLUSION: Malgré les prétendus avantages des DMÉ, les inexactitudes et les omissions sont fréquentes. Une étude à grande échelle pourrait contribuer à déterminer l'efficacité des DMÉ.

Methodological guide to adopting new aesthetic surgical innovations.

Aesthetic surgery is known for its prolific introduction of new techniques, devices, and products. The implementation of any aesthetic innovation, however, may inadvertently expose patients to potential complications and adverse events. How do we decide whether a new technique or technology is superior-in both safety and effectiveness-compared with prevailing interventions? In this paper, we present some basic steps anchored in evidence-based surgery that aesthetic surgeons need to pursue in the adoption of a new technique, technology, or product. These steps include: (1) gaining familiarity with and understanding the levels of evidence; (2) performing an effective literature search; (3) formulating a critical appraisal of an article; (4) making the decision to adopt or reject; (5) recognizing the need for continued assessment; (6) acknowledging the need for education and credentialing; and (7) translation of the gathered knowledge. We hope that this paper will foster critical thinking and reduce the reliance on "photographic evidence" in aesthetic surgery literature.

A systematic review of utilities in hand surgery literature.

PURPOSE: To systematically review the literature to determine if utilities (a quantitative way to express patient preferences for health outcomes) have been measured in hand surgery studies. METHODS: A literature search was conducted using Cochrane, EMBASE, HealthSTAR, MEDLINE, and CINAHL electronic databases (1966-2013). This search was supplemented by cited and manual reference searches and expert consultation to retrieve all relevant studies. Studies were selected by 2 independent reviewers if they pertained to hand or wrist surgery, were published in English, and measured utilities as an outcome. Descriptive data were extracted, including the hand surgery procedure investigated, study design, value of utilities, and methodology of utilities measurement. RESULTS: Eleven studies were included after reviewing 989 studies. Most hand conditions were associated with utilities less than 0.8. Utilities in the reviewed studies were measured using different methods and from different subjects. Three studies paradoxically mapped greater utilities for poorer heath states. CONCLUSIONS: Hand conditions cause impairment, as evidenced by their utilities. Measurement of utilities remains uncommon in hand surgery literature. Future studies should not only measure utilities but also do so with consistent and appropriate methodology to ensure that mapped values are valid and comparable. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision analysis III.

Plastic surgeons' self-reported operative infection rates at a Canadian academic hospital.

BACKGROUND: Surgical site infection rates are of great interest to patients, surgeons, hospitals and third-party payers. While previous studies have reported hospital-acquired infection rates that are nonspecific to all surgical services, there remain no overall reported infection rates focusing specifically on plastic surgery in the literature. OBJECTIVE: To estimate the reported surgical site infection rate in plastic surgery procedures over a 10-year period at an academic hospital in Canada. METHODS: A review was conducted on reported plastic surgery surgical site infection rates from 2003 to 2013, based on procedures performed in the main operating room. For comparison, prospective infection surveillance data over an eight-year period (2005 to 2013) for nonplastic surgery procedures were reviewed to estimate the overall operative surgical site infection rates. RESULTS: A total of 12,183 plastic surgery operations were performed from 2003 to 2013, with 96 surgical site infections reported, corresponding to a net operative infection rate of 0.79%. There was a 0.49% surgeon-reported infection rate for implant-based procedures. For non-plastic surgery procedures, surgical site infection rates ranged from 0.04% for cataract surgery to 13.36% for high-risk abdominal hysterectomies. DISCUSSION: The plastic surgery infection rate at the study institution was found to be <1%. This rate was equal to, or somewhat less than, surgical site infection rates. However, these results do not report patterns of infection rates germane to procedures, season, age groups or sex. To provide more in-depth knowledge of this topic, multicentre studies should be conducted.

HISTORIQUE: Les patients, les chirurgiens, les hôpitaux et les tiers payeurs s'intéressent au taux d'infections au site opératoire. Des études antérieures ont fait état du taux d'infections nosocomiales non spécifiques dans tous les services chirurgicaux, mais les publications ne rendent pas compte du taux global d'infections attribuables exclusivement à la chirurgie plastique. OBJECTIF: Estimer le taux d'infections déclaré au site opératoire en chirurgie plastique sur une période de dix ans dans un hôpital universitaire du Canada. MÉTHODOLOGIE: Les chercheurs ont effectué une analyse du taux d'infections au site opératoire en chirurgie plastique entre 2003 et 2013, d'après les interventions effectuées au bloc opératoire principal. À titre comparatif, ils ont examiné les données prospectives de surveillance des infections colligées sur une période de huit ans (2005 à 2013) après des interventions non chirurgicales pour évaluer le taux global d'infections au site opératoire. RÉSULTATS: Au total, 12 183 opérations ont été effectuées en chirurgie plastique entre 2003 et 2013, dont 96 infections au site opératoire, pour un taux net d'infections opératoires s'élevant à 0,79 %. Les chirurgiens ont déclaré un taux d'infections de 0,49 % après des implants. Pour ce qui est des opérations non liées à la chirurgie plastique, le taux d'infections au site opératoire variait entre 0,04 % après des chirurgies des cataractes, et 13,36 % après des hystérectomies abdominales à haut risque. EXPOSÉ: Le taux d'infections après une chirurgie plastique au sein de l'établissement à l'étude était inférieur à 1 %. Ce taux était égal ou quelque peu inférieur au taux d'infections au site opératoire. Cependant, ces résultats ne tiennent pas compte des profils des taux d'infections liées aux interventions, à la saison, aux groupes d'âge ou au sexe. Pour approfondir le sujet, il faudrait mener une étude plus vaste.

Cost-effectiveness analysis parallel to a randomized controlled trial comparing vertical scar reduction and inverted T-shaped reduction mammaplasty.

BACKGROUND: A previous randomized controlled trial showed no clear superiority of vertical scar over inverted T-shaped reduction mammaplasty in terms of health-related quality of life. No economic evaluation has been undertaken comparing vertical scar reduction and inverted T -shaped reduction. METHODS: A total of 255 patients were randomized to either vertical scar or inverted T -shaped reduction. The effectiveness was measured with the Health Utilities Index Mark 3. Direct and productivity costs were captured parallel to the randomized controlled trial. Perspectives of the Ministry of Health, patient, and society were considered. RESULTS: Inverted T -shaped reduction dominated vertical scar reduction from the Ministry of Health perspective by being slightly less costly ($3090.06 versus $3106.58) and slightly more effective (0.87 quality-adjusted life-years versus 0.86 quality-adjusted life-years). From the societal and patient perspectives, vertical scar reduction was both less costly and less effective. At the commonly quoted Canadian threshold of $50,000 per quality-adjusted life-year gained, the probability that vertical scar reduction was cost-effective was 29.3, 68.2, and 66.9 percent from the Ministry of Health, patient, and societal perspectives. Subgroup analysis of reductions less than 500 g found that vertical scar reduction was more likely cost-effective. CONCLUSIONS: Vertical scar reduction is more likely than not cost-effective from patient and societal perspectives but not from the Ministry of Health perspective at a willingness-to-pay threshold of $50,000 per quality-adjusted life-year. If we limit vertical scar reduction for resections less than 500 g per breast, this technique is more likely cost-effective from all perspectives.

Long-term outcomes of major upper extremity replantations.

BACKGROUND: Long-term outcomes of major upper extremity replantations are infrequently reported. It is believed that replantation is indicated for amputations at all levels in children and for all distal amputations in adults. Replantations of arm or proximal forearm amputations in adults are controversial. OBJECTIVE: To evaluate the results of major upper extremity replantations, defined as those that are transmetacarpal, through the wrist, forearm, elbow or arm. METHODS: A review of these types of replantations performed at the authors' institution from 2002 to 2012 was conducted. Patients' strength, range of motion and two-point discrimination were assessed. Patients completed the Disabilities of the Arm, Shoulder and Hand (DASH), the Michigan Hand Questionnaire (MHQ), and the Hospital Anxiety and Depression scale (HADS). RESULTS: Seventeen patients underwent major upper extremity replantation surgery. The majority (16 of 17 [94%]) of the included patients were male. Of 17 patients, 13 (76.5%) required reoperations. The mean (± SD) DASH score of seven patients who consented to completing all questionnaires was 75.4±14.2 of 100 (range 59.2 to 91.1). On the MHQ, the mean score for affected hand function was 16% compared with 84% in the unaffected hand. Patients generally demonstrated at least mild levels of anxiety and depression on the HADS. DISCUSSION: The results suggest that major upper extremity injuries and replantations have a significant impact on patients' long-term hand function, and produce long-term anxiety and depressive symptoms.

HISTORIQUE: On rend rarement compte des issues à long terme des réimplantations majeures des membres supérieurs. On croit que la réimplantation est indiquée pour tout type d'amputation chez les enfants et pour toute amputation distale chez les adultes. Chez les adultes, la réimplantation d'un bras ou de la partie proximale d'un avant-bras amputé est controversée. OBJECTIF: Évaluer les résultats de réimplantations majeures des membres supérieurs, définies comme des réimplantations transmétacarpiennes, à partir du poignet, de l'avant-bras, du coude ou du bras. MÉTHODOLOGIE: Les auteurs ont analysé ce type de réimplantations effectuées au sein de leur établissement entre 2002 et 2012. Ils ont évalué la force, l'amplitude de mouvement et la discrimination en deux points des patients. Ceux-ci ont rempli le questionnaire DASH sur l'invalidité du bras, de l'épaule et de la main, le questionnaire Michigan de la main (MHQ) et l'échelle HADS d'anxiété et de dépression en milieu hospitalier. RÉSULTATS: Dix-sept patients ont subi une réimplantation majeure d'un membre supérieur. La majorité d'entre eux (16 sur 17 [94 %]) étaient de sexe masculin. Sur les 17 patients, 13 (76,5 %) ont dû être réopérés. L'indice DASH moyen (±ÉT) des sept patients qui ont consenti à remplir tous les questionnaires était de 75,4±14,2 sur 100 (plage de 59,2 à 91,1). Au MHQ, l'indice moyen de la fonction de la main touchée s'élevait à 16 % par rapport à 84 % dans la main non touchée. En général, les patients présentaient au moins un taux moyen d'anxiété et de dépression selon l'échelle HADS. EXPOSÉ: Selon les résultats, les blessures et les réimplantations majeures des membres supérieurs ont des conséquences importantes sur la fonction à long terme de la main des patients et entraînent des symptômes d'anxiété et de dépression à long terme.

Psychometric properties of health-related quality of life instruments in patients undergoing palmar fasciectomy for dupuytren's disease: a prospective study.

BACKGROUND: The traditional outcome measured following treatment of Dupuytren's Disease (DD) has been digital range of motion; specifically the gain in digital extension. The outcomes research movement in the last three decades however has been advocating the measurement of outcomes from the patient's perspective using Health-Related Quality of Life questionnaires (HRQOL). Although several generic and region-specific HRQOL questionnaires exist, there is no guidance as to which one is the most appropriate for this population. The objective of this study is to evaluate the psychometric properties of three self-reported HRQOL outcome measures in patients with DD. METHODS: Patients with DD were enrolled from the practices of three plastic surgeons. Test-retest reliability, concurrent validity and responsiveness of three HRQOL questionnaires were compared in a prospective study design. The HRQOL measures included Health Utilities Index Mark 3 (HUI3), Short Form-36 (SF-36), and the Michigan Hand Questionnaire (MHQ). RESULTS: All three measures demonstrated good test-retest reliability (ICC = 0.77-0.85). Concurrent validity was found between the HUI3 pain and dexterity attributes and SF-36 physical summary score. The sensitivity of the MHQ to detect changes in the status of the patient was found to be high (effect size = 1.14) whereas that of the SF-36 was trivial. CONCLUSIONS: The HUI3 and the MHQ seem to be reliable and valid tools to assess the HRQOL in patients with Dupuytren's Disease.

Health-related quality of life in patients undergoing palmar fasciectomy for Dupuytren's disease.

BACKGROUND: The present study was undertaken to assess the health-related quality of life in patients with Dupuytren's disease who undergo palmar fasciectomy. METHODS: A prospective cohort of patients with Dupuytren's disease undergoing palmar and/or digital fasciectomy was recruited from the practice of three plastic surgeons in Hamilton, Ontario, Canada. After written informed consent was obtained, participants were asked to complete three health-related quality-of-life questionnaires (i.e., Short Form-36, Michigan Hand Outcomes Questionnaire, and Health Utility Index Mark 3) at five time points: at 1 week and 1 day preoperatively, and at 1, 3, 6, and 12 months postoperatively. Ranges of motion and grip strength measurement were also recorded. RESULTS: For the 26 patients in the study, the multiattribute scores of the Health Utility Index Mark 3 improved from 0.80 before surgery to 0.83 at 12 months postoperatively (p > 0.05). There was no difference in the Short Form-36 scores, but the Michigan Hand Outcomes Questionnaire scores improved from 74 at 1 week preoperatively to 90 at the 12-month postoperative visit (p < 0.001). CONCLUSIONS: Patients who undergo palmar fasciectomy for Dupuytren's disease experience a substantial improvement in their health-related quality of life 12 months after surgery. In the authors' study population, a benefit of 0.85 quality-adjusted life-year within 12 months was observed. This can be translated as follows: the average patient who undergoes palmar fasciectomy gains the equivalent of approximately 14.4 days (0.48 months) in perfect health by undergoing palmar fasciectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Functional outcomes post-radial head arthroplasty: a systematic review of literature.

BACKGROUND: The present study was conducted to determine the quality and content of research on the functional outcomes and complications post-metal radial head arthroplasty (RHAP). METHODS: A comprehensive search of medical databases for studies reporting on functional outcomes of patients undergoing metallic RHAP was conducted. The Structured Effectiveness Quality Evaluation Scale (SEQES) was used to evaluate quality of the studies. RESULTS: We identified 21 Sackett's Level IV studies reporting on 391 radial heads. The mean duration of follow-up was 47.2 months and the mean (SD) age of patients was 48.4 years (6.9 years). The male to female ratio was found to be 1.05 : 1 and the dominant arm was involved in 54% of patients. When functional outcomes achieved post-RHAP were compared with normative scores, the comparison suggested that RHAP has good to excellent functional outcomes in short- to mid-term follow-up. The weighted mean (SD) Mayo Elbow Performance Score was 85.8 (4.1) (95% confidence interval 85.3 to 86.3). Incidences of implant removal (3.06%) and revision (2.22%) were found to be low. CONCLUSIONS: There is consistent low-quality evidence of positive functional outcomes following RHAP. The heterogeneity of type of implant, patient characteristics and outcome measures used, along with an inadequate reporting of study details, restrict any definitive conclusions being made.