Nerve block efficacy in breast augmentation: A systematic review and meta-analysis.

Breast augmentation is often performed as a day-case general anaesthetic operation, with postoperative, opioid-based analgesia regimens. However, it may also be performed using regional anaesthesia; a variety of nerve block techniques are available to reduce postoperative pain and analgesic requirements. This systematic review and meta-analysis were undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines comparing breast augmentation using regional anaesthesia with general anaesthesia, versus general anaesthesia alone or with local field infiltration. All randomised or quasi-randomised studies that recruited adult female patients undergoing breast augmentation using regional anaesthesia were considered. The primary outcome measures were postoperative pain and analgesic requirements. A randomised effects model was used, with standardised mean difference or mean difference outcomes used as appropriate. Thirteen studies were included for systematic review, out of which eight met the inclusion criteria for meta-analysis. Nerve blocks had statistically significant standardised mean difference reductions in postoperative pain scores across all time points: 0 h (-1.2 [-2.1 to -0.3], p = 0.01, I2 = 85%), 1 h (-1.3 [-2.1 to -0.5], p = 0.002, I2 = 89%), 2 h (-1.8 [-2.8 to -0.9], p = 0.0002, I2 = 88%), 4-6 h (-1.2 [-2.1 to -0.4], p = 0.006, I2 = 89%), 24 h (-1.4 [-2.5 to -0.2], p = 0.02, I2 = 94%). There was also a statistically significant reduction in postoperative opioid requirements: -150 mcg fentanyl (-259.2 to -40.9), p = 0.007. Although an element of study heterogeneity is noted, this systematic review and meta-analysis support the concept that regional anaesthesia using nerve blocks in breast augmentation surgery, reduces both postoperative pain and opioid requirements, compared with general anaesthesia.

Platelet-Rich Plasma (PRP) for Sacrococcygeal Pilonidal Disease: An Updated Systematic Review and Meta-Analysis.

BACKGROUND: Pilonidal disease can be a debilitating condition which carries a significant physical and economic burden. This systematic review and updated meta-analysis presents the evidence for the use of platelet-rich plasma (PRP) for wound healing following open and minimally-invasive sacrococcygeal pilonidal surgery. METHODS: A literature search was performed during December 2021 for studies relating to platelet-rich plasma and pilonidal wound healing following surgery. RESULTS: Nine studies remained after applying the exclusion criteria, incorporating a total of 621 (open surgery group) and 309 (minimally-invasive group) patients, respectively. Pooled analysis of the six open surgery group studies demonstrated a significant reduction in wound healing time (mean difference [MD] = - 13.98 days, 95% CI - 18.41 to - 9.55, p < 0.001, I2 = 98%). Three open surgery group studies compared post-operative time off work, while three recorded mean pain duration; pooled analysis also revealed a significant reduction in both outcomes, respectively (MD = - 8.7 days, 95% CI - 9.4 to - 8.0, p < 0.001, I2 = 57%; MD = - 9.5 days, 95% CI - 15.6 to - 3.3, p = 0.002, I2 = 98%). Methodological heterogeneity among the minimally-invasive studies precluded formal meta-analysis; however, two studies demonstrated a modest improvement in wound healing when treated with PRP. CONCLUSIONS: This systematic review and updated meta-analysis provide further evidence supporting the use of PRP for wound healing in sacrococcygeal pilonidal disease. PRP application was demonstrated to significantly reduce healing time, postoperative pain and time off work in the open surgery group. Nevertheless, there is still considerable heterogeneity among PRP manufacture and administration techniques, and further high-powered RCTs with consistent methodology are required to substantiate these findings.

Aggressive paediatric camptodactyly: The evolution of a proposed treatment algorithm.

INTRODUCTION: It is a long-established teaching to avoid operating on camptodactyly unless there is a failure of non-operative treatment, such as serial splinting and hand therapy, and there is an established proximal interphalangeal joint (PIPJ) contracture of 60°; a recent systematic review reflects this continuing approach, with some papers advocating intervention with a lesser degree of contracture. AIM: To evaluate whether early flexor digitorum superficialis (FDS) release, followed by gentle passive manipulation (GPM), will correct severe 'congenital' camptodactyly, if undertaken at an earlier age than usual, thus avoiding the more aggressive surgical approach required in the established adolescent cases. METHOD: The surgical technique and treatment algorithm are described. A multi-centre case series is presented; data analysis included patient demographics, syndromic association, side/digit affected, ages at onset, progression, referral and at surgery, operation details, pre- and post-operative contracture and range of motion. RESULTS: There were 12 patients (3 males, 9 females) who underwent 15 operations for 24 involved digits. Patients had surgery by 3 months (median) post-referral, and there was a significant improvement in median (range) PIPJ contracture (90°(30°-90°) vs. 0°(0°-45°); p<0.001) and range of motion (0°(0°-60°) vs. 90°(50°-95°); p<0.001), at a median post-operative follow-up of 2.5 years. According to the Siegert grade, 87.5% of digits had excellent/good post-operative outcomes and 12.5% had fair outcomes. CONCLUSION: This paper specifically addresses the problem of aggressive and progressive camptodactyly in the young child. By this, we mean patients who have failed non-operative treatment and have PIPJ contractures ≥60°, and those whose contractures have increased by 30° within 1 year. All cases responded to early FDS release and GPM, hence correcting the PIPJ contracture. However, cases with multiple digital involvement, whether syndromic or not, and failed previous surgery or the older child, required additional procedures to restore a dynamic dorsal apparatus and active extension.

St Andrew's COVID-19 Surgery Safety (StACS) study: Skin cancer.

BACKGROUND: Skin cancer represents the most common malignancy worldwide and it is imperative that we develop strategies to ensure safe and sustained delivery of cancer care which are resilient to the ongoing impact of COVID-19. OBJECTIVE: This study prospectively evaluates the COVID-19 related patient risk and skin cancer management at a single tertiary referral centre, which rapidly implemented national COVID-19 safety guidelines. METHOD: A prospective cohort study was performed in all patients who underwent surgery for elective skin cancer service management, during the UK COVID-19 pandemic peak (April-May 2020). 'Real-time' 30-day hospital database deceased data were collected. Random selection was undertaken for patients who either underwent operative (surgery group) management or remained on the waiting list (control group); these groups were also prospectively followed-up within a controlled cohort study design and telephoned at the end of June 2020 for the control group or 30 days post-operatively. RESULTS: Of the 767 patients who had operations, there were no COVID-19 related deaths. Both the surgery (n = 384) and control (n = 100) groups were matched for age, sex, ethnicity, BMI, presence of comorbidities, smoking and positive COVID-19 contact. There were no differences in post-operative versus any symptom development (1.3%, 5/384 vs. 4%, 4/100, p = 0.093), or proportion of positive tests (8.6%, 33/384 vs. 8%, 8/100; p = 0.849), between the surgery and control groups. CONCLUSION: These data support continued and safe service provision, and no increased risk to skin cancer patients who require surgical management, which is vital for continuation of cancer treatment in the context of a pandemic. LEVEL OF EVIDENCE: II.

St Andrew's COVID-19 surgery safety study: hand trauma.

INTRODUCTION: Adaptation is vital to ensure successful healthcare recovery during the COVID-19 pandemic. Hand trauma represents the most common acute emergency department presentation internationally. This study prospectively evaluates the COVID-19 related patient risk, when undergoing management within one of the largest specialist tertiary referral centres in Europe, which rapidly implemented national COVID-19 safety guidelines. MATERIALS AND METHODS: A prospective cohort study was undertaken in all patients referred to the integrated hand trauma service, during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. Random selection was undertaken for patients with hand trauma who either underwent non-operative (control group) or operative (surgery group) management; these groups were prospectively followed-up within a controlled cohort study design and telephoned at 30 days following first intervention (control group) or postoperatively (surgery group). RESULTS: Of 731 referred patients (566 operations), there were no COVID-19 related deaths. Both groups were matched for sex, age, ethnicity, body mass index, comorbidities, smoking, preoperative/first assessment COVID-19 symptoms, pre- and postoperative/first assessment isolation and positive COVID-19 contact (p > 0.050). There were no differences in high service satisfaction (10/10 compared with 10/10; p = 0.067) and treatment outcome (10/10 compared with 10/10; p = 0.961) scores, postoperative/first assessment symptoms (1%, 1/100 compared with 0.8%, 2/250; p = 1.000) or proportion of positive tests (7.1%, 1/14 compared with 2.2%, 2/92; p = 0.349), between the control (n = 100) and surgery (n = 250) groups. CONCLUSION: These data support continued and safe service provision and no increased risk to patients who require surgical management. Such findings are vital for healthcare providers when considering service adaptations to reinstate patient treatment.

St Andrew's COVID-19 surgery safety (StACS) study: The Burns Centre experience.

BACKGROUND: The COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has the potential to significantly impact burns patients both directly through infective complications of an immunocompromised cohort, and indirectly through disruption of care pathways and resource limitations. The pandemic presents new challenges that must be overcome to maintain patient safety; in particular, the potential increased risks of surgical intervention, anaesthesia and ventilation. This study comprehensively reviews the measures implemented to adapt referral pathways and mitigate the risk posed by COVID-19 during the height of the pandemic, within a large Burns Centre. METHODS: A prospective cohort study was designed to assess patients treated at the Burns Centre during the UK COVID-19 pandemic peak (April-May 2020), following implementation of new safety measures. All patients were analysed for 30-day mortality. In addition, a prospective controlled cohort study was undertaken on all inpatients and a random sample of outpatients with telephone follow-up at 30 days. These patients were divided into three groups (operative inpatients, non-operative inpatients, outpatients). COVID-19 related data collected included test results, contact with proven cases, isolation status and symptoms. The implemented departmental service COVID-19 safety adaptations are described. RESULTS: Of 323 patients treated at the Burns Centre during the study period, no 30-day COVID-19 related deaths occurred (0/323). Of the 80 patients analysed in the prospective controlled cohort section of the study, 51 underwent COVID-19 testing, 3.9% (2/51) were positive. Both cases were in the operative group, however in comparison to the non-operative and outpatient groups, there was no significant increase in COVID-19 incidence in operative patients. CONCLUSIONS: We found no COVID-19 related mortality during the study period. With appropriate precautions, burns patients were not exposed to an increased COVID-19 risk. Similarly, burns patients undergoing operative management were not at a significantly increased risk of contracting COVID-19 in comparison to non-operative groups.

St Andrew's COVID-19 surgery safety (StACS) study: Elective plastic surgery, trauma & burns.

INTRODUCTION: This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines. METHOD: A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group). RESULTS: Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236). CONCLUSION: We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

50 Shades of Red: The Predictive Value of Closed Suction Drains for the Detection of Postoperative Bleeding in Breast Surgery.

BACKGROUND: While closed suction drains (CSDs) are still frequently employed in clinical practice, the supporting evidence is limited with some studies demonstrating a failure of routine CSD use in preventing hematoma or seroma. Nonetheless, CSD quantity and quality fluid assessment is still appreciated by clinicians to detect postoperative bleeding. This study investigates the value of routine CSD use, in breast surgery, to predict postoperative bleeding. METHODS: A retrospective, intra-individual analysis, of CSD fluid volumes between the hematoma side and the unaffected contralateral breast, was undertaken in patients (n = 20) with unilateral postoperative bleeding following bilateral breast surgery (2003-2018). Statistical analysis was undertaken to establish a minimum cutoff fluid volume that might assist in the detection of postoperative bleeding. To determine the usefulness of quality assessment of CSD fluid output by visual inspection, surgeons (n = 56) prospectively matched six eligible hemoglobin concentrations corresponding to pre-filled CSDs. RESULTS: Statistical analysis did not yield a clinically reliable cutoff fluid volume indicating postoperative bleeding. All six eligible hemoglobin concentrations were completely successfully matched to pre-filled CSDs by 30.4% (17/56) of surgeons. CONCLUSIONS: This study questions the significance of routine CSD use to assist in the decision-making process to return to the theater and address postoperative bleeding. Quantity as well as quality analysis of CSD fluid output failed the reliability and diagnostic validity tests. Hemoglobin measurements in drain fluid specimens via blood gas analysis might contribute to the detection of postoperative bleeding. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hand trauma: A prospective observational study reporting diagnostic concordance in emergency hand trauma which supports centralised service improvements.

BACKGROUND: Hand injuries are common, contributing up to 30% of accident and emergency (A&E) attendances. The aim of this study was to prospectively analyse the pathological demographics of hand injuries in a level 1 trauma centre with a Hand Trauma Unit and direct A&E links, and compare clinical and intra-operative findings. The null hypothesis was that there would be no differences between clinical and intra-operative findings (100% diagnostic concordance). METHODS: Data were prospectively collected for referrals during 2012. Referral diagnosis, additional pathologies found on clinical assessment and intra-operative findings were documented on a live database accessible from both the Hand Unit and associated operating theatres. Odds ratios were calculated using SAS. RESULTS: Injuries (1526) were identified in 1308 patients included in the study. Diagnostic concordance between Hand Unit clinical examination and intra-operative findings was 92.5% ± 2.85% (mean ± SEM); this was lower for flexor tendon injuries (56.3%) because a greater number of additional pathologies were found intra-operatively (2.25 ± 0.10). This 'trend' was noted across multiple referral pathologies including phalangeal fractures (1.28 ± 0.02; 82.9%), lacerations (1.33 ± 0.04; 79.1%), extensor tendon injuries (1.30 ± 0.05; 87.8%) and dislocations (1.18 ± 0.05; 87.8%). Odds ratio analysis indicated a relationship between primary referral diagnoses that were more or less likely to be associated with additional injuries (p < 0.05); referral diagnoses of flexor tendon injuries and lacerations were most likely to be associated with additional injuries. CONCLUSIONS: As hand injuries are a common presentation to A&E departments, greater emphasis should be placed on training clinicians in the management of hand trauma. Our findings, coupled with the presented relevant literature reports, lead us to advocate that A&E departments should move towards a system wherein links to specialist hand trauma services are in place; we hereby present useful data for hospitals implementing such services.

The drain game: Abdominal drains for transverse rectus abdominis myocutaneous breast reconstruction.

INTRODUCTION: We recently published data for the duration of donor site drain use in latissimus dorsi and deep inferior epigastric perforator breast reconstruction, due to a reported requirement in the literature; evidence is still required for transverse rectus abdominis myocutaneous (TRAM) reconstruction. AIM: To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction abdominal drain removal by post-operative day (POD) 3 regardless of output (early group), versus after POD 3 where instructions were by drainage volume/24 h ± output consistency (late group), in post-mastectomy TRAM breast reconstruction. METHOD: A retrospective review of TRAM breast reconstructions, between June 2008-2013, was undertaken with a minimum 1 year follow-up per patient. RESULTS: Of 65 patients who underwent TRAM breast reconstruction, 56 hospital records contained complete documentation. Both the late (n = 35) and early (n = 21) drain removal group were matched for age and number of donor site drains (2 per patient). Mean drain removal day (5.34 ± 0.20 days vs. 2.67 ± 0.14 days; p < 0.0001), total drainage (797.86 ± 77.15 mls vs. 295.71 ± 29.72 mls; p < 0.0001) and hospital inpatient stay (7.46 ± 0.29 days vs. 6.09 ± 0.32 days; p = 0.003) were greater for patients in the late versus early group. There were no differences in total complications (5.71% (2/35) vs. 14.29% (3/21); p = 0.28), including seroma (2.86% (1/35) vs. 4.76% (1/21); p = 0.71) rates between the late and early groups. DISCUSSION: These data suggest significant advantages for patients who have abdominal drains removed early by POD 3, without increased post-operative complications including seroma rates; these data are in keeping with our LD data. We recommend drain removal by POD 3.

Spontaneous flexor tendon rupture due to atraumatic chronic carpal instability.

Background Spontaneous flexor tendon rupture is considered to be invariably associated with previous hand/wrist injury or systemic disease such as rheumatoid arthritis. Case Description A 54-year-old man presented with a 4-month history of mild ulnar wrist pain and spontaneous left little finger flexion loss in the absence of distant/recent trauma and systemic arthropathy. Surgical exploration confirmed a zone IV left little finger flexor digitorum profundus (FDP5) attritional rupture (100%), ring finger flexor digitorum profundus (FDP4) attenuation (40%) and a disrupted lunotriquetral ligament and volar-ulnar wrist capsule. Volar subluxation of the narrowed carpal tunnel resulted in flexor tendon attrition against the hamate hook. A side-to-side tendon transfer was performed along with a lunotriquetral ligament repair and temporary Kirschner wire fixation. At 6 months the patient had full active, synchronous flexion of the ring and little fingers and reduced wrist pain. Literature Review Traumatic flexor tendon ruptures have been reported following distal radius/hamate hook fractures, from carpal bone osteophytes, accessory carpal bones and intraosseous ganglia. Attritional ruptures caused by chronic, degenerative carpal pathology are less common. Clinical Relevance This case highlights an unusual cause of flexor tendon rupture due to chronic carpal instability.

The drain game: abdominal drains for deep inferior epigastric perforator breast reconstruction.

INTRODUCTION: The deep inferior epigastric perforator (DIEP) flap is often preferred for breast reconstruction as it allows for autologous reconstruction with less donor site morbidity versus transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. Our group has presented and published data for the duration of donor site back drain use in latissimus dorsi (LD) flap breast reconstruction due to insufficient evidence and a requirement for further investigation in the literature; this evidence is still lacking for DIEP reconstruction. AIM: To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction abdominal drain removal by post-operative day (POD) 3 regardless of output (early group), with removal after POD 3 where instructions were by drainage volume/24 h±output consistency (late group), in post-mastectomy DIEP reconstruction donor sites. METHOD: A retrospective review of DIEP breast reconstructions, between January 2011 and July 2012, was undertaken to facilitate 1 year minimum follow-up per patient. RESULTS: Of 78 patients who underwent DIEP breast reconstructions, 74 hospital records contained complete documentation. There were 41 patients in the late, and 33 in the early removal group; both groups were matched for age and number of donor site drains (2 per patient). Mean drain removal day (4.32±0.10 days vs. 2.87±0.06 days, p<0.0001), total drainage (518.90±41.53 mls vs. 283.79±18.06 mls; p<0.0001) and hospital inpatient stay were greater for patients in the late versus early group. There were no differences in total complications (21.95% (9/41) vs. 12.12% (5/33); p=0.46), seroma (4.88% (2/41) vs. 0% (0/33); p=0.20), dehiscence (4.88% (2/41) vs. 9.09% (3/33); p=0.47) or haematoma (7.32% (3/41) vs. 3.0% (1/33); p=0.42) rates between the late and early groups. DISCUSSION: These data suggest significant advantages for patients who have abdominal drains removed early by POD 3, without increased post-operative complications including seroma rates; these data are in keeping with our LD data. We recommend drain removal and patient discharge by POD 3.

The drain game: back drains for latissimus dorsi breast reconstruction.

INTRODUCTION: The pedicled latissimus dorsi myocutaneous (LD) flap is a popular breast reconstruction choice, representing approximately 50% of procedures undertaken in the UK. Donor site drain use may reduce complication rates, however no evidence exists regarding the duration of back drain use for LD flap breast reconstruction and calls have been made in the literature to investigate this further. AIM: To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction back drain removal by post-operative day (POD) 3 regardless of output (early group), with removal after POD 3 where instructions were documented by drainage volume/24 h ± output consistency (late group), in post-mastectomy LD reconstruction donor sites. METHOD: A retrospective review of LD breast reconstruction procedures, performed between January 2010 and July 2011, was undertaken to ensure 1 year minimum follow-up per patient. RESULTS: There were 81 patients who underwent unilateral LD breast reconstructions; 78 hospital records contained complete documentation. There were 48 patients in the late removal group and 30 patients in the early removal group. The mean drain removal day (5.42 ± 0.17 days vs. 2.87 ± 0.06 days, p < 0.001), total drainage (907.71 ± 76.07 ml vs. 492.67 ± 35.15 ml, p < 0.0001) and hospital inpatient stay (4.60 ± 0.19 days vs. 3.63 ± 0.17 days, p < 0.001) were greater for patients in the late group, versus the early group. There were no differences in total complications (16.67%(8/48) vs. 10%(3/30), p = 0.41), seroma (6.25%(3/48) vs. 6.67%(2/30), p = 0.94), dehiscence (4.17%(2/48) vs. 3.33%(1/30), p = 0.85) or haematoma rates (10.42%(5/48) vs. 0%(0/30), p = 0.07) between patients in the late and early groups; seroma sub-analysis also indicated no differences in number of seroma aspirations, duration of drainage (months) and mean total drainage (ml) prior to resolution. DISCUSSION: These data suggest significant advantages for patients who have back drains removed by POD 3, without increased post-operative complications including seroma rates, and we recommend drain removal and patient discharge by POD 3.

Tendon 'turnover lengthening' technique.

Tendon defect reconstruction is amongst the most technically challenging areas in hand surgery. Tendon substance deficiency reconstruction techniques include lengthening, grafting, two-stage reconstruction and tendon transfers, however each is associated with unique challenges over and above direct repair. We describe a novel 'turnover lengthening' technique for hand tendons that has successfully been applied to the repair of several cases, including a case of attritional flexor and traumatic extensor tendon rupture in two presented patients where primary tenorrhaphy was not possible. In both cases a good post-operative outcome was achieved, as the patients were happy having returned back to normal activities of daily living such that they were discharged 12 weeks post-operatively. Our technique avoids the additional morbidity and complications associated with grafting, transfers and two stage reconstructions. It is quick, simple and reproducible for defects not exceeding 3-4 cm, provides a means of immediate one stage reconstruction, no secondary donor site morbidity and does not compromise salvage by tendon transfer and/or two-stage reconstruction in cases of failure. To our knowledge no such technique has been previously been described to reconstruct such hand tendon defects.