Pharmacological interventions for early-stage frozen shoulder: a systematic review and network meta-analysis.

OBJECTIVES: To evaluate the efficacy of pharmacological interventions for treating early-stage, pain predominant, adhesive capsulitis, also known as frozen shoulder. METHODS: We performed a systematic review in accordance with PRSIMA guidelines. Searches were conducted on PUBMED, EMBASE and Cochrane Central Register of Controlled Trials on the 24th of February 2022. Outcomes were shoulder pain, shoulder function and range of movement. Synthesis involved both qualitative analysis for all studies and pairwise meta-analyses followed by a network meta-analysis for randomised controlled trials (RCTs). RESULTS: A total of 3,252 articles were found, of which 31 met inclusion criteria, and 22 of these were RCTs. Intraarticular (IA) injection of corticosteroids (8 RCTS, 340 participants) and IA injection of platelet-rich plasma (PRP) (3 RCTs, 177 participants) showed benefit at 12 weeks compared with physical therapy in terms of shoulder pain and function, while oral non-steroidal anti-inflammatories (NSAIDs) (2 RCTs, 44 participants) and IA injection of hyaluronate (2 RCTs, 42 participants) did not show a benefit. Only IA PRP showed benefit over physical therapy for shoulder range of movement. CONCLUSION: These results shows that IA corticosteroids IA PRP injections are beneficial for early-stage frozen shoulder. These findings should be appraised with care considering the risk of bias, heterogeneity, and inconsistency of the included studies. We believe that research focused on early interventions for frozen shoulder could improve patient outcomes and lead to cost-savings derived from avoiding long-term disability. Further well-designed studies comparing with standardised physical therapy or placebo are required to improve evidence to guide management.

Clinical characteristics and treatment outcomes of angiosarcoma of the head and neck: A 17-year single-centre experience.

INTRODUCTION: Angiosarcomas in the head and neck region are aggressive tumours associated with high local recurrence and metastatic rates. We present our 17-year experience at the North of England Bone and Soft Tissue Tumour Service. METHODS: A retrospective review of our prospectively maintained database was undertaken, looking for patients diagnosed with angiosarcomas affecting the head and neck. Data were gathered using a pre-defined proforma to include demographics, histological characteristics, treatment modalities, adjuvant therapies, local recurrence, distant spread, and disease-specific survival. RESULTS: A total of 23 patients (17 males, 6 females) were identified, with a mean age of 76 years at presentation. Fourteen presented with scalp lesions, whereas the remainder arose on the face. Eighteen patients underwent resection with curative intent, whereas three received palliative radiotherapy and two received comfort-based care only. Of the patients undergoing surgery, 12 had local flap reconstruction and 6 underwent free tissue transfer. Clear resection margins were obtained in nine cases (50%). Fourteen patients (78%) presented with local recurrence after surgery, and 11 (61%) developed distant metastases. The median disease-specific survival time for patients treated with curative intent was 38 months. Eight patients had mapping biopsies ahead of their resection; however, complete resection was achieved in only two cases. DISCUSSION: Angiosarcomas of the head and neck are associated with a poor prognosis, with most patients rapidly developing local recurrence, resulting in adverse clinical outcomes. Mapping biopsies do not demonstrate a clear advantage for achieving complete surgical resection. A radical surgical approach is warranted, given the aggressiveness of the pathology. However, there remains no consensus on optimal surgical management; we recommend further synthesising studies to determine the most appropriate treatment pathway.

Lymphedema-associated fibroblasts are a TGF-ß1 activated myofibroblast subpopulation related to fibrosis and stage progression in patients and a murine microsurgical model.

BACKGROUND: The driver of secondary lymphedema (SL) progression is chronic inflammation, which promotes fibrosis. Despite advances in preclinical research, a specific effector cell subpopulation as a biomarker for therapy response or stage progression is still missing for SL. METHODS: Whole skin samples of 35 murine subjects of a microsurgical-induced SL model and 12 patients with SL were collected and their fibroblasts were isolated. These lymphedema-derived fibroblasts (LAF) were cultured in a collagen I-poly-D-Lysine 3D hydrogel to mimic skin conditions. Fibroblasts from non-lymphedema skin were used as negative control and TGF-ß-stimulated fibroblasts were used to recreate profibrotic myofibroblasts. Quantitative immunocytofluorescence confocal microscopy analysis and invasion functional assays were performed in all subpopulations and statistically compared. RESULTS: In contrast to normal skin fibroblasts, LAF exhibit α-SMA-positive stress fibers and a reduced number of tight junctions in 3D hydrogel conditions. The switch from normal E-cadherin high phenotype to an N-cadherin high-E-cadherin low morphology suggests epithelial to mesenchymal transition for expansion and proliferation. This pathological behavior of LAF was confirmed by live cell imaging analysis of invasion assays. The significant activation of markers of the TGFBR2-Smad pathway and collagen synthesis (HSP-47) in LAF supports EMT phenotypic changes and previous findings relating to TGF-ß1 and fibrosis with lymphedema. CONCLUSIONS: A characteristic SL myofibroblast subpopulation was identified and translationally related to fibrosis and TGF-ß1-associated stage progression. This SL-related subpopulation was termed lymphedema-associated fibroblasts. A comprehensive stage-related characterization is required to validate LAF as a reliable biomarker for SL disease progression.

Beyond Borders: A Global Microsurgery Training and Case Exposure Survey.

BACKGROUND: Microsurgery is essential in modern reconstructive surgery and plastic surgery training. Surgeon's proficiency and experience are crucial for effective microsurgical interventions. Despite anecdotal evidence of varying quality of microsurgery training globally, no empirical studies have investigated this. We conducted a global survey to investigate microsurgical training and clinical case exposure among plastic surgery trainees worldwide. METHODS: An online survey was conducted using a secure platform to gather information on microsurgical case exposure and training among plastic surgery trainees between August 2020 and April 2021. Participants provided consent and completed a 37-question survey across four themes: clinical caseload, surgical exposure to microsurgery, microsurgical simulation training exposure, and barriers and opportunities. RESULTS: A total of 202 responses were received, with most respondents in formal training programs (86.7%). The data highlighted regional variation in microsurgery case indications and flap types, with North America and Europe exhibiting the highest activity levels in microsurgery. Trainees in Asia have the highest cumulative practical exposure in microsurgery, followed by Australia and Oceania, and North America. Only 39.6% of respondents reported formal microsurgical simulation training, and almost one-third (29.7%) received no simulation training. Trainee access to practical experience is limited by several factors, including insufficient time and procedure complexity. Notably, practical experience was most commonly denied without reason being given. CONCLUSION: Our study highlights significant disparities in microsurgical training and exposure among plastic surgery trainees globally. Further research is needed to identify strategies for addressing these issues, given the growing demand for complex reconstructive microsurgery and its impact on health care inequalities.

Adverse Events Associated with Hyaluronic Acid Filler Injection for Non-surgical Facial Aesthetics: A Systematic Review of High Level of Evidence Studies.

BACKGROUND: Hyaluronic acid (HA) dermal fillers are widely used in aesthetic medicine. While generally safe, potential complications can arise. OBJECTIVE: This systematic review aims to identify and classify potential complications linked to the use of HA dermal fillers, as informed by high-quality, low-risk-of-bias studies. METHODS: This review follows the Cochrane review standards for clinical systematic reviews. This systematic review analyzed 48 high level of evidence studies on the use of hyaluronic acid (HA) dermal fillers in non-surgical facial aesthetics and the adverse events that occurred.The inclusion criteria were randomized control studies on HA dermal fillers and their complications. Excluded were case reports, case series, observational studies, and other non-randomized research due to their inability to provide generalized conclusions and their inherent publication bias. RESULTS: Adverse events were classified into three categories: expected reactions, product or technique-related adverse events, and severe adverse events. Most adverse events were short-lived injection site reactions, which resolved spontaneously. Specific HA fillers and injection techniques influenced the occurrence of adverse events, which generally resolved within weeks without treatment. Severe adverse events were rare, persisting for months and requiring active medical intervention. DISCUSSION: This classification system can enhance understanding, prevention, and treatment of HA filler complications, and support patient education. The common complications were injection site reactions, with persistent symptoms treated with topical steroids, NSAIDs, or hyaluronidase. Severe complications included severe edema, angioedema and others, often necessitating specific treatments. CONCLUSION: HA dermal fillers are generally safe and effective, with most adverse events being transient and mild to moderate in severity. Severe adverse events, although rare, do occur and are generally non-treatment related. Informed consent, patient education, and professional training are crucial for safe and successful outcomes. Level of Evidence II 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 .

'Thou shalt not throw away a living thing': A single-centre 10-year experience using the spare parts principle for complex sarcoma reconstruction.

INTRODUCTION: For aggressive limb sarcomas beyond reconstructive reach, an amputation may be the only alternative to achieve a complete tumour resection. However, very proximal amputations result in greater loss of function and quality-of-life impact. The spare parts principle advocates utilising tissues distal to the amputation site, for reconstructing complex defects and preserving the function. We aim to present our 10-year experience utilising this principle in complex sarcoma surgery. METHODS: A retrospective review of our prospective sarcoma database was conducted for sarcoma patients treated with an amputation between 2012 and 2022. Cases in which distal segments were used for the reconstruction were identified. Demographic data, tumour characteristics, and surgical and non-surgical treatment, along with oncological outcomes and complications, were recorded and analysed. RESULTS: Fourteen patients were eligible for inclusion. The median age was 54 years at presentation (8-80 years) with 43% being females. Nine had a primary sarcoma resection, two were treated for recurrent tumours, two presented intractable osteomyelitis following sarcoma treatment and one had an amputation as a palliative procedure. The latter was the only oncological case in which tumour clearance was not achieved. Three patients developed metastasis and subsequently died during follow-up. DISCUSSION: Careful balancing of oncological goals and preservation of function is required for proximal limb-threatening sarcomas. When an amputation is required, tissues distal to the cancer site provide a safe reconstructive alternative, optimising patient recovery and preserving function. Our experience is limited by the small number of cases presenting with these rare and aggressive tumours.

Standardising the management of open extremity fractures: a scoping review of national guidelines.

INTRODUCTION: Open extremity fractures can be life-changing events. Clinical guidelines on the management of these injuries aim to standardise the care of patients by presenting evidence-based recommendations. We performed a scoping systematic review to identify all national clinical practice guidelines published to date. MATERIALS AND METHODS: A PRISMA-compliant scoping systematic review was designed to identify all national or federal guidelines for the management of open fractures, with no limitations for language or publication date. EMBASE and MEDLINE database were searched. Article screening and full-text review was performed in a blinded fashion in parallel by two authors. RESULTS: Following elimination of duplicates, 376 individual publications were identified and reviewed. In total, 12 clinical guidelines were identified, authored by groups in the UK, USA, the Netherlands, Finland, and Malawi. Two of these focused exclusively on antibiotic prophylaxis and one on combat-related injuries, with the remaining nine presented wide-scope recommendations with significant content overlap. DISCUSSION: Clinical practice guidelines serve clinicians in providing evidence-based and cost-effective care. We only identified one open fractures guideline developed in a low- or middle-income country, from Malawi. Even though the development of these guidelines can be time and resource intensive, the benefits may outweigh the costs by standardising the care offered to patients in different healthcare settings. International collaboration may be an alternative for adapting guidelines to match local resources and healthcare systems for use across national borders.

One-stop autologous breast reconstruction: A safe and effective cost-saving pathway.

INTRODUCTION: Patients undergoing autologous breast reconstruction usually require further operations as part of their reconstructive journey. This involves contralateral breast symmetrization and nipple-areola complex (NAC) reconstruction. Restrained access to elective operating space led us to implement a one-stop breast reconstruction pathway. METHODS: Patients undergoing contemporaneous contralateral breast symmetrization and immediate NAC reconstruction with free nipple grafts between July 2020 and June 2021 were identified. A retrospective review of our prospectively maintained database was conducted, to retrieve surgical notes, postoperative complications, and length of inpatient stay. A cost analysis was performed considering savings from contralateral symmetrization. RESULTS: A total of 50 eligible cases were identified, which had unilateral one-stop breast reconstructions. Complication rates and length of stay were not affected by this approach, with only one free flap being lost for this cohort. This approach resulted in £181,000 being saved for our service over a calendar year. DISCUSSION: A one-stop breast reconstruction pathway has proven to be safe and effective in our unit. During these uncertain times, it has streamlined the management of eligible patients, while releasing capacity for other elective operations. Patients avoid having to wait for secondary procedures, finishing their reconstructive pathway earlier. We plan to continue providing this service which has shown to be beneficial clinically and financially.

Plastic Surgery Training across Seven Continents: Results from the First Global Trainee Survey.

Little is known about the demographics and ambitions of plastic surgery trainees and if these differ between regions. This study sought opinion from current and recently graduated plastic surgery trainees to map demographics, training structure, and ambitions of plastic surgery trainees worldwide. Methods: A cross-sectional study was designed and administered by the international trainee organization International Confederation of Societies of Plastic Surgery Trainees. A questionnaire of 45 questions was distributed digitally through several international channels using the REDCap platform. Results: A total of 290 junior plastic surgeons, of whom 124 (42.8%) were women, from all seven International Confederation of Societies of Plastic Surgery regions, participated in this study. Of the trainees, 21% have emigrated, and 75% expressed a desire to undertake a part of their training abroad. The most common length of training in plastic surgery is 5 years. There is a difference in working hours between regions, where more than 80-hour work weeks are most common in Asia (24.1%), and work weeks of less than 40 hours are most common in Middle East (30.8%). A majority of trainees (85%) reported a research interest, and we found a negative correlation between the extent of research ambition and reported clinical workload. Conclusions: We present here the first international investigation of trainee experiences of plastic surgery training. We show that training structure and organization vary between institutions, and that plastic surgery trainees report a strong interest in international training as well as in research.

Augmented Reality-Assisted Design of Local Flaps: A New Practical and Educational Tool in the Field of Plastic Surgery.

ABSTRACT: Augmented reality (AR) is a new and promising technology that has been incorporated into several aspects of our everyday life, including surgery. Examples of its application throughout various fields of surgery, although most of them are in experimental stage, have already been demonstrated and published. In this article, we describe the utilization of AR to design effectively and accurately surgical flap markings just with the help of an AR-compatible mobile phone and a low-cost application. We believe that, due to its ease of use, AR will play a pivotal role to the education and the training in the field of plastic surgery and burns, and other surgical specialties alike.

Watch One, Do One? A Systematic Review and Educational Analysis of YouTube Microsurgery Videos, and a Proposal for a Quality Assurance Checklist.

Background Educational resources on the internet are extensively used to obtain medical information. YouTube is the most accessed video platform containing information to enhance the learning experience of medical professionals. This study systematically analyzed the educational value of microsurgery-related videos on this platform. Methods A systematic review was conducted on YouTube from April 18 to May 18, 2020, using the following terms: "microsurgery," "microsurgical," "microsurgical anastomosis," "free flap," and "free tissue transfer." The search was limited to the first 100 videos, and two independent reviewers screened for eligible entries and analyzed their educational value using validated scales, including a modified version of the DISCERN score (M-DISCERN), Journal of the American Medical Association (JAMAS) benchmark criteria, and the Global Quality Score (GQS). Evaluation of video popularity was also assessed with the video power index (VPI). Results Of 356 retrieved videos, 75 (21%) were considered eligible. The educational quality of videos was highly variable, and the mean global scores for the M-DISCERN, JAMAS, and GQS for our sample were consistent with medium to low quality. Conclusions A limited number of videos on YouTube for microsurgical education have high-educational quality. The majority scored low on the utilized criteria. Peer-reviewed resources seem to be a more reliable resource. Although the potential of YouTube should not be disregarded, videos should be carefully appraised before being used as an educational resource.

Descriptive Study of Facial Motor Cocontractions During Voluntary Facial Movement in a Healthy Population: A New Hypothesis Contributing to Synkinesis.

Background: Motor overflow refers to involuntary movements that accompany voluntary movements in healthy individuals. This may have a role in synkinesis. Objective: To describe the frequency and magnitude of facial motor overflow in a healthy population. Methodology: Healthy participants performed unilateral facial movements: brow elevation, wink, snarl, and closed smile. Two reviewers analyzed the magnitude of each movement and cocontraction. Patterns of movements are described. Univariate analysis was used to assess the relationship between efficacy of unilateral facial control and the frequency and magnitude of cocontractions. Results: Eighty-nine participants completed the videos. Consensual mirror movements occurred in 96% of participants during unilateral eye closure and 86% during brow elevation. The most common associated movement was ipsilateral eye constriction occurring during snarl (90.1%). Improved unilateral facial control was associated with a decrease in frequency and magnitude of associated movements during brow elevation, wink, and snarl. Conclusion: This study showed stereotyped patterns of motor overflow in facial muscles that resemble those in synkinesis and become more evident as unilateral control of the face decreases.

Outcomes of the Pedicled Medial Sural Artery Perforator Flap for Soft Tissue Reconstruction Around the Knee: When to Use It and How to Look After It.

Introduction The medial gastrocnemius flap is an established workhorse flap to cover proximal leg defects due to its reliability and simplicity to raise. However, it has the disadvantage of being bulky, requiring a skin graft for coverage, and is associated with loss of muscle power. The pedicled medial sural artery perforator (MSAP) flap has gained popularity as a reconstructive alternative for defects of the lower extremities. We present a case series of pedicled MSAP flaps for reconstructing defects around the knee as an alternative to the medial gastrocnemius flap. Materials and Methods A consecutive series of patients with proximal leg defects following trauma, osteomyelitis, burns, and chronic wounds were included. A hand-held Doppler was used to map out the MSAPs. Defects were reconstructed using pedicled MSAP flaps, preserving the nerve supply to the gastrocnemius muscle. Patient outcomes were recorded, including their Enneking scores postreconstruction. Results A total of 10 pedicled flaps was performed to reconstruct defects around the knee joint between October 2017 and November 2018. All the patients were discharged 1 week postoperatively, and rehabilitation consisted of graduated flexion in a knee brace by means of controlled passive mobilization. Three out of the ten patients developed complications: one patient developed flap congestion, one developed epidermolysis of the tip of the flap, and the other patient had partial necrosis of the skin paddle. The average Enneking score was 29 out of 35. Conclusion The pedicled MSAP flap is a good reconstructive option for proximal leg defects as it is associated with lower donor site morbidity and provides an aesthetically pleasing reconstruction.

Supermicrosurgical treatment for lymphedema: a systematic review and network meta-analysis protocol.

BACKGROUND: Lymphedema is a condition that affects up to 130 million subjects worldwide. Since it is related to several complications and a significant reduction in terms of quality of life, it is a heavy burden not only to the patients but also for the healthcare system worldwide. Despite the development of supermicrosurgery, such as vascularized lymph node transfer (VLNT) and lymphovenous anastomosis LVA, the indications and outcomes of these complex groups of interventions remain a controversial topic in the field of reconstructive plastic surgery. METHODS: This systematic review and network meta-analysis aims to assess the evidence of outcomes of LVA and VLNT in patients with lymphedema. Secondary aims of the project are to determine if for any outcomes, LVA or VLNT is superior to conservative therapy alone, and whether the available evidence favors any kind of supermicrosurgical interventions for lymphedema patients. This study will include original studies of patients with lymphedema on the extremities indexed in PubMed, EMBASE, CENTRAL, PASCAL, FRANCIS, ISTEX, LILACS, CNKI, and IndMED that reported microsurgery (supermicrosurgery) of all techniques aiming the re-functionalization of the lymphatic system. As comparators, mere observation, conservative treatment of any kind, and the other subgroups of supermicrosurgery are planned. The primary outcome of this systematic review and network meta-analysis is the difference of the limb volume, while the secondary outcomes of interest will be erysipelas rates, major and minor complications, postoperative necessity of continuous compression garments, and patient satisfaction, measured by already published and validated scores for quality of life. DISCUSSION: We will provide an overview and evidence grade analysis of the scientific literature available on the effectiveness of the subcategories of supermicrosurgical interventions for lymphedema.

Reconstruction of Digital Defects with the Free Proximal Ulnar Artery Perforator Flap.

The aim of post-traumatic digital reconstruction is to restore form and function, allowing early rehabilitation. In the absence of feasible local options, free tissue transfer can be a versatile and reliable alternative. The aim of this study was to describe our experience with the use of the free proximal ulnar artery perforator flap (PUPF). METHODS: Our prospectively maintained free flap database was inquired for patients that had undergone digital reconstructions with free PUPFs. RESULTS: Six patients that underwent digital reconstruction were eligible. The ipsilateral forearm was donor site of choice, with all flaps based on a perforator of the ulnar artery, without the need to compromise the main vessel. A superficial vein was routinely included with the flap. No flap failures were encountered. Mean hospital stay was 5.5 days, and all patients achieved a satisfactory functional result. CONCLUSIONS: The proximal ulnar perforator free flap offers an alternative for finger reconstruction, having the advantage of including thin and hairless skin from the proximal ulnar forearm. The vascular anatomy of the ulnar perforators seems to be constant. Furthermore, donor site morbidity is low, as the ulnar artery is not harvested with the flap, the donor site defect can generally be closed directly, and the scar is well concealed.