Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) protocol.

Aims: Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods: This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion: The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication.

Updates in diagnostic tools for diagnosing nerve injury and compressions.

Predicting prognosis after nerve injury and compression can be challenging, even for the experienced clinician. Although thorough clinical assessment can aid diagnosis, we cannot always be precise about long-term functional recovery of either motor or sensory nerves. To evaluate the severity of nerve injury, surgical exploration remains the gold standard, particularly after iatrogenic injury and major nerve injury from trauma, such as brachial plexus injury. Recently, advances in imaging techniques (ultrasound, magnetic resonance imaging [MRI] and MR neurography) along with multimodality assessment, including electrodiagnostic testing, have allowed us to have a better preoperative understanding of nerve continuity and prediction of nerve health and possible recovery. This article outlines the current and potential roles for clinical assessment, exploratory surgery, electrodiagnostic testing ultrasound and MRI in entrapment neuropathies, inflammatory neuritis and trauma. Emphasis is placed on those modalities that are improving in diagnostic accuracy of nerve assessment before any surgical intervention.

Comparison of distortion correction preprocessing pipelines for DTI in the upper limb.

PURPOSE: DTI characterizes tissue microstructure and provides proxy measures of nerve health. Echo-planar imaging is a popular method of acquiring DTI but is susceptible to various artifacts (e.g., susceptibility, motion, and eddy currents), which may be ameliorated via preprocessing. There are many pipelines available but limited data comparing their performance, which provides the rationale for this study. METHODS: DTI was acquired from the upper limb of heathy volunteers at 3T in blip-up and blip-down directions. Data were independently corrected using (i) FSL's TOPUP & eddy, (ii) FSL's TOPUP, (iii) DSI Studio, and (iv) TORTOISE. DTI metrics were extracted from the median, radial, and ulnar nerves and compared (between pipelines) using mixed-effects linear regression. The geometric similarity of corrected b = 0 images and the slice matched T1-weighted (T1w) images were computed using the Sörenson-Dice coefficient. RESULTS: Without preprocessing, the similarity coefficient of the blip-up and blip-down datasets to the T1w was 0·80 and 0·79, respectively. Preprocessing improved the geometric similarity by 1% with no difference between pipelines. Compared to TOPUP & eddy, DSI Studio and TORTOISE generated 2% and 6% lower estimates of fractional anisotropy, and 6% and 13% higher estimates of radial diffusivity, respectively. Estimates of anisotropy from TOPUP & eddy versus TOPUP were not different but TOPUP reduced radial diffusivity by 3%. The agreement of DTI metrics between pipelines was poor. CONCLUSIONS: Preprocessing DTI from the upper limb improves geometric similarity but the choice of the pipeline introduces clinically important variability in diffusion parameter estimates from peripheral nerves.

Surgical site infection following surgery for hand trauma: a systematic review and meta-analysis.

Surgical site infection is the most common healthcare-associated infection. Surgical site infection after surgery for hand trauma is associated with increased antibiotic prescribing, re-operation, hospital readmission and delayed rehabilitation, and in severe cases may lead to amputation. As the risk of surgical site infection after surgery for hand trauma remains unclear, we performed a systematic review and meta-analysis of all primary studies of hand trauma surgery, including randomized controlled trials, cohort studies, case-control studies and case series. A total of 8836 abstracts were screened, and 201 full studies with 315,618 patients included. The meta-analysis showed a 10% risk of surgical site infection in randomized control trials, with an overall risk of 5% when all studies were included. These summary statistics can be used clinically for informed consent and shared decision making, and for power calculations for future clinical trials of antimicrobial interventions in hand trauma.

The management of partial extensor tendon lacerations of the hand and forearm: A systematic review.

Injuries to the extensor mechanism of the hand and forearm are common and cause significant functional disability. Complete tendon lacerations are managed with surgical repair, whereas selected partial tendon injuries may be managed without repair but with splinting and physiotherapy alone. There is limited evidence to support the management of partial lacerations, in particular the decision of whether to repair or not. We aimed to systematically review the literature to determine the optimal management of partial extensor tendon lacerations in the hand and forearm. A protocol for the systematic review was developed prospectively and registered with PROSPERO (CRD42021250431). PubMed, EMBASE, clinicaltrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 1990 to 27/05/2022. 4565 studies were screened, of which 88 underwent full text review. Five studies were included, one randomised control trial and four cohort studies. One study examined outcomes of partial lacerations treated without repair; the other four studies examined outcomes following repair. Pinch and grip strength and time to return to work were similar regardless of management. Adverse outcomes were reported for patients undergoing surgical repair; none were observed in those managed without repair. Meta-analysis was precluded by study heterogeneity and high risk of bias. There is limited evidence to support the management of partial extensor tendon lacerations, with some low-quality evidence that non-operative management of selected partial lacerations is safe. There is a pressing need for pragmatic, multicentre randomised trials to assess the cost-effectiveness of current treatments.

RSTN COVID Hand: Hand trauma in the United Kingdom and Europe during the COVID-19 pandemic.

The COVID-19 pandemic rapidly impacted the delivery of hand surgery services throughout the UK and Europe; from triage to treatment. Our aim was to assess the impact on management of common hand trauma injuries to inform future service delivery and research. The Reconstructive Surgery Trials Network led a service evaluation during the first wave of COVID-19 in 2020. Data was collected on hand injury management during the COVID-19 pandemic and was compared to the management clinicians would have delivered prior. Across 35 hand surgery units, 2540 patients with hand trauma were included. There was an increase of between 3% and 7% in non-operative management of injuries, apart from flexor tendon injuries where management remained unchanged. Cases triaged by a consultant doubled, with a 22% increase in the see-and-treat model. There was a move to operating in low-resource settings; a 13% increase in the use of minor operating theatres and 10% in clinic rooms. Use of WALANT, absorbable sutures, and remote follow-up also increased by 16%, 24%, and between 11% and 25%, respectively. The reported 30-day complication rate was 3.2%, with a surgical site infection rate of 1.8%. The pandemic led to rapid change in many aspects of hand trauma care. It was the impetus for increased out-of-theatre operating, use of local anaesthetic, and more non-operative management of injuries, without an increase in complication rate. Further research needs to assess the clinical and cost-effectiveness of these changes to ensure that COVID-19 is a catalyst for a modern, evidence-based, and environmentally sustainable delivery of hand trauma services.

Median Nerve Palsy in Pediatric Supracondylar Humerus Fractures Recovers Faster With Open Than Closed Reduction.

BACKGROUND: Management of supracondylar humerus fractures (SCHF) with coexisting median nerve injury is controversial. Although many nerve injuries improve with the reduction and stabilization of the fracture, the speed and completeness of recovery are unclear. This study investigates median nerve recovery time using the serial examination. METHODS: A prospectively maintained database of SCHF-related nerve injuries referred to a tertiary hand therapy unit between 2017 and 2021 was interrogated. Factors related to the injury (vascularity, Gartland grade, open vs. closed fracture) and treatment (fixation modality, adequacy, timing of reduction, vascular and nerve intervention, and secondary procedures) were assessed.Primary outcomes were the motor recovery of Medical Research Council (MRC) grade 4 or 5 in flexor pollicis longus or flexor digitorum profundus (index) and detection of the 2.83 Semmes Weinstein monofilament.A retrospective clinical note review of all SCHF presenting during the same period was also conducted. RESULTS: Of 1096 SCHF, 74 (7%) had an associated median nerve palsy. Twenty-one patients [mean age 7 years (SD 1.6)] with SCHF-related median nerve injuries underwent serial examination. Nineteen (90%) were modified Gartland III or IV, and 10 (48%) were pulseless on presentation. The mean follow-up was 324 days.The mean motor recovery time was 120 days (SD 71). Four (27%) and 2 (13%) patients had not achieved MRC grade 4 by 6 months and 2 years, respectively. Only 50% attained MRC grade 5 at 2 years.When compared with closed reduction, those who underwent open reduction recovered motor function 80 days faster (mean 71 vs. 151 d, P =0.03) and sensory function 110 days faster (52 vs. 162, P =0.02). Fewer patients recovered after closed reduction (8 of 10) than open (5 of 5).Modified Gartland grade, vascular status, adequacy of reduction, and secondary surgery were not associated with recovery time. CONCLUSIONS: Median nerve recovery seems to occur slower than previously thought, is often incomplete, and is affected by treatment decisions (open vs. closed reduction). Retrospective reporting methods may overestimate median nerve recovery. LEVEL OF EVIDENCE: Level III-therapeutic.

Meta-analysis of the normal diffusion tensor imaging values of the peripheral nerves in the upper limb.

Peripheral neuropathy affects 1 in 10 adults over the age of 40 years. Given the absence of a reliable diagnostic test for peripheral neuropathy, there has been a surge of research into diffusion tensor imaging (DTI) because it characterises nerve microstructure and provides reproducible proxy measures of myelination, axon diameter, fibre density and organisation. Before researchers and clinicians can reliably use diffusion tensor imaging to assess the 'health' of the major nerves of the upper limb, we must understand the "normal" range of values and how they vary with experimental conditions. We searched PubMed, Embase, medRxiv and bioRxiv for studies which reported the findings of DTI of the upper limb in healthy adults. Four review authors independently triple extracted data. Using the meta suite of Stata 17, we estimated the normal fractional anisotropy (FA) and diffusivity (mean, MD; radial, RD; axial AD) values of the median, radial and ulnar nerve in the arm, elbow and forearm. Using meta-regression, we explored how DTI metrics varied with age and experimental conditions. We included 20 studies reporting data from 391 limbs, belonging to 346 adults (189 males and 154 females, ~ 1.2 M:1F) of mean age 34 years (median 31, range 20-80). In the arm, there was no difference in the FA (pooled mean 0.59 mm2/s [95% CI 0.57, 0.62]; I2 98%) or MD (pooled mean 1.13 × 10-3 mm2/s [95% CI 1.08, 1.18]; I2 99%) of the median, radial and ulnar nerves. Around the elbow, the ulnar nerve had a 12% lower FA than the median and radial nerves (95% CI - 0.25, 0.00) and significantly higher MD, RD and AD. In the forearm, the FA (pooled mean 0.55 [95% CI 0.59, 0.64]; I2 96%) and MD (pooled mean 1.03 × 10-3 mm2/s [95% CI 0.94, 1.12]; I2 99%) of the three nerves were similar. Multivariable meta regression showed that the b-value, TE, TR, spatial resolution and age of the subject were clinically important moderators of DTI parameters in peripheral nerves. We show that subject age, as well as the b-value, TE, TR and spatial resolution are important moderators of DTI metrics from healthy nerves in the adult upper limb. The normal ranges shown here may inform future clinical and research studies.

Image analysis of cutaneous melanoma histology: a systematic review and meta-analysis.

The current subjective histopathological assessment of cutaneous melanoma is challenging. The application of image analysis algorithms to histological images may facilitate improvements in workflow and prognostication. To date, several individual algorithms applied to melanoma histological images have been reported with variations in approach and reported accuracies. Histological digital images can be created using a camera mounted on a light microscope, or through whole slide image (WSI) generation using a whole slide scanner. Before any such tool could be integrated into clinical workflow, the accuracy of the technology should be carefully evaluated and summarised. Therefore, the objective of this review was to evaluate the accuracy of existing image analysis algorithms applied to digital histological images of cutaneous melanoma. Database searching of PubMed and Embase from inception to 11th March 2022 was conducted alongside citation checking and examining reports from organisations. All studies reporting accuracy of any image analysis applied to histological images of cutaneous melanoma, were included. The reference standard was any histological assessment of haematoxylin and eosin-stained slides and/or immunohistochemical staining. Citations were independently deduplicated and screened by two review authors and disagreements were resolved through discussion. The data was extracted concerning study demographics; type of image analysis; type of reference standard; conditions included and test statistics to construct 2 × 2 tables. Data was extracted in accordance with our protocol and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Diagnostic Test Accuracy (PRISMA-DTA) Statement. A bivariate random-effects meta-analysis was used to estimate summary sensitivities and specificities with 95% confidence intervals (CI). Assessment of methodological quality was conducted using a tailored version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The primary outcome was the pooled sensitivity and specificity of image analysis applied to cutaneous melanoma histological images. Sixteen studies were included in the systematic review, representing 4,888 specimens. Six studies were included in the meta-analysis. The mean sensitivity and specificity of automated image analysis algorithms applied to melanoma histological images was 90% (CI 82%, 95%) and 92% (CI 79%, 97%), respectively. Based on limited and heterogeneous data, image analysis appears to offer high accuracy when applied to histological images of cutaneous melanoma. However, given the early exploratory nature of these studies, further development work is necessary to improve their performance.

International, prospective cohort study comparing non-absorbable versus absorbable sutures for skin surgery: CANVAS service evaluation.

BACKGROUND: Absorbable or non-absorbable sutures can be used for superficial skin closure following excisional skin surgery. There is no consensus among clinicians nor high-quality evidence supporting the choice of suture. The aim of the present study was to determine current suture use and complications at 30 days after excisional skin surgery. METHODS: An international, prospective service evaluation of adults undergoing excision of skin lesions (benign and malignant) in primary and secondary care was conducted from 1 September 2020 to 15 April 2021. Routine patient data collected by UK and Australasian collaborator networks were uploaded to REDCap©. Choice of suture and risk of complications were modelled using multivariable logistic regression. RESULTS: Some 3494 patients (4066 excisions) were included; 3246 (92.9 per cent) were from the UK and Ireland. Most patients were men (1945, 55.7 per cent), Caucasian (2849, 81.5 per cent) and aged 75-84 years (965, 27.6 per cent). The most common clinical diagnosis was basal cell carcinoma (1712, 42.1 per cent). Dermatologists performed most procedures, with 1803 excisions (44.3 per cent) on 1657 patients (47.4 per cent). Most defects were closed primarily (2856, 81.9 per cent), and there was equipoise in regard to use of absorbable (2127, 57.7 per cent) or non-absorbable (1558, 42.2 per cent) sutures for superficial closure. The most common complications were surgical-site infection (103, 2.9 per cent) and delayed wound healing (77, 2.2 per cent). In multivariable analysis, use of absorbable suture type was associated with increased patient age, geographical location (UK and Ireland), and surgeon specialty (oral and maxillofacial surgery and plastic surgery), but not with complications. CONCLUSION: There was equipoise in suture use, and no association between suture type and complications. Definitive evidence from randomized trials is needed.

The Effectiveness of Different Nerve Transfers in the Restoration of Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis.

PURPOSE: Restoration of elbow flexion is an important goal in the treatment of patients with traumatic brachial plexus injury. Numerous studies have described various nerve transfers for neurotization of the musculocutaneous nerve (or its motor branches); however, there is uncertainty over the effectiveness of each method. The aim of this study was to summarize the published evidence in adults with traumatic brachial plexus injury. METHODS: Medline, Embase, medRxiv, and bioRxiv were systematically searched from inception to April 12, 2021. We included studies that reported the outcomes of nerve transfers for the restoration of elbow flexion in adults. The primary outcome was elbow flexion of grade 4 (M4) or higher on the British Medical Research Council scale. Data were pooled using random-effects meta-analyses, and heterogeneity was explored using metaregression. Confidence intervals (CIs) were generated to the 95% level. RESULTS: We included 64 articles, which described 13 different nerve transfers. There were 1,335 adults, of whom 813 (61%) had partial and 522 (39%) had pan-plexus injuries. Overall, 75% of the patients with partial brachial plexus injuries achieved ≥M4 (CI, 69%-80%), and the choice of donor nerve was associated with clinically meaningful differences in the outcome. Of the patients with pan-plexus injuries, 45% achieved ≥M4 (CI, 31%-60%), and overall, each month delay from the time of injury to reconstruction reduced the probability of achieving ≥M4 by 7% (CI, 1%-12%). CONCLUSIONS: The choice of donor nerve affects the chance of attaining a British Medical Research Council score of ≥4 in upper-trunk reconstruction. For patients with pan-plexus injuries, delay in neurotization may be detrimental to motor outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bacterial sensitivity to chlorhexidine and povidone-iodine antiseptics over time: a systematic review and meta-analysis of human-derived data.

Surgical site infection (SSI) is the most common complication of surgery, increasing healthcare costs and hospital stay. Chlorhexidine (CHX) and povidone-iodine (PVI) are used for skin antisepsis, minimising SSIs. There is concern that  resistance to topical biocides may be emergeing, although the potential clinical implications remain unclear. The objective of this systematic review was to determine whether the minimum bactericidal concentration (MBC) of topical preparations of CHX or PVI have changed over time, in microbes relevant to SSI. We included studies reporting the MBC of laboratory and clinical isolates of common microbes to CHX and PVI. We excluded studies using non-human samples and antimicrobial solvents or mixtures with other active substances. MBC was pooled in random effects meta-analyses and the change in MBC over time was explored using meta-regression. Seventy-nine studies were included, analysing 6218 microbes over 45 years. Most studies investigated CHX (93%), with insufficient data for meta-analysis of PVI. There was no change in the MBC of CHX to Staphylococci or Streptococci over time. Overall, we find no evidence of reduced susceptibility of common SSI-causing microbes to CHX over time. This provides reassurance and confidence in the worldwide guidance that CHX should remain the first-choice agent for surgical skin antisepsis.

Primary treatment of type B post-axial ulnar polydactyly: A systematic review and meta-analysis.

Optimal management of pedunculated ulnar polydactyly is not defined. This systematic review summarises objective and patient-reported outcomes following primary treatment. Two authors screened articles for inclusion according to a PROSPERO published protocol. The meta-analysis of adverse events was performed, and a narrative synthesis of satisfaction and patient-reported outcomes was reported. The risk of bias was assessed using Cochrane's ROBINS-I tool. Of 1650 articles identified, 15 were eligible, including 13 single-arm and 2 multi-arm studies. Complications were 6 times as likely with ligation procedures (22%), compared to surgical removal (1%) whether this was performed in the outpatient setting or operating theatre (OR 6.89 [95% CI 1.73, 27]). Parent-reported satisfaction was high for all treatments. Studies were at high risk of bias and low methodological quality. Outcome measurement and follow-up were heterogenous. Well-designed prospective observational and experimental studies are required to inform practice, incorporating clinician and parent-reported outcomes and economic analyses. Level of evidence: I.

Adapting to the COVID-19 pandemic: A survey of UK and European hand surgery units.

Hand surgery services had to rapidly adapt to the coronavirus disease 2019 (COVID-19) pandemic. The aim of the Reconstructive Surgery Trials Network #RSTNCOVID Hand Surgery survey was to document the changes made in the UK and Europe and consider which might persist. A survey developed by the Reconstructive Surgery Trials Network, in association with the British Association of Hand Therapists, was distributed to hand surgery units across the UK and Europe after the first wave of COVID-19. It was completed by one consultant hand surgeon at each of the 44 units that responded. Adult and paediatric trauma were maintained but elective services stopped. Consultations were increasingly virtual, and surgery was more likely to be under local anaesthetic and in a lower resource setting. Many of the changes are viewed as being beneficial. However, it is important to establish that they are clinically and cost effective. These survey results will help prioritise and support future research initiatives.

The baseline neutrophil lymphocyte ratio predicts survival in soft-tissue sarcoma: A 17-year cohort study.

BACKGROUND: Abnormal ratios of peripheral blood cells, e.g. neutrophil-lymphocyte ratio (NLR), are strongly associated with poor outcomes in numerous cancers. In soft-tissue sarcoma (STS), the NLR has been studied in populations outside the UK although many have major methodological flaws, which represents the rationale for this study. METHODS: Over 17 years old (2002-2019) adults with extremity STS were included. The baseline NLR (at the time of diagnosis) was calculated. The association between NLR, disease recurrence and survival was explored using cubic splines and a threshold of 3 selected, which is in keeping with the literature. Multivariable Cox regression was used to estimate overall survival, disease-free survival and recurrence with Hazard Ratios (HR) and 95% confidence intervals (CI). RESULTS: Overall, 401 patients were included. The median follow-up was 3 years 8 months (interquartile range 1 years 7 months to 5 years 2 months). During surveillance 148 died (37%), of which 123 (76%) were attributable to sarcoma. At the time of diagnosis, an NLR≥3 was independently associated with worse overall survival (adjusted HR 1.44 [95% 1.01, 2.03]). However, the baseline NLR was not associated with the risk of recurrence (adjusted HR 0.98 [95% CI 0.62, 1.57]) or disease-free survival (adjusted HR 1.11 [95% CI 0.79, 1.56]). CONCLUSIONS: At the time of diagnosis of STS, the NLR is strongly associated with survival and may serve as a cheap and readily available biomarker to personalise treatment plans for patients.

MelRisk: Using neutrophil-to-lymphocyte ratio to improve risk prediction models for metastatic cutaneous melanoma in the sentinel lymph node.

BACKGROUND: Identifying metastatic melanoma in the sentinel lymph node (SLN) is important because 80% of SLN biopsies are negative and 11% of patients develop complications. The neutrophil-to-lymphocyte ratio (NLR), a biomarker of micrometastatic disease, could improve prediction models for SLN status. We externally validated existing models and developed 'MelRisk' prognostic score to better predict SLN metastasis. METHODS: The models were externally validated using data from a multicenter cohort study of 1,251 adults. Additionally, we developed and internally validated a new prognostic score `MelRisk', using candidate predictors derived from the extant literature. RESULTS: The Karakousis model had a C-statistic of 0.58 (95% CI, 0.54-0.62). The Sondak model had a C-statistic of 0.57 (95% CI 0.53-0.61). The MIA model had a C-statistic of 0.60 (95% CI. 0.56-0.64). Our 'MelRisk' model (which used Breslow thickness, ulceration, age, anatomical site, and the NLR) showed an adjusted C-statistic of 0.63 (95% CI, 0.56-0.64). CONCLUSION: Our prediction tool is freely available in the Google Play Store and Apple App Store, and we invite colleagues to externally validate its performance .

Inferior gluteal artery perforator (IGAP) flap versus profunda artery perforator (PAP) flap as an alternative option for free autologous breast reconstruction.

BACKGROUND: When patients are unsuitable for deep inferior epigastric perforator (DIEP) flap breast reconstruction, the inferior gluteal artery perforator (IGAP) flap has been used as an alternative option. However, the profunda artery perforator (PAP) flap is also gaining popularity as an alternative to the DIEP flap for several reasons. This retrospective cohort study compares baseline characteristics, peri- and post-operative outcomes following IGAP flap and PAP flap breast reconstructions after mastectomy for cancer. METHODS: In a single center in the UK, from September 2008 through December 2016, 43 women underwent IGAP Flap(s) breast reconstruction and 51 received PAP flap(s) breast reconstructions. Statistical analysis was performed to compare baseline, peri-operative and post-operative variables between the two reconstruction methods. RESULTS: Perioperative complications requiring reoperation were experienced in women undergoing IGAP flap breast reconstructions only (21% versus 0%, p = 0.001), principally due to the risk of total flap failure (12% versus 0%, p = 0.01). Women undergoing IGAP flap breast reconstructions were at significantly higher odds of revision surgery (OR 17 [95% CI: 5.5-53], p < 0.001), which was unchanged after adjusting for bilateral reconstructions (adjusted OR 18 [95% CI: 5.3-58], p < 0.001). CONCLUSIONS: PAP flaps appear to be associated with significantly fewer complications and revision surgeries than IGAP flaps for breast reconstruction in women undergoing mastectomy for cancer and who are unsuitable for a DIEP flap breast reconstruction.

Chlorhexidine versus povidone-iodine skin antisepsis before upper limb surgery (CIPHUR): an international multicentre prospective cohort study.

INTRODUCTION: Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) before surgery. However, upper limb surgeons continue to use other antiseptics, citing a lack of applicable evidence, and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics before upper limb surgery. METHODS: This international multicentre prospective cohort study recruited consecutive adults and children who underwent surgery distal to the shoulder joint. The intervention was use of CHX or povidone-iodine (PVI) antiseptics in either aqueous or alcoholic form. The primary outcome was SSI within 90 days. Mixed-effects time-to-event models were used to estimate the risk (hazard ratio (HR)) of SSI for patients undergoing elective and emergency upper limb surgery. RESULTS: A total of 2454 patients were included. The overall risk of SSI was 3.5 per cent. For elective upper limb surgery (1018 patients), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70 per cent (adjusted HR 0.30, 95 per cent c.i. 0.11 to 0.84), when compared with aqueous PVI. Concerning emergency upper limb surgery (1436 patients), aqueous PVI appeared to be the least effective antiseptic for preventing SSI; however, there was uncertainty in the estimates. No adverse events were reported. CONCLUSION: The findings align with the global evidence base and international guidance, suggesting that alcoholic CHX should be used for skin antisepsis before clean (elective upper limb) surgery. For emergency (contaminated or dirty) upper limb surgery, the findings of this study were unclear and contradict the available evidence, concluding that further research is necessary.