Learning from the QUEST multicentre feasibility randomization trials in breast reconstruction after mastectomy

BACKGROUND: Breast reconstruction aims to improve health-related quality of life after mastectomy. However, evidence guiding patients and surgeons in shared decision-making concerning the optimal type or timing of surgery is lacking.

METHODS: QUEST comprised two parallel feasibility phase III randomized multicentre trials to assess the impact of the type and timing of latissimus dorsi breast reconstruction on health-related quality of life when postmastectomy radiotherapy is unlikely (QUEST A) or highly probable (QUEST B). The primary endpoint for the feasibility phase was the proportion of women who accepted randomization, and it would be considered feasible if patient acceptability rates exceeded 25 per cent of women approached. A companion QUEST Perspectives Study (QPS) of patients (both accepting and declining trial participation) and healthcare professionals assessed trial acceptability.

RESULTS: The QUEST trials opened in 15 UK centres. After 18 months of recruitment, 17 patients were randomized to QUEST A and eight to QUEST B, with overall acceptance rates of 19 per cent (17 of 88) and 22 per cent (8 of 36) respectively. The QPS recruited 56 patients and 51 healthcare professionals. Patient preference was the predominant reason for declining trial entry, given by 47 (53 per cent) of the 88 patients approached for QUEST A and 22 (61 per cent) of the 36 approached for QUEST B. Both trials closed to recruitment in December 2012, acknowledging the challenges of achieving satisfactory patient accrual.

CONCLUSION: Despite extensive efforts to overcome recruitment barriers, it was not feasible to reach timely recruitment targets within a feasibility study. Patient preferences for breast reconstruction types and timings were common, rendering patients unwilling to enter the trial.

Subclinical femoral neuropathy after anterior cruciate ligament reconstruction

Background and aim of the study: Patients with anterior cruciate ligament (ACL) reconstruction and femoral catheter analgesia may develop quadriceps amyotrophy. We aimed to determine whether this amyotrophy might be related to a femoral neuropathy. Material and method: After Ethical Committee approval and patients' written informed consent, 17 patients ASA I and II scheduled to undergo ACL reconstruction were recruited. An electromyography (EMG) was performed before the operation in order to exclude a femoral neuropathy. A femoral nerve catheter was inserted before the surgery with the aid of a nerve stimulator, and 20 ml of 0.5% ropivacaine was injected. The operation was done under spinal or general anaesthesia. Postoperative analgesia was provided with 0.2% ropivacaine for 72 hours, in association with oxycodone, paracetamol and ibuprofen. A second EMG was performed 4 weeks after the ACL repair. A femoral neuropathy was defined as a reduction of the surface of the motor response of more than 20%, compared to the first EMG. A third EMG was performed at 6 months if a neuropathy was present. Results: Mean age of this group of patients was 27 years old (range 18-38 y.). Among the 17 patients, 4 developed a transient femoral neuropathy (incidence of 24%) without clinical complain. Conclusion: In this study, the incidence of subclinical femoral neuropathy after ACL reconstruction is high. This lesion may be caused by the femoral catheter (mechanical damage, toxicity of local anaesthesia) or by the Tourniquet. Further studies are needed to investigate the incidence of subclinical neuropathy, according to the type of analgesia (epidural analgesia, PCA) and surgery.

Évaluation de la reconstruction des ligaments croisés post luxation aiguë du genou avec l’utilisation des ligaments synthétiques

La luxation du genou, bien que très rare, demeure une blessure dévastatrice car elle entraîne de multiples complications en raison de la nature complexe du traumatisme associé à cette lésion. La luxation peut résulter d'un traumatisme à haute ou basse énergie. Les blessures sévères aux ligaments et aux structures associées donnent à la luxation du genou un potentiel élevé d'atteinte fonctionnelle. Le traitement conservateur, qui était considéré comme acceptable auparavant, est maintenant réservé à un très faible pourcentage de patients. La reconstruction chirurgicale est maintenant préconisée dans la plupart des cas, mais de nombreuses options existent et le traitement chirurgical optimal à préconiser reste controversé. Certains chirurgiens recommandent la reconstruction complète de tous les ligaments endommagés le plus tôt possible, tandis que d'autres, craignant l’établissement d’arthrofibrose, limitent l'intervention chirurgicale immédiate à la reconstruction du ligament croisé postérieur et de l'angle postéro-externe. En raison des multiples structures endommagées lors d’une luxation du genou, les chirurgiens utilisent couramment la combinaison des autogreffes et des allogreffes pour compléter la reconstruction ligamentaire. Les complications associées au prélèvement de la greffe, l'allongement de la greffe, l’affaiblissement précoce du greffon ainsi que les risques de transmission de maladies ont poussé les chirurgiens à rechercher différentes options d’intervention. L'utilisation de matériaux synthétiques pour le remplacement du ligament lésé a été proposée dans les années ´80. Après une première vague d'enthousiasme, les résultats décevants à long terme et les taux élevés d'échec ont diminué sa popularité. Depuis lors, une nouvelle génération de ligaments artificiels a vu le jour et parmi eux, le Ligament Advanced Reinforced System (LARS) a montré des résultats prometteurs. Il a été utilisé récemment dans les reconstructions isolées du ligament croisé antérieur et du ligament croisé postérieur pour lesquelles il a montré de bons résultats à court et moyen termes. Le but de cette étude rétrospective était d'évaluer la fonction et la stabilité du genou après la luxation aiguë suivant la reconstruction des ligaments croisés avec le ligament artificiel de type LARS. Cette étude a évalué 71 patients présentant une luxation du genou et qui ont subi une chirurgie de reconstruction du ligament croisé antérieur et du ligament croisé postérieur à l'aide du ligament LARS. Suite à la chirurgie le même protocole intensif de réadaptation a été suivi pour tous les patients, où la mise en charge progressive était permise après une période d’environ 6 semaines pendant laquelle la force musculaire et la stabilité dynamique se rétablissaient. Les outils d’évaluation utilisés étaient le score Lysholm, le formulaire de «l’International Knee Documentation Committee», le «Short Form-36», les tests cliniques de stabilité du genou, l'amplitude de mouvement articulaire à l’aide d’un goniomètre et la radiographie en stress Telos à 30° et 90° de flexion du genou. Le même protocole d’évaluation a été appliqué au genou controlatéral pour des fins de comparaison. Les résultats subjectifs et objectifs de cette étude sont satisfaisants et suggèrent que la réparation et la reconstruction combinées avec ligaments LARS est une alternative valable pour le traitement des luxations aiguës du genou. Ces résultats démontrent que ces interventions produisent des effets durables en termes d’amélioration de la fonction et révèlent la durabilité à long terme des ligaments artificiels LARS. Les patients sont à la fois plus autonomes et plus satisfaits avec le temps, même si la luxation du genou est considérée comme une catastrophe au moment où elle se produit. Des études prospectives randomisées sont maintenant nécessaires afin de comparer la sélection de la greffe et le délai de reconstruction chirurgicale.

Facial artery musculomucosal flap for reconstruction of skull base defects

Facial Artery Musculomucosal Flap in Skull Base Reconstruction Xie L. MD, Lavigne F. MD, Rahal A. MD, Moubayed SP MD, Ayad T. MD Introduction: Failure in skull base defects reconstruction can have serious consequences such as meningitis and pneumocephalus. The nasoseptal flap is usually the first choice but alternatives are necessary when this flap is not available. The facial artery musculomucosal (FAMM) flap has proven to be successful in head and neck reconstruction but it has never been reported in skull base reconstruction. Objective: To show that the FAMM flap can reach some key areas of the skull base and be considered as a new alternative in skull base defects reconstruction. Methods: We conducted a cadaveric study with harvest of modified FAMM flaps, endoscopic skull base dissection and maxillectomies in 13 specimens. Measures were taken for each harvested FAMM flap. Results: The approximate mean area for reconstruction from the combination of the distal FAMM and the extension flaps is 15.90 cm2. The flaps successfully covered the simulated defects of the frontal sinus, the ethmoid areas, the planum sphenoidale, and the sella turcica. Conclusion: The FAMM flap can be considered as a new alternative in the reconstruction of skull base defects. Modifications add extra length to the traditional FAMM flap and can contribute to a tighter seal of the defect as opposed to the FAMM flap alone.

Applying scanning electron microscopy for the ultrastructural and clinical analysis of periprosthetic capsules in implant-based breast reconstruction

La reconstruction en deux étapes par expanseur et implant est la technique la plus répandue pour la reconstruction mammmaire post mastectomie. La formation d’une capsule périprothétique est une réponse physiologique universelle à tout corps étranger présent dans le corps humain; par contre, la formation d’une capsule pathologique mène souvent à des complications et par conséquent à des résultats esthétiques sous-optimaux. Le microscope électronique à balayage (MEB) est un outil puissant qui permet d’effectuer une évaluation sans pareille de la topographie ultrastructurelle de spécimens. Le premier objectif de cette thèse est de comparer le MEB conventionnel (Hi-Vac) à une technologie plus récente, soit le MEB environnemental (ESEM), afin de déterminer si cette dernière mène à une évaluation supérieure des tissus capsulaires du sein. Le deuxième objectif est d‘appliquer la modalité de MEB supérieure et d’étudier les modifications ultrastructurelles des capsules périprothétiques chez les femmes subissant différents protocoles d’expansion de tissus dans le contexte de reconstruction mammaire prothétique. Deux études prospectives ont été réalisées afin de répondre à nos objectifs de recherche. Dix patientes ont été incluses dans la première, et 48 dans la seconde. La modalité Hi-Vac s’est avérée supérieure pour l’analyse compréhensive de tissus capsulaires mammaires. En employant le mode Hi-Vac dans notre protocole de recherche établi, un relief 3-D plus prononcé à été observé autour des expanseurs BIOCELL® dans le groupe d’approche d’intervention retardée (6 semaines). Des changements significatifs n’ont pas été observés au niveau des capsules SILTEX® dans les groupes d’approche d’intervention précoce (2 semaines) ni retardée.

Sexual abuse in childhood and postoperative depression in women with breast cancer who opt for immediate reconstruction after mastectomy

INTRODUCTION Breast reconstruction is routinely offered to women who undergo mastectomy for breast cancer. However, patient-reported outcomes are mixed. Child abuse has enduring effects on adults’ well-being and body image. As part of a study into damaging effects of abuse on adjustment to breast cancer, we examined: (i) whether women with history of abuse would be more likely than other women to opt for reconstruction; and (ii) whether mood problems in women opting for reconstruction can be explained by greater prevalence of abuse. PATIENTS AND METHODS We recruited 355 women within 2-4 days after surgery for primary breast cancer; 104 had mastectomy alone and 29 opted for reconstruction. Using standardised questionnaires, women self-reported emotional distress and recollections of childhood sexual abuse. Self-report of distress was repeated 12 months later. RESULTS Women who had reconstruction were younger than those who did not. Controlling for this, they reported greater prevalence of abuse and more distress than those having mastectomy alone. They were also more depressed postoperatively, and this effect remained significant after controlling for abuse. CONCLUSIONS One interpretation of these findings is that history of abuse influences women's decisions about responding to the threat of mastectomy, but it is premature to draw inferences for practice until the findings are replicated. If they are replicated, it will be important to recognise increased vulnerability of some patients who choose reconstruction. Studying the characteristics and needs of women who opt for immediate reconstruction and examining the implications for women's adjustment should be a priority for research.

Optimizing the nipple-areola sparing mastectomy with double concentric periareolar incision and biodimensional expander-implant reconstruction: Aesthetic and technical refinements

Although the biodimensional anatomical expander-implant system (BEIS) is a reliable technique, little information has been available regarding outcome following nipple-areola sparing mastectomy (NSM). To perform the resection of glandular tissue, while improving the surgical access and maintaining the nipple-areola vascularization we have developed a new approach for NSM based on the double concentric periareolar incision (DCPI). The purpose of this study is to analyze the feasibility, surgical planning and its outcome following NSM. 18 patients underwent NSM reconstructions. Mean time of follow-up was 29 months. The technique was indicated in patients with small/moderate volume breasts. Flap complications were evaluated and information on aesthetic results and patient satisfaction were collected. 83.3% had tumors measuring 2 cm or less (T1) and 72.1% were stage 0 and 1. All patients presented peripherally tumors located (at least 5 cm from the nipple). Skin complications occurred in 11.1%. One patient (5.5%) presented small skin necrosis and a wound dehiscence was observed in one patient (5.5%). The aesthetic result was good/very good in 94.4 percent and the majority of patients were very satisfied/satisfied. No local recurrences were observed. All complications except one were treated by a conservative approach. DCPI-BEIS is a simple and reliable technique for NSM reconstruction. The success depends on patient selection, coordinated planning with the oncologic surgeon and careful intra-operative and post-operative management. (C) 2009 Elsevier Ltd. All rights reserved.

Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery

Background: The Medical Outcomes General Health Survey (SF-36) is a widely used health status measure; however, limited evidence is available for its performance in orthopedic settings. The aim of this study was to examine the magnitude and meaningfulness of change and sensitivity of SF-36 subscales following orthopedic surgery.

Methods: Longitudinal data on outcomes of total hip replacement (THR, n = 255), total knee replacement (TKR, n = 103), arthroscopic partial meniscectomy (APM, n = 74) and anterior cruciate ligament reconstruction (ACL, n = 62) were used to estimate the effect sizes (ES, magnitude of change) and minimal detectable change (sensitivity) at the group and individual level. To provide context for interpreting the magnitude of changes in SF-36 scores, we also compared patients' scores with age and sex-matched population norms. The studies were conducted in Sweden. Follow-up was five years in THR and TKR studies, two years in ACL, and three months in APM.

Results: On average, large effect sizes (ES≥0.80) were found after orthopedic surgery in SF-36 subscales measuring physical aspects (physical functioning, role physical, and bodily pain). Small (0.20–0.49) to moderate (0.50–0.79) effect sizes were found in subscales measuring mental and social aspects (role emotional, vitality, social functioning, and mental health). General health scores remained relatively unchanged during the follow-up. Despite improvements, post-surgery mean scores of patients were still below the age and sex matched population norms on physical subscales. Patients' scores on mental and social subscales approached population norms following the surgery. At the individual level, scores of a large proportion of patients were affected by floor or ceiling effects on several subscales and the sensitivity to individual change was very low.

Conclusion: Large to moderate meaningful changes in group scores were observed in all SF-36 subscales except General Health across the intervention groups. Therefore, in orthopedic settings, the SF-36 can be used to show changes for groups in physical, mental, and social dimensions and in comparison with population norms. However, SF-36 subscales have low sensitivity to individual change and so we caution against using SF-36 to monitor the health status of individual patients undergoing orthopedic surgery.

Is anterior cruciate reconstruction superior to conservative treatment?

Not all patients who have a rupture of the anterior cruciate ligament (ACL) elect to have surgical reconstruction. The aim of this study was to assess the short-to-medium-term results of patients who chose conservative management in comparison to patients who had reconstructive surgery within the same time period. Sixty-three patients with an ACL injury were retrospectively studied. Forty patients were managed, according to patient choice, with ACL reconstruction and 23 conservatively. Four validated questionnaires were used to assess general and knee-specific function in a cohort with a median age of 32 years and a median follow-up period of 38 months. Patients were matched on demographic variables except for gender. There were no statistically significant differences in the outcome measures, and the majority of patients would proceed with the same treatment in the event the control leg became injured. Patients who elect to have conservative management of an ACL rupture can achieve similar function and satisfaction to those who elect to have reconstruction. Until a large randomized controlled trial is conducted, patients need to be made aware of the merits of both management strategies and the lack of evidence of superiority of one over the other.

Biliary tract reconstruction using jejunal tube: an experimental study in dogs

BACKGROUND: To physiologically reconstruct the biliary tract, Crema et al suggested the application of the Monti principle to the biliary tract, already used in humans for the urinary tract. With this technique, a jejunal segment is transversely retubularized. This study aimed to evaluate the efficacy of jejunal tube interposition between the common bile duct and duodenum in dogs.METHODS: Thirteen dogs underwent a laparoscopic common bile duct ligature, followed by a biliodigestive connection by jejunal tube interposition after one week. The levels of glutamic-pyruvic and glutamic-oxalacetic transaminases, total bilirubins, alkaline phosphatase and gamma-glutamyltransferase were assessed before surgery and thereafter weekly until euthanasia, which was performed 6 weeks after biliodigestive connection.RESULTS: Data on 9 dogs were analyzed statistically. The dogs presented with obstructive jaundice after common bile duct ligature, as confirmed by biochemical examination. They showed a statistically significant reduction in cholestasis after biliodigestive connection by jejunal tube interposition and were healthy until the end of the experiment.CONCLUSION: A statistically significant reduction was seen in total bilirubin and canalicular enzymes (alkaline phosphatase and gamma-glutamyltransferase) in the 9 dogs 6 weeks after biliodigestive conviction by jejunal tube interposition.

Gel and porous polyethylene implants for anophthalmic cavity reconstruction-evaluation using the B scan ultrasound

AIM: To evaluate the host response of the gel and porous polyethylene implants in anophthalmic cavities using the B scan ultrasound.METHODS: Thirty-six white rabbits underwent unilateral enucleation with placement of gel or porous polyethylene spheres implants. The animals were submitted to clinical examination weekly and to ultrasound evaluation on 30, 60 and 90 days after surgery.RESULTS: All rabbits with gel polyethylene spheres, except one, showed implant extrusion probably because the gel spheres have hydrated and increased in volume. The B ultrasound of the gel polyethylene implant did not show vessels inside during the following period. Five animals (27.8%) with porous polyethylene spheres presented implant extrusion after 30 days of surgery. According to B ultrasound, the porous polyethylene implant showed irregular and heterogeneous architecture and reflective peaks similar to vascularized tissues.CONCLUSION: More studies are required to determine the ideal volume of gel polyethylene implant necessary to correct the diminished orbital content in the anophthalmic cavity. The B ultrasound effectiveness showed in this study for anophthalmic socket implants evaluation provides useful information for further in vivo studies and might substitute expensive methods of implants vascularization evaluation,

Use of Titanium Mesh for Reconstruction of Extensive Defects in Fronto-orbito-ethmoidal Fracture

Traumatic injuries treatment of the fronto-naso-orbito-ethmoidal region has been one of the most challenging treatments within maxillofacial surgery, particularly of extensive orbital defects, very common in this type of pathologic condition. A 48-year-old man involved in a car collision presented an extensive bilateral fracture of the orbit medial wall, nasal bones, the nasal septum, and the frontal anterior table. The clinical and tomographic findings concluded the diagnosis of a maxilla and fronto-naso-orbito-ethmoidal fracture. Among the variety of biomaterials, the titanium mesh was elected because of the extension and magnitude of the bone defect, obtaining this way esthetic and functional results with better prognosis.

Use of 4 Immediately Loaded Zygomatic Fixtures for Retreatment of Atrophic Edentulous Maxilla After Complications of Maxillary Reconstruction

This article reports the 20-month clinical outcome of the use of 4 zygomatic implants with immediate occlusal loading and reverse planning for the retreatment of atrophic edentulous maxilla after failed rehabilitation with autogenous bone graft reconstruction and maxillary implants. The intraoral clinical examination revealed mispositioned and loosened implants underneath a maxillary complete denture. The panoramic radiograph showed 6 maxillary implants. One implant was displaced into the right maxillary sinus, and the implant anchored in the region of tooth 21 was fractured. The other implants presented peri-implant bone loss. The implants anchored in the regions of teeth 21 to 23 and 11 to 13 were first removed. After 2 months, the reverse planning started with placement of 4 zygomatic fixtures, removal of the implants migrated into the sinus cavity and anchored in the region of tooth 17, and installation of a fixed denture. After 20 months of follow-up, no painful symptoms, peri-implant inflammation or infection, implant instability, or bone resorption was observed. The outcomes of this case confirm that the zygoma can offer a predictable anchorage and support function for a fixed denture in severely resorbed maxillae.

Maxillary Bone Defect Reconstruction Using Porous Polyethylene Implants

Purpose: The aim of this study was to evaluate the bone repair process in the maxillary sinus in monkeys treated with high-density porous polyethylene (Medpor)Methods: Four capuchin monkeys (Cebus apella) were submitted to bilateral horizontal osteotomies in the anterior wall of the maxillary sinus and divided into 2 groups: control group, left side with no implants, and porous polyethylene group, right side with Medpor. After a period of 145 days after implant placement, the maxillae were removed for histologic and histometric analyses.Results: Bone repair in osteotomized areas took place by connective tissue in 58.5% and 58.7% in the control group and the porous polyethylene group, respectively. In the contact surface with Medpor, bone repair occurred in 41.3%.Conclusions: Medpor was not reabsorbed within the period of this study and allowed bone repair surrounding it. The porous polyethylene constitutes a feasible alternative for bone defect reconstruction.