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Background: Acute wrist trauma with clinical suspicion of a scaphoid fracture, but normal radiographs, is known as a clinical scaphoid fracture. Standard treatment involves immobilization and repeat radiographs in 10 to 14 days. When repeat radiographs are normal but a scaphoid fracture is still clinically suspected, the optimal management in children is unknown. This study retrospectively assessed the management and outcomes of pediatric patients diagnosed with clinical scaphoid fractures. Methods: A retrospective study was performed of all patients over a 2-year period treated for a clinical scaphoid fracture at a tertiary pediatric center. Patients were included if they had clinical signs of a scaphoid fracture and 2 negative x-rays 7 to 14 days apart postinjury. Results: Ninety-one patients with a mean age of 13.2 years (range: 7.8-17.7) were included. Sixteen patients (17.6%) underwent computed tomography (CT) or magnetic resonance imaging (MRI) at a mean time of 10.2 weeks postinjury. Five patients (5.5%) were diagnosed with a scaphoid fracture by x-ray or CT at an average of 4.5 weeks postinjury (range: 3-6). Six patients were diagnosed with other wrist fractures at a mean time postinjury of 3.1 (range: 3-6.5) weeks. Out of 195 total radiographs, the surgeon and radiologist disagreed on 59 (30.2%) images. No patients underwent surgery. Conclusions: Management of clinical scaphoid fractures at our institution was relatively uniform: nearly all patients were immobilized and less than 20% received advanced imaging. Our findings suggest a low but non-zero occult scaphoid fracture rate, discordance in radiologic interpretation, and lack of advanced imaging, providing an avenue for future prospective studies.

Brief abstractThis is a protocol to assess feasibility of conducting a prospective cohort study comparing local flaps versus skin grafts for surgical excision of skin cancer from the face.IntroductionSkin cancer is the most common malignancy worldwide and the face is one of the most common locations of occurrence. Surgical excision is the most popular treatment for small lesions of the face. Defects can be reconstructed using local flaps or skin grafts. There is a paucity of literature evaluating outcomes after skin cancer surgery from the patient’s perspective using valid measurement tools. The purpose of this study is to assess the feasibility of conducting a prospective observational cohort study. The primary outcomes include recruitment rates, eligibility rate, compliance of intervention and rate of completion of the primary outcome (FACE-Q scales) at 3 months. Secondary outcomes include examining patient characteristic and FACE-Q score differences between local flaps to skin grafts and adverse events.Methods and analysisThis study is a prospective cohort study consisting of an anticipated 30 patients aged ≥18 years. The study population will consist of a consecutive sample of non-melanoma facial skin cancer patients undergoing a skin graft or local flap. Patients will be followed and evaluated with the FACE-Q questionnaire at 2 weeks, 3 months, 6 months and 1 year post-operation. The following criteria will determine success: patients who meet eligibility criteria >70%; recruitment rate >70%; compliance with intervention >90%; rate of completion of full-scale prospective study primary outcome (FACE-Q at 3 months) >80%; retention rate at 6-month follow-up visit >70%.DiscussionThe findings of this study will be used to guide the sample size calculation for a future, large-scale prospective study.Trial registration: ClinicalTrials.gov (NCT04842279).

Breast augmentation is a commonly performed cosmetic procedure. We set out to determine whether there was any effect on breastfeeding in females after breast implants. The aim of this study was to perform a systematic review and meta-analysis of the current evidence on breastfeeding outcome and complications in females with breast augmentation. A systematic review was performed utilizing MEDLINE, EMBASE, and all evidence-based medicine reviews from their respective inception dates to November 7, 2022, to assess outcomes of breastfeeding in females with breast implants (PROSPERO ID: CRD42022357909). This review was in accordance with both the Cochrane Handbook for Systematic Review of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eleven studies (4 prospective and 7 retrospective) in total were included in the review. A total of 8197 out of 9965 (82.25%) patients were successfully able to breastfeed after breast implants. Of 5 studies that included a control group, 343,793 of 388,695 (88.45%) women without breast implants successfully breastfed. A meta-analysis of 5 comparative studies showed a significant reduction of breastfeeding in females with breast implants, n = 393,686, pooled odds ratio = 0.45 (95% CI, 0.38 to 0.53). Complications described included pain, mastitis, insufficient or excessive lactation, and nipple inversion. There may be impairment in ability to breastfeed for females who receive breast implants when compared with those without. Additional studies on the topic are needed to further clarify the relationship. Level of Evidence: 4

Background: Venous thrombosis, the leading cause of free flap failure, may have devastating consequences. Many anti-thrombotic agents and protocols have been described for prophylaxis and treatment of venous thrombosis in free flaps. Methods: National surveys were distributed to microsurgeons (of both Plastics and ENT training) and hematology and thrombosis specialists. Data were collected on routine screening practices, perceived risk factors for flap failure, and pre-, intra-, and post-operative anti-thrombotic strategies. Results: There were 722 surveys distributed with 132 (18%) respondents, consisting of 102 surgeons and 30 hematologists. Sixty-five surgeons and 9 hematologists routinely performed or managed patients with free flaps. The top 3 perceived risk factors for flap failure according to surgeons were medical co-morbidities, past arterial thrombosis, and thrombophilia. Hematologists, however, reported diabetes, smoking, and medical co-morbidities as the most important risk factors. Fifty-four percent of physicians routinely used unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) as a preoperative agent. Surgeons routinely flushed the flap with heparin (37%), used UFH IV (6%), or both (8%) intra-operatively. Surgeons used a range of post-operative agents such as UFH, LMWH, aspirin, and dextran while hematologists preferred LMWH. There was variation of management strategies if flap thrombosis occurred. Different strategies consisted of changing recipient vessels, UFH IV, flushing the flap, adding post-operative agents, or a combination of strategies. Conclusions: There are diverse practice variations in anti-thrombotic strategies for free tissue transfers and a difference in perceived risk factors for flap failure that may affect patient management.

Summary Purpose Cervicofacial flaps represent an excellent option for coverage of cheek defects secondary to oncologic resection, trauma or infection. However, there remains clinical equipoise regarding whether superficial plane or deep plane dissection results in the lowest rates of complications and optimal outcomes. Methods A systematic review and meta-analysis of proportions was conducted to assesses outcomes between cheek reconstruction superficial plane or deep plane cervicofacial flaps. Outcome measures included flap necrosis, ectropion, hematoma formation, facial nerve injury, and requirement for further operative or non-operative intervention. Results Of 881 citations identified for review, 10 met the inclusion criteria. In total, 284 patients received superficial plane flaps while 44 patients received deep plane flaps. Overall, reported rates of complications were low for cervicofacial flaps. The proportion of necrosis, ectropion, and hematoma were 3.05% (95% CI: 0.00–10.71%), 2.03% (95% CI: 0.41–4.42%), and 0.05% (95% CI: 0.00–3.29%), respectively. No cases of permanent facial nerve injury were reported. Sub-group analysis demonstrated comparable rates of complications between superficial and deep plane dissection and no difference was found between groups. Other complications were noted with low incidence. Conclusions Currently published literature demonstrates that superficial and deep plane cervicofacial flaps exhibit similar rates of complications, although there is a low level of evidence overall. Overall, the rates of flap necrosis (3.05%), ectropion (2.03%), and hematoma (0.05%) are low. Notably, there were no reported cases of permanent facial nerve injury from either technique.

Background: With numerous treatment modalities available, it is unclear whether the treatment of recurrent Dupuytren disease is as effective as its initial treatment. We aimed to investigate the outcomes of management of recurrent Dupuytren contracture. Methods: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, PubMed, CINAHL, and Cochrane Central Register of Controlled Trials were searched from their inception to April 2020. Studies of patients aged above 18 years undergoing treatment for recurrent Dupuytren contractures were included. The Risk Of Bias In Non-randomized Studies-of Interventions tool was used for quality assessment. The study was registered with Open Science Foundation. Results: A systematic review identified 12 studies: 311 patients with 224 affected digits—index (n = 5; 2.2%), long (n = 17; 7.6%), ring (n = 57; 25.4%), small (n = 112; 50%), and unspecified (n = 33; 14.7%); of these, there were 76 metacarpophalangeal joints (MCPJ; 45.5%), 90 proximal phalangeal joints (PIPJ; 53.9%), and 1 distal interphalangeal joint (0.6%). Previous treatment included the following: percutaneous needle aponeurotomy (n = 103 of 311 patients; 33.1%), collagenase clostridium histolyticum-injection (CCH; n = 75 of 311; 24.1%), limited fasciectomy (LF) ± skin graft (n = 83 of 311; 26.7%), fasciotomy (n = 1 of 311; 0.3%), and unspecified (n = 64 of 311; 20.6%). Recurrence was treated by percutaneous needle aponeurotomy (n = 68 of 311 patients; 21.9%); CCH injection (n = 53 of 311; 17.0%); aponeurotomy or dermofasciectomy or LF (n = 176 of 311; 56.6%); ray/digit amputation (n = 8 of 311; 2.6%); and PIPJ arthrodesis (n = 6 of 293; 2.0%). Range of motion was improved by 23.31° (95% confidence interval [CI] = 13.13°-33.50°; I2 = 67%; P = .05) and 15.49° (95% CI = 2.67°-28.31°; I2 = 76%; P = .01) for MCPJ and PIPJ, respectively. Conclusions: There is low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture.

Background “Spin” is a form of reporting bias where there is a misappropriated presentation of study results, often overstating efficacy, or understating harms. Abstracts of systematic reviews (SRs) in other clinical domains have been demonstrated to employ spin, which may lead to clinical recommendations not justified by the literature. Objectives The authors sought to determine the prevalence of spin strategies in abstracts of plastic surgery SRs. Methods A literature search was conducted in MEDLINE, Embase, and CENTRAL to identify all SRs published in the top 5 plastic surgery journals from 2015 to 2021. Screening, data extraction, and spin analysis were performed by 2 independent reviewers. Data checking of the spin analysis was performed by a plastic surgery resident with graduate-level training in clinical epidemiology. Results From an initial search of 826 SRs, 60 SRs and meta-analyses were included in this study. Various types of spin were identified in 73% of SR abstracts (n = 44). “Conclusion claims the beneficial effect of the experimental treatment despite high risk of bias in primary studies” was the most prevalent type of spin and was identified in 63% of SRs (n = 38). There were no significant associations between the presence of spin and study characteristics. Conclusions This study found that 73% of abstracts in plastic surgery SRs contain spin. Although systemic reviews represent the highest level of evidence, readers should be aware of types of “spin” when interpreting results and incorporating recommendations into patient care.

There is currently an overprescription of opioids, which may result in abuse and diversion of narcotics. The aim of this systematic review was to investigate opioid prescription practices and consumption by patients after upper extremity surgery. This review was registered a priori on Open Science Framework (osf.io/6u5ny) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search strategy was performed using MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases (from their inception to October 17, 2021). Prospective studies investigating opioid consumption of patients aged 18 years or older undergoing upper extremity surgeries were included. The Risk of Bias in Nonrandomized Studies of Interventions and Risk of Bias 2.0 tools were used for quality assessment. In total, 21 articles met the inclusion criteria, including 7 randomized controlled trials and 14 prospective cohort studies. This represented 4195 patients who underwent upper extremity surgery. Most patients took less than half of the prescribed opioids. The percentage of opioids consumed ranged from 11% to 77%. There was moderate to severe risk of bias among the included studies. This review demonstrated that there is routinely excessive opioid prescription relative to consumption after upper limb surgery. Additional randomized trials are warranted, particularly with standardized reporting of opioid consumption and assessment of patient-reported outcomes.

Summary Background Dermal regenerative matrices (DRMs) have been used for several decades in the treatment of acute and reconstructive burn injury. The objective of this study was to perform a systematic review of the literature to assess clinical outcomes and safety profile of DRMs in full-thickness burn injury. Methods Comprehensive searches of MEDLINE, EMBASE, CINAHL, and Cochrane Library were performed from 1988 to 2017. Two independent reviewers completed preliminary and full-text screening of all articles. English-language articles reporting on DRM use in patients with full-thickness burn injury were included. Results Literature search generated 914 unique articles. Following screening, 203 articles were assessed for eligibility, and 72 met inclusion criteria for analysis. DRM was applied to1084 patients (74% acute burns, 26% burn reconstruction). Of the twelve studies that described changes in ROM, significant improvement was observed in 95% of reconstructive patients. The most frequently treated reconstructive sites were the neck, hand/wrist, lower extremity, and axilla. Vancouver scar scale was used in eight studies and indicated a significant improvement in the scar quality with DRM. The overall complication rate was 13%, most commonly infection, graft loss, hematoma formation, and contracture. Conclusions Although variability in functional and cosmetic outcomes was observed, DRM demonstrates improvements in ROM and scar appearance without objective regression. Essential demographic data were lacking in many studies, highlighting the need for future standardization of reporting outcomes in burns following application of dermal substitutes.

This study aims to assess the quality and readability of Internet-based patient resources for vascular tumours in order to understand which areas require improvement.A World Wide Web search was performed, in addition to a literature review using PubMed, Ovid MEDLINE, and EMBASE. Any material that contained information on vascular tumours pertaining to patient education was included. We evaluated resources with DISCERN and Flesch Reading Ease scores when applicable. The language of publication was restricted to English and French. This review was registered with PROSPERO (CRD42018087885).A total of 117 online resources were screened, with 73 resources included in the final analysis. The overall DISCERN rating for the patient resources was 1.8 (0.8). The majority of online resources failed to depict the entire spectrum of benign vascular tumours. The mean Flesch score was 36 (19), which translates to a college-level readability.The majority of resources were not adequate or comprehensive and were written at a much higher level than the average reader would be expected to comprehend.La présente étude vise à évaluer la qualité et la lisibilité de ressources en ligne sur les tumeurs vasculaires pour les patients afin de déterminer les améliorations à apporter.Les chercheurs ont effectué une recherche dans Internet et procédé à une analyse bibliographique dans PubMed, Ovid MEDLINE et EMBASE. Tous les documents qui contenaient de l’information sur les tumeurs vasculaires à l’intention des patients étaient inclus. Les chercheurs ont évalué les ressources à l’aide des scores de DISCERN et de Flesch Reading Ease, si la situation le justifiait. La langue des publications était restreinte à l’anglais et au français. La présente analyse a été enregistrée dans PROSPERO (CRD42018087885).Au total, les chercheurs ont examiné 117 ressources en ligne, dont 73 ont fait partie de l’analyse définitive. La classification DISCERN globale des ressources pour les patients était de 1,8 (0,8). La majorité des ressources en ligne ne décrivaient pas tout le spectre des tumeurs vasculaires bénignes. Le score de Flesch moyen s’élevait à 36 (19), soit une lisibilité de niveau collégial.La majorité des ressources étaient inadéquates ou incomplètes et étaient rédigées à un niveau de lecture beaucoup plus élevé que ce à quoi on pourrait s’attendre chez un lecteur moyen.

Background: Pediatric outcomes after flexor tendon repairs are variable, and evidence in the literature remains scarce. Methods: Repair of pediatric flexor tendon injuries was reviewed over a 10-year period (2005-2015). Data collection consisted of patient demographics, injury characteristics, anesthetic choice, repair technique, rehabilitation protocol, American Society for Surgery of the Hand Total Active Motion (TAM) scores, and complications. Results: There were 109 patients included in our study, with a total of 162 digits injured and 235 flexor tendon injuries. The mean age was 12 ± 4.6 years. The small finger (48 of 162; 30%) and the flexor digitorum profundus tendon (126 of 235) were the most commonly injured. The mechanism of injury was mainly from a knife (46 of 109; 42.2%) in zone II (82 of 159; 52%). Injuries were mostly repaired under general anesthetic (61 of 104; 56%). The Kessler technique was the predominant repair mechanism (111 of 225 repairs; 49%). Most patients (103 of 109; 95%) had excellent or good TAM scores with 5 postoperative ruptures reported. The most common complication was stiffness (17 of 121 complications; 14%), with most patients having no complications ( 74 of 109 patients; 68%). Patients were commonly immobilized (mean 8.4 ± 10.3 weeks) with a splint (93 of 109; 85%). There were 85 patients who followed a postoperative rehabilitation protocol for 12 ± 18 weeks. Patient demographics, time of repair, injury characteristics, anesthetic choice, and rehabilitation protocol were not significantly correlated with TAM scores or complication rates. Conclusions: Pediatric tendon injuries have good outcomes with no predictive factors identified. Surgical repairs performed under local anesthetic have similar outcomes without increased rates of complications, but remain underused in the pediatric population.

Worldwide, 4.8 billion people do not have access to safe, adequate surgical care and anaesthetic management. Surgical care has been deemed “the neglected child of global health,” a startling reminder of the disparities in health services. The provision of surgical interventions can avert 11% of the global burden of disease and 1.5 million deaths each year. Many obstacles exist for low- and middle-income countries (LMIC) to progress towards accessible surgical care. The first challenge is delivering cost-effective surgical care despite financial constraints and political turmoil. Foreign aid was established to alleviate the financial burden and its contributions have been pivotal. However, based on the political climate in certain countries, funds are siphoned to government sectors other than health care. Moreover, the lack of infrastructure, equipment, and personnel in LMIC compound the issue. The other challenge is determining if surgery is as feasible and effective as non-surgical health interventions. Surgical care is crucial and this paper aims to assess the challenges that limit its stature in global health discussions. The paper will address the influence of financing, infrastructure, workforce, service delivery, and information management on surgical care, and the current resolutions, such as humanitarian aid missions.

Introduction: One of the important factors in achieving gender equity is ensuring equitable surgical training for all. Previous studies have shown that females get significantly lower surgical exposure than males in certain surgical specialties. Gender gap in surgical exposure has never been assessed in plastic surgery. To that end, the goal of this study was to assess if there are any differences in plastic surgery training between male and female residents. Methods: A survey was sent to all plastic surgery residency programs in Canada to assess the No. of surgeries residents operated on as a co-surgeon or primary assistant during their training. The survey also assessed career goals, level of interest in the specialty, and subjective perception of gender bias. Results: A total of 89 plastic surgery residents (59.3% participation rate) completed the survey and were included in the study. The average No. of reconstructive cases residents operated on as a co-surgeon or primary assistant was 245 ± 312 cases. There was no difference in either reconstructive or aesthetic surgery case logs between male and female residents ( p > .05). However, a significantly larger proportion of females (39%) compared to males (4%) felt that their gender limited their exposure to surgical cases and led to a worsening of their overall surgical training ( p

Background: The optimal management of pediatric thumb ulnar collateral ligament (UCL) avulsion fractures remains poorly defined. The purpose of this study was to elucidate patient outcomes based on initial management and fracture characteristics. Methods: A retrospective study of all patients younger than 18 years of age presenting with a thumb UCL avulsion fracture was performed. Patients were grouped by their initial management. The primary outcome of the study was time to return to full activity. Fractures were characterized by articular surface involvement, displacement, and rotation. Results: Forty-seven patients with thumb UCL avulsion fractures were identified. Ten patients underwent surgery as initial treatment; all healed without complication, with a mean recovery time of 6.2 ± 1.8 weeks. Thirty-seven patients were treated conservatively; although most healed, the recovery time was longer (9.2 ± 8.3 weeks, adjusted hazard ratio = 2.3, 95% confidence interval = 1.0-5.5). Four cases (11%) required conversion to surgery that all healed without complications. Fractures treated with immobilization alone were significantly smaller, less displaced, and less rotated than those initially treated with surgery; however, 19 fractures that would have met criteria for surgery were treated with immobilization and successfully healed within 7.1 ± 2.9 weeks. Fracture characteristics did not predict which patients would fail conservative treatment or have prolonged recovery times. Conclusions: While surgery provided definitive treatment without delay in recovery, immobilization may not be an unreasonable treatment choice even for patients with large or displaced fractures. In cases where patients failed immobilization, surgery as a second-line treatment had good results.

International audience; Aromatic chemistry on metallic surfaces is involved in many processes within the contexts of biomass valorization, pollutant degradation, or corrosion protection. Albeit theoretically and experimentally challenging, knowing the structure and the stability of aromatic compounds on such surfaces is essential to understand their properties. To gain insights on this topic, we performed periodic ab initio calculations on Pt(111) to determine a set of simple molecular descriptors that predict both the stability and the structure of aromatic adsorbates substituted with alkyl and alkoxy (or hydroxy) groups. While the van der Waals (vdW) interaction is controlled by the molecular weight and the deformation energy by both the nature and the relative position of the substituents to the surface, the chemical bonding can be correlated to the Hard and Soft Acids and Bases (HSAB) interaction energy. This work gives general insights on the interaction of aromatic compounds with the Pt(111) surface.

Purpose: Variations in brachial plexus anatomy are common. As such, the knowledge of variations is essential for surgeons and anesthesiologists to decrease the risk of iatrogenic injuries. Moreover, brachial plexus variations often co-exist with aberrant vasculature. The median nerve is formed from contributions by the lateral and medial cords. This case report details a unique variant in the formation of the median nerve. Methods: The anatomical variant presented was identified during an upper-limb dissection of an adult cadaver.Results: The anatomical variant presented demonstrates a bifurcation of the middle trunk of the brachial plexus that coalesces to the radix of the median nerve. Although prior studies have demonstrated median nerve brachial plexus variations, the aforementioned variant arises directly from the middle trunk and communicates directly with the median nerve, while previously mentioned variants often connect to the medial or lateral cords. Conclusion: The communicating branch between the anterior division of the middle trunk and radix of the median nerve represents a unique and uncommon anatomical variation.