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Background: Functional restoration of upper limb paralysis represents a major reconstructive challenge. Free functional muscle transfer (FFMT) enables reanimation in patients with a lack of local donor tissues or delayed presentation. This systematic review summarises the evidence for FFMT in the reconstruction of upper limb paralysis. Methods: A comprehensive search of MEDLINE and EMBASE was performed with a systematic review using methodology adapted from the Cochrane Handbook and the PRISMA statement. Data from included studies were compiled and narratively synthesised. Studies were assessed for risk of bias. Results: A total of 1155 records were screened, with 39 observational studies of 904 patients included. The most common aetiology was brachial plexus injury (736, 81.4%). Mean time from injury to intervention was 26 months. Restoration of elbow flexion was the commonest reconstructive goal. The most common donor muscle was gracilis (91.5%). Reported outcomes were heterogeneous with patient-reported outcome measures (PROMs) available in only 7 of 39 studies. Nearly half of FFMTs had a post-operative MRC grade of Conclusions: FFMT may be an effective surgical intervention for upper limb paralysis; however, the current evidence has significant shortcomings. There is no consensus regarding outcome measures nor is it possible to identify prognostic factors for its effectiveness. This review highlights a need for improved study design with pre-operative assessment, standardisation in outcome reporting, and the use of PROMs to determine the effectiveness of FFMT in upper limb paralysis.

Background Hand fractures are common and sometimes require surgery to restore function. Placement of Kirschner wires (K-wires) is the most common form of surgical fixation. After placement, a key decision is whether to bury the end of a K-wire or leave it protruding from the skin (exposed). A recent systematic review found no evidence to support either approach and a national clinician and surgeon survey demonstrated further uncertainty. We aim to determine the design of a definitive randomised controlled trial assessing the cost and clinical effectiveness of buried versus exposed Kirschner wires for adults with metacarpal or phalangeal fractures. Methods We will employ three methodologies: a national service evaluation of current clinical practice, patient and surgeon focus groups and a consensus meeting to finalise the protocol for a randomised controlled trial. For the service evaluation, all outcomes will be summarised using descriptive statistics overall and split by group (buried versus exposed K-wires). Information collected in the patient focus groups will be analysed thematically. The surgeon consensus meeting will address each part of the design in turn and through discussion agree a final protocol. Discussion The study may be monitored, or audited in accordance with the current approved protocol, Good Clinical Practice (GCP), relevant regulations and standard operating procedures. The Chief Investigator will submit and, where necessary, obtain approval from the above parties for all substantial amendments to the original approved documents. A feasibility study report will be published by the Wire Study Steering committee. Additional members of the steering group and citable collaborators will be listed within the manuscript and their roles identified.

Background Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates. Objectives We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta-analysis of primary clinical studies. Methods A PRISMA-compliant systematic review and meta-analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000–27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random-effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta-analysis and meta-regression, which were presented as risk ratios (RRs). Results Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7–12·4] and for SCC 9·4% (95% CI 7·6–11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0–7·3) and SCCs (RR 4·8, 95% CI 1·0–22·8). Studies were heterogeneous (I2 = 98%) and at high risk of bias. Conclusions The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.

Background Plastic surgery training in the UK continues to evolve towards an outcome-based rather than time-served curriculum. UK plastic surgery trainees are appointed nationally, and are assessed according to national standards, but training is delivered regionally. This study sought opinion from current UK plastic surgery trainees in order to highlight strengths and shortcomings of the higher surgical training programme. Method A cross-sectional study was designed and administered by the UK Plastic Surgery Trainees Association (PLASTA). A questionnaire was distributed to all UK plastic surgery trainees holding a National Training Number, using the REDCap web-based application. Results Of the 320 UK plastic surgery trainees, 131 (41%) participated in this survey, with responses from all 12 UK training regions. The most common subspecialty career aspirations for trainees were hand surgery, cleft lip and palate, lower limb and oncoplastic breast reconstruction. The survey highlighted regional variation in teaching programmes, the ability to achieve indicative operative logbook numbers, and training in aesthetic surgery. Of the trainees, 82% expressed a desire to undertake a fellowship within their training, but most did not know whether their deanery would support this. Fifteen per cent of the respondents were currently training flexibly and the majority of these had experienced negative behaviours towards their less than full time working status. Of the respondents, 44% reported stress, 25% reported a lack of autonomy and 17% reported feeling burnt out at work at least once a week. A total of 85% perceived that they did not have access to a mentoring service. Conclusions Plastic surgery remains a popular and highly competitive surgical speciality in the UK, and many trainees reported high levels of satisfaction during their training. Aspects of training that could be improved have been highlighted and recommendations made accordingly.

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 United Kingdom 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 was 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 authors wish to acknowledge the RSTN Hand Collaborative; an official list of collaborators/individuals and institutions that participated in the study can be found in its entirety in the Declarations section.

Background: The perspective of the patient in measuring the outcome of their hand treatment is of key importance. We developed a hand-specific patientreported outcome measure to provide a means to measure outcomes and experiences of care from the patient perspective, that is, HAND-Q. Methods: Data were collected from people with a broad range of hand conditions in hand clinics in six countries between April 2018 and January 2021. Rasch measurement theory analysis was used to perform item reduction and to examine reliability and validity of each HAND-Q scale. Results: A sample of 1277 patients was recruited. Participants ranged in age from 16 to 89 years, 54% were women, and a broad range of congenital and acquired hand conditions were represented. Rasch measurement theory analysis led to the refinement of 14 independently functioning scales that measure hand appearance, health-related quality of life, experience of care, and treatment outcome. Each scale evidenced reliability and validity. Examination of differential item functioning by age, gender, language, and type of hand condition (ie, nontraumatic versus traumatic) confirmed that a common scoring algorithm for each scale could be implemented. Conclusions: The HAND-Q was developed following robust psychometric methods to provide a comprehensive modular independently functioning set of scales. HAND-Q scales can be used to assess and compare evidence-based outcomes in patients with any type of hand condition. publishedVersion

Background Advances in natural language processing and other machine learning techniques have led to the development of automated agents (chatbots) that mimic human conversation. These systems have mainly been used in commercial settings, and within medicine, for symptom checking and psychotherapy. The aim of this systematic review was to determine the acceptability and implementation success of chatbots in the follow-up of patients who have undergone a physical healthcare intervention. Methods A systematic review of MEDLINE, MEDLINE In-process, EMBASE, PsychINFO, CINAHL, CENTRAL and the grey literature using a PRISMA-compliant methodology up to September 2020 was conducted. Abstract screening and data extraction were performed in duplicate. Risk of bias and quality assessments were performed for each study. Results The search identified 904 studies of which 10 met full inclusion criteria: three randomised control trials, one non-randomised clinical trial and six cohort studies. Chatbots were used for monitoring after the management of cancer, hypertension and asthma, orthopaedic intervention, ureteroscopy and intervention for varicose veins. All chatbots were deployed on mobile devices. A number of metrics were identified and ranged from a 31 per cent chatbot engagement rate to a 97 per cent response rate for system-generated questions. No study examined patient safety. Conclusion A range of chatbot builds and uses was identified. Further investigation of acceptability, efficacy and mechanistic evaluation in outpatient care pathways may lend support to implementation in routine clinical care., The COVID-19 pandemic has necessitated a shift away from in-person consultation and follow-up. The authors performed a systematic review to determine the acceptability of using chatbots to engage with patients following intervention. They identified ten studies which report the use of chatbots following intervention and outline pragmatic steps which must be taken before clinical implementation.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and safety of different methods of surgical excision for skin cancer involving the nail unit.

Background Traumatic brachial plexus injuries affect 1% of patients involved in major trauma. MRI is the best test for traumatic brachial plexus injuries, although its ability to differentiate root avulsions (which require urgent reconstructive surgery) from other types of nerve injury remains unknown. Purpose To evaluate the accuracy of MRI for diagnosing root avulsions in adults with traumatic brachial plexus injuries. Materials and Methods For this systematic review, MEDLINE and Embase were searched from inception to August 20, 2018. Studies of adults with traumatic nonpenetrating unilateral brachial plexus injuries were included. The target condition was root avulsion. The index test was preoperative MRI, and the reference standard was surgical exploration. A bivariate meta-analysis was used to estimate summary sensitivities and specificities of MRI for avulsion. Results Eleven studies of 275 adults (mean age, 27 years; 229 men) performed between 1992 and 2016 were included. Most participants had been injured in motorcycle collisions (84%). All studies were at risk of bias, and there were high applicability concerns for the index test (ie, MRI) in four studies given the lack of diagnostic criteria, inadequate descriptions of pulse sequences, and multiplicity of reporting radiologists. Overall, 72% of patients with brachial plexus injuries had at least one root avulsion (interquartile range [IQR]: 53%-86%); meta-analysis of patient-level data was not performed because of sparse and heterogeneous data. With the nerve root as the unit of analysis, 583 of 918 roots were avulsed (median, 55%; IQR: 38%-71%); the mean sensitivity of MRI for root avulsion was 93% (95% confidence interval [CI]: 77%, 98%) with a mean specificity of 72% (95% CI: 42%, 90%). Conclusion On the basis of limited data, MRI offers modest diagnostic accuracy for traumatic brachial plexus root avulsion(s), and early surgical exploration should remain as the preferred method of diagnosis. Published under a CC BY 4.0 license. Online supplemental material is available for this article.

Introduction: Endoscopic strip craniectomy with helmeting (ESCH) has been shown to be a safe and efficacious alternative to fronto-orbital remodeling (FOR) for selected children with craniosynostosis. In addition to clinical factors, there may be economic benefits from the use of ESCH instead of FOR. Methods: A retrospective review of 23 patients with nonsyndromic unicoronal craniosynostosis (UCS) treated with FOR was carried out at Great Ormond Street Hospital (GOSH) for Children in London, UK. Secondary data were used for the ESCH cohort from a paper published by Jimenez and Barone (2013). Data were collected on surgical time, transfusion rates, length of hospital stay, adverse event rates, reintervention rates, and overall costs. Costs were categorized and then assigned to the appropriate data sets. Results: The mean age of patients undergoing FOR (vs. ESCH) was 17.4 mo (vs. 3.1 mo) with a mean surgical time of 234 min (vs. 55 min), mean transfusion volume of 221.6 mL (vs. 80.0 mL), mean transfusion rate of 14/23 (vs. 2/115), and a total immediate overnight stay of 3.13 days (vs. 97% next-day discharge). The FOR group had a higher adverse event rate (5/23 vs. 4/115, p=

ObjectivesObstructive sleep apnoea is a common chronic sleep disorder characterised by collapse of the upper airway during sleep. The nasal airway forms a significant part of the upper airway and any obstruction is thought to have an impact on obstructive sleep apnoea. A systematic review was performed to determine the role of rhinological surgical interventions in the management of obstructive sleep apnoea.MethodsA systematic review of current literature was undertaken; studies were included if they involved comparison of a non-surgical and/or non-rhinological surgical intervention with a rhinological surgical intervention for treatment of obstructive sleep apnoea.ResultsSixteen studies met the selection criteria. The pooled data suggest that there are reductions in the apnoea/hypopnea index and respiratory disturbance index following nasal surgery. However, the current body of studies is too heterogeneous for statistically significant meta-analysis to be conducted.ConclusionNasal surgery may have limited benefit for a subset of patients based on current evidence.

Background In the reconstruction of burns using split-skin grafts (SSGs), fibrin glue can be used to improve graft take and reduce haematoma formation, although the efficacy and cost-effectiveness are unknown. This systematic review evaluated outcomes of fibrin glue compared with conventional SSG attachment techniques. Outcomes of interest included SSG take, haematoma formation, patient satisfaction and cost-effectiveness. Methods This PROSPERO-registered review was performed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA statement. Embase, PubMed, Cochrane and ClinicalTrial.gov databases were searched systematically. Observational and experimental studies comparing fibrin glue with other methods of SSG attachment in burn wounds were included. Risk of bias was assessed using the Cochrane risk-of-bias and Risk of Bias In Non-Randomized Studies – of Intervention tools. The quality of the evidence was assessed using the GRADE tool. Results Two RCTs and four observational studies were included. Graft take at day 5 was not significantly different between groups (3 studies, 183 individuals). Fibrin glue significantly reduced the risk of postoperative haematoma in two studies and reduced patient-reported pain in two studies, with suggested cost savings in four studies. All studies were at risk of methodological bias and the quality of the evidence was universally very low. Conclusion As the evidence is sparse, the quality very low and the risk of bias significant both within and across studies, it is not possible to make any recommendations regarding the use of fibrin glue in burn wounds.

As the UK entered the first wave of the COVID-19 pandemic, the National Health Service published consensus guidance to UK burns services advising changes to the acute management of burns; to allow continuation of safe care while protecting limited hospital resources. We aimed to describe the demographics of burns service users, changes to clinical pathways and experiences of the burns team during the first wave of the COVID-19 pandemic. All burns services in the United Kingdom were invited to participate in a national collaborative, trainee-led study supported by the Reconstructive Surgery Trials Network. The study consisted of; (1) a service evaluation of patients receiving burns treatment during the COVID-19 pandemic; (2) a multidisciplinary team survey. Analyses were descriptive and narrative depending on data types. Collaborators from 18 sites contributed data from burns MDT surveys and 512 patients. Patient demographics were consistent with typical burns patterns in the UK. Delayed presentation occurred in 20% of cases, with 24 patients developing complications. MDT surveys indicated substantial adaptations and challenges as a result of the pandemic. Access to theatres and critical care were limited, yet a comprehensive acute burns service was maintained. Telemedicine was utilised heavily to reduce patient footfall. Adaptations in provision of burns care, including greater outpatient care and telemedicine have emerged out of necessity with reported success. The impact of reduced scar therapy and psychological interventions for burns patients during the pandemic requires longer-term follow-up. Lessons from the UK experience can be used to strategise for future pandemics.

Background Desmoplastic melanoma (DM) is an uncommon malignancy associated with a high local recurrence rate. The aim of this systematic review was to determine the positivity rate of sentinel lymph node biopsy (SLNB) in patients with DM. The secondary outcome was to establish if SLNB is warranted for both pure DM (PDM) and mixed DM (MDM). Methods A full systematic literature review of SLNB in DM was performed by two authors in January 2016. Ovid MEDLINE, Ovid EMBASE and the Cochrane Central Register of Controlled Trials were searched. Results Sixteen studies involving 1519 patients having SLNB in DM were included, of which 99 patients had positive SLNB (6.5%). Two articles reported a significantly reduced disease-free survival (DFS) with positive SLNB and three published a reduced melanoma-specific survival (MSS). Six studies compared SLNB in MDM and PDM. Of the 275 patients, 38 (13.8%) had a positive SLNB in MDM compared to 17 of 313 patients (5.4%) with positive SLNB in PDM. Conclusions Rates of positive SLNB in DM are reduced compared to other variants of melanoma; however, nodal status may still predict DFS and MSS. MDM is associated with a higher rate of micro-metastases to regional lymph nodes than PDM, and DFS and MSS may be lesser in MDM than in PDM. We would recommend the consideration of SLNB in MDM. However, with such low rates of positive SLNB in PDM, and in the absence of high-risk features to stratify patients, we would not recommend SLNB in PDM.

Background Burn injuries are the fourth most common traumatic injury, causing an estimated 180,000 deaths annually worldwide. Superficial burns can be managed with dressings alone, but deeper burns or those that fail to heal promptly are usually treated surgically. Acute burns surgery aims to debride burnt skin until healthy tissue is reached, at which point skin grafts or temporising dressings are applied. Conventional debridement is performed with an angled blade, tangentially shaving burned tissue until healthy tissue is encountered. Hydrosurgery, an alternative to conventional blade debridement, simultaneously debrides, irrigates, and removes tissue with the aim of minimising damage to uninjured tissue. Despite the increasing use of hydrosurgery, its efficacy and the risk of adverse events following surgery for burns is unclear. Objectives To assess the effects of hydrosurgical debridement and skin grafting versus conventional surgical debridement and skin grafting for the treatment of acute partial-thickness burns. Search methods In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria We included randomised controlled trials (RCTs) that enrolled people of any age with acute partial-thickness burn injury and assessed the use of hydrosurgery. Data collection and analysis Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment, and GRADE assessment of the certainty of the evidence. Main results One RCT met the inclusion criteria of this review. The study sample size was 61 paediatric participants with acute partial-thickness burns of 3% to 4% total burn surface area. Participants were randomised to hydrosurgery or conventional debridement. There may be little or no difference in mean time to complete healing (mean difference (MD) 0.00 days, 95% confidence interval (CI) -6.25 to 6.25) or postoperative infection risk (risk ratio 1.33, 95% CI 0.57 to 3.11). These results are based on very low-certainty evidence, which was downgraded twice for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in operative time between hydrosurgery and conventional debridement (MD 0.2 minutes, 95% CI -12.2 to 12.6); again, the certainty of the evidence is very low, downgraded once for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in scar outcomes at six months. Health-related quality of life, resource use, and other adverse outcomes were not reported. Authors' conclusions This review contains one randomised trial of hydrosurgery versus conventional debridement in a paediatric population with low percentage of total body surface area burn injuries. Based on the available trial data, there may be little or no difference between hydrosurgery and conventional debridement in terms of time to complete healing, postoperative infection, operative time, and scar outcomes at six months. These results are based on very low-certainty evidence. Further research evaluating these outcomes as well as health-related quality of life, resource use, and other adverse event outcomes is required.

Background Non-melanoma skin cancer, which includes basal cell carcinoma and cutaneous squamous cell carcinoma, is the commonest malignancy worldwide. The mainstay of treatment is surgical excision. Despite this being an exceptionally common procedure, it is not known what the accepted standard is for incomplete excision. Multiple single-centre, regional and national studies have previously reported their incidence of incomplete excision in isolation. Furthermore, is it not known what effect potential risk factors such as the operating group, location of lesions, type of reconstruction, histological components or use of loupe magnification have on the incidence of incomplete excisions. The objective of this study will be to systematically evaluate observational data that present incidence of incomplete surgical excision amongst adult patients with non-melanoma skin cancer worldwide. Methods We designed and registered a study protocol for a systematic review and meta-analysis of descriptive epidemiology data. A comprehensive literature search will be conducted (from January 2000 onwards) in MEDLINE, EMBASE, Scopus, CINAHL, EMCare and Cochrane Library. Grey literature will be identified through searching Open Grey, dissertation databases (e.g. Open Access Theses and Dissertations) and clinical trial registers (e.g. WHO ICTRP). Observational studies (cohort, cross-sectional, case series and clinical audits) reporting the incidence of incomplete surgical excision and conducted in adult patients with non-melanoma skin cancer will be included. The primary outcome will be the incidence of incomplete surgical excision (defined as residual tumour at either the peripheral or deep margin). Secondary outcomes will be risk factors that may affect incomplete excision (e.g. operating group, location of lesions, types of reconstruction, histological components). Data will not be extracted if the study uses other surgical techniques such as Mohs micrographic surgery, intra-operative frozen section, incision, shave or punch biopsies. Two investigators will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion. No limitations will be imposed on publication status or language of publication. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct a random effect meta-analysis of observational data. Incidence estimates will be stratified according to cancer type (e.g. basal cell carcinoma vs squamous cell carcinoma) and operating group (e.g. dermatology, plastic surgery and general practice). Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g. methodological quality, sample size). Discussion This systematic review will summarise the best available evidence and definitively establish the incidence of incomplete surgical excision in non-melanoma skin cancer. It will determine if there is variation observed amongst different operating groups and provide some evidence for potential other factors causing this difference. This knowledge will provide a standard for future audits and will contribute to improving the treatment of non-melanoma skin cancer treatment. Systematic review registration PROSPERO CRD42019157936

Background Adult brachial plexus injuries (BPI) are becoming more common. The reconstruction and prognosis of pre-ganglionic injuries (root avulsions) are different to other types of BPI injury. Preoperative magnetic resonance imaging (MRI) is being used to identify root avulsions, but the evidence from studies of its diagnostic accuracy are conflicting. Therefore, a systematic review is needed to address uncertainty about the accuracy of MRI and to guide future research. Methods We will conduct a systematic search of electronic databases alongside reference tracking. We will include studies of adults with traumatic BPI which report the accuracy of preoperative MRI (index test) against surgical exploration of the roots of the brachial plexus (reference standard) for detecting either of the two target conditions (any root avulsion or any pseudomeningocoele as a surrogate marker of root avulsion). We will exclude case reports, articles considering bilateral injuries and studies where the number of true positives, false positives, false negatives and true negatives cannot be derived. The methodological quality of the included studies will be assessed using a tailored version of the QUADAS-2 tool. Where possible, a bivariate model will be used for meta-analysis to obtain summary sensitivities and specificities for both target conditions. We will investigate heterogeneity in the performance of MRI according to field strength and the risk of bias if data permits. Discussion This review will summarise the current diagnostic accuracy of MRI for adult BPI, identify shortcomings and gaps in the literature and so help to guide future research. Systematic review registration PROSPERO CRD42016049702. Electronic supplementary material The online version of this article (10.1186/s13643-018-0737-2) contains supplementary material, which is available to authorized users.

Background: Prior to DIEP flap breast reconstruction, mapping the perforators of the lower abdominal wall using ultrasound, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) reduces the risk of flap failure. This review aimed to investigate the additional potential benefit of a reduction in operating time. Methods: We systematically searched the literature for studies concerning adult women undergoing DIEP flap breast reconstruction, which directly compared the operating times and adverse outcomes for those with and without preoperative perforator mapping by ultrasound, CTA or MRA. Outcomes were extracted, data meta-analysed and the quality of the evidence appraised. Results: Fourteen articles were included. Preoperative perforator mapping by CTA or MRA significantly reduced operating time (mean reduction of 54 minutes [95% CI 3, 105], p = 0.04), when directly compared to DIEP flap breast reconstruction with no perforator mapping. Further, perforator mapping by CTA was superior to ultrasound, as CTA saved more time in theatre (mean reduction of 58 minutes [95% CI 25, 91], p

ObjectivesThis systematic review aims to assess the quality of literature supporting surgical interventions for paediatric extravasation injury and to determine and summarize their outcomes.MethodsWe performed a systematic review by searching Ovid MEDLINE and EMBASE as well as AMED, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews andclinicaltrials.govfrom inception to February 2019. All studies other than case reports were eligible for inclusion if the population was younger than 18 years old, there was a surgical intervention aimed at treating extravasation injury and they reported on outcomes. Risk of bias was graded according to the National Institutes of Health (NIH) study quality assessment tools.Results26 studies involving 728 children were included – one before-and-after study and 25 case series. Extravasation injuries were mainly confined to skin and subcutaneous tissues but severe complications were also encountered, including amputation (one toe and one below elbow). Of the surgical treatments described, the technique of multiple puncture wounds and instillation of saline and/or hyaluronidase was the most commonly used. However, there were no studies in which its effectiveness was tested against another treatment or a control and details of functional and aesthetic outcomes were generally lacking.ConclusionThere is a lack of high quality evidence to support treatment of extravasation injury in children. A definitive trial of extravasation injuries, or a centralized extravasation register using a universal grading scheme and core outcome set with adequate follow-up, are required to provide evidence to guide clinician decision-making.Strengths and LimitationsA systematic review was performed according to PRISMA guidelines and registered on PROSPEROTwo authors used a bespoke inclusion/exclusion form to independently assess study eligibilityStudies were eligible for inclusion if the population was younger than 18 years old, if there was a surgical intervention aimed at treating extravasation injury in any setting and if they reported on short- or long-term outcomesTwo researchers also independently assessed the included studies’ risk of methodological bias using the National Institutes of Health (NIH) study quality assessment tools18 years old may represent a relatively arbitrary cut-off age to differentiate between ‘paediatric’ and ‘adult’ in terms of extravasation injury

Background Coupler devices and hand-sewn anastomosis techniques are both routinely employed for venous anastomosis in microsurgical free flap transfer. However, uncertainty remains about whether those two techniques are different in terms of risk of venous thrombosis. The aim of this review was to evaluate the quality of the evidence and quantify the difference in venous thrombosis rates in both techniques. Method A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant systematic review and meta-analysis were performed according to a previously published protocol. MEDLINE and Embase databases were searched from inception to 1 October 2018. Clinical studies using coupler devices for venous anastomoses in free tissue transfer were included. The primary outcome was post-operative venous thrombosis risk. Surgical anastomosis time was a secondary outcome. The risk of bias was assessed with the ROBINS-I or NIH tool and recommendations were made using the GRADE criteria. Results A total of 10,851 patients across 32 observational retrospective studies were included, with data available for 12,769 free flaps in breast, head and neck, limb and other reconstructions. Direct comparison meta-analysis of 7 studies showed a reduced post-operative thrombosis risk for venous coupler, although this was an imprecise estimate (RR 0.68 [95% CI 0.39–1.19]). The risk of bias was consistently high across all studies. Conclusion Venous couplers may reduce the risk of venous thrombosis, but further randomised trial data are needed to improve the accuracy of this estimate. Further research should also assess size-mismatch between donor and recipient vessel, and the influence of coupler size on outcomes (PROSPERO registration ID: CRD42018110111).

This systematic review describes and compares outcomes of operative and non-operative management of central slip extensor tendon injuries. A PRISMA-compliant methodology identified 3785 studies. Of these, 29 underwent full text review. No randomized controlled trials were identified. Nine studies evaluated treatment modalities specific to cohorts with acute central slip injuries in adults. A range of operative and non-operative elements of management was identified although no studies directly compared the two. Where aspects of rehabilitation were studied, this was always after surgery. The evidence base regarding treatment of central slip injury is limited and the roles of different treatment strategies for open as well as closed injuries are not well-supported by evidence.

Recruitment to clinical trials requires efficient and timely identification of suitable participants. Trial coordination and recruitment can be difficult in practice and can result in appropriate participants being missed. Communication between the core trial team and the recruiters ‘on the ground’ ensures all potentially eligible participants are identified and approached for recruitment.1 Much has been published regarding the use of smartphone-based communication tools in clinical care, including considerations of clinical governance and data. We present our experience of using the smartphone communication app: ‘WhatsApp’ to manage the logistics of a surgical randomised controlled trial. WhatsApp is advantageous in that it is easy to download and operate2 given that 80%–98% of clinicians own a smartphone,3 4 Furthermore, unlike email, it is an immediate communication tool with the potential for multiple group conversations with members able to contribute simultaneously and contemporaneously. It is also inclusive of all trial team members allowing everyone to be updated with the trial progress and ‘on-the-ground’ issues in real time. Our experience is drawn from the observation of two UK-based plastic surgery tertiary centres running a multicentre hand trauma surgery trial involving paediatric patients: The Nail bed INJury …

Hospital Episode Statistics (HES) include freely accessible records of all hospital episodes in England. We analysed HES from 1998–1999 to 2014–2015 for diagnoses of hand fractures, tendon injuries, nerve injuries, blood vessel injuries, traumatic amputations and nail bed injuries. Population data were used to calculate the incidence. The overall incidence of the injuries increased from 70 to 110 per 100,000. There were especially large increases in the incidence of fractures in the over 75 years age group and nail bed injuries in the 0–14 years age group. The incidence of nerve injuries also increased. We conclude from this study that HES is a useful tool. The information from HES may help plan service provision and also highlight important clinical problems that may benefit from further research.

Background: Traumatic brachial plexus injuries (BPI) affect 1% of patients involved in major trauma. Magnetic resonance imaging (MRI) is the best indicator of traumatic BPIs although its ability to differentiate root avulsions (which require urgent reconstructive surgery) from other types of nerve injury remains unknown. Methods: Medline and Embase were searched from inception to August 20th 2018, with no restrictions. Studies of adults with traumatic non-penetrating unilateral brachial plexus injuries were included. The target condition was root avulsion. The index test was pre-operative MRI and the reference standard was operative exploration of the roots of the brachial plexus. Results: Eleven studies of 275 adults were included. Most patients were males (94%) injured in motorcycle collisions (84%). The majority of studies were at unclear or high risk of bias and there were high applicability concerns for the index test (MRI) given the lack of diagnostic criteria for root avulsion, inadequate descriptions of pulse sequences and multiplicity of reporting radiologists. At least one root of the brachial plexus was avulsed in 72% of patients (IQR 53%, 86%) but meta-analysis of patient-level data was not performed due to sparse and heterogeneous data. With the nerve as the unit of analysis, 583 out of 918 roots were avulsed (median 55%; IQR 38%, 71%); the mean sensitivity of MRI for root avulsion was 93% (95% CI 77%, 98%) with a mean specificity of 72% (95% CI 42%, 90%). Conclusions: Based on the limited data, MRI has modest accuracy for diagnosing root avulsions following traumatic BPI and operative exploration should remain the diagnostic option. Funding Statement: Ryckie Wade is a Doctoral Research Fellow funded by the National Institute for Health Research (NIHR, DRF-2018-11-ST2-028). This research is supported by NIHR infrastructure at Leeds, Oxford and Birmingham. The views expressed are those of the author(s) and not necessarily those of the United Kingdom’s National Health Service, NIHR or Department of Health. Declaration of Interests: The authors state: "none." Ethics Approval Statement: The authors state: "Not required."

Highlights • A focus on sound systematic review methodology to present an unbiased and scientific assessment of the body of knowledge for migraine surgery. • Comprehensive search strategy included a range of study types to capture all relevant reports of primary clinical research, enabling a global evaluation of the topic. • A descriptive analysis allowing an overview of the likely effect of a variety of surgical interventions, with a snapshot of the rates of recurrence and adverse events. • Formalised assessment of methodological quality using the GRADE approach identifies specific flaws affecting the reliability of migraine surgery research to date. • Limited by a paucity of methodological quality in included studies, heterogeneous interventions, inconsistent outcome reporting and variability in baseline data, intervention data and outcome data., Aims Migraine is a global phenomenon, affecting more than 10% of the world's population. It is characterized by unilateral headache that may be accompanied by vomiting, nausea, photophobia and phonophobia. Some patients with chronic migraine respond to extra-cranial botulinum toxin type A injection, although the benefits observed are temporary. The rationale for surgical trigger site deactivation is to achieve lasting symptomatic improvement or permanent relief from migraine. Methods We performed a PRISMA-compliant systematic review of clinical studies evaluating surgical intervention for migraine by searching Ovid MEDLINE and EMBASE databases from inception to June 2017. Studies were independently screened by two authors. Data were extracted on study characteristics, migraine outcomes, adverse events and recurrence. The quality of evidence was assessed using the GRADE approach. The review protocol was prospectively registered on the PROSPERO database (CRD42017068577). Results The search strategy identified 789 articles; of them, 18 studies (4 RCTs and 14 case series) were eligible for analysis. Surgical interventions were heterogeneous and variably involved peripheral nerve decompression by myectomy or foraminotomy, nerve excision, artery resection and/or nasal surgery. All studies reported significant reductions in migraine intensity, frequency, duration and composite headache scores following surgery. Study heterogeneity precluded formal meta-analysis. Where reported, adverse event rates varied markedly between studies. The quality of included studies was consistently low or very low. Conclusion There is insufficient evidence to support the effectiveness of any specific surgical intervention for chronic migraine, especially with regard to permanent relief; however, all included studies report improvements in key outcomes following migraine surgery. A definitive, well-powered RCT with objective surgical and patient-reported outcome measures and robust adverse event reporting is required.

Key Clinical Message Aorto‐esophageal fistula is often a terminal event in many patients. The commonest causes are thoracic aortic aneurysm and esophageal malignancy. To achieve a good outcome in this condition, a MDT approach is required that combines the expertize of vascular surgeons, radiologists, and emergency physicians.

Outcome measurement in plastic surgery is often surgeon-centred, and clinician-derived. Greater emphasis is being placed on patient-reported outcomes (PROs), in which the patients' perspective is measured directly from them. Numerous patient-reported outcome measures (PROMs) have been developed in a range of fields, with a number of good quality PROMs in plastic surgery. They can be deployed to support diagnosis, disease severity determination, referral pathways, treatment decision-making, post-operative care and in determining cost-effectiveness. In order to understand the impact of disease and health interventions, appropriate PROMs are a logical choice in plastic surgery, where many conditions involve detriment of function or cosmesis. PROMS can be classified as disease-specific, domain-specific, dimension-specific, population-specific and generic. Choosing the correct outcome and measure can be nebulous. The two most important considerations are: is it suitable for the intended purpose? And how valid is it? Measurement that combines being patient-centred and aligning with clinicians' understanding is achievable, and can be studied scientifically. Rational design of new PROMs and considered choice of measures is critical in clinical practice and research. There are a number of tools that can be employed to assess the quality of PROMs that are outlined in this overview. Clinicians should consider the quality of measures both in their own practice and when critically appraising evidence. This overview of outcome measurement in plastic surgery provides a tool set enabling plastic surgeons to understand, implement and analyse outcome measures across clinical and academic practice.

Background:The aim of this study was to evaluate the effectiveness of interventions for acute complete rupture of the ulnar collateral ligament (UCL) of the thumb in adults.Methods:The following databases were searched: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO, from database inception to 31stJanuary 2018. Inclusion criteria were: (i) randomised controlled clinical trials (RCTs) or study of intervention with a comparator; (ii) participants with diagnosis of acute complete rupture of the UCL of the thumb; (iii) participants aged 18 years of age or older at enrolment; and (iv) published in a peer-reviewed English-language journal.Results:In total, six studies were identified for inclusion after screening. All studies had a high risk of bias. Three studies were retrospective comparative case series which compared two different surgical techniques (bone anchor versus pull out suture, suture versus pull out suture, suture versus steel wire). Of these studies, three were RCTs, two of which compared different rehabilitation regimes in patients managed surgically (plaster versus early mobilization, new spica versus standard spica). The remaining RCT compared two different rehabilitation regimes in a mixed group of surgically/non-surgically treated patients. The RCT comparing a standard spica with a new spica demonstrated a statistically significant improvement in outcomes with the new spica at all time points (range of motion, Dreiser index and VAS); this was also the only study to provide sufficient outcome data for further analysis.Conclusion:There is no prospective evidence comparing surgery to non-operative treatment for acute complete ruptures of the ulnar collateral ligament of the thumb. There is weak evidence to suggest that early mobilisation may be beneficial following surgical repair. Further research is necessary to better define which patients benefit from which specific interventions.

BACKGROUND: Carpal tunnel syndrome is a common problem and surgical decompression of the carpal tunnel is the most effective treatment. After surgical decompression, the palmar skin may be closed using either absorbable or non‐absorbable sutures. To date, there is conflicting evidence regarding the ideal suture material and this formed the rationale for our review. OBJECTIVES: To assess the effects of absorbable versus non‐absorbable sutures for skin closure after elective carpal tunnel decompression surgery in adults on postoperative pain, hand function, scar satisfaction, wound inflammation and adverse events. SEARCH METHODS: We searched the following databases on 30 October 2017: the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two clinical trials registries on 30 October 2017. SELECTION CRITERIA: We considered all randomised or quasi‐randomised controlled trials comparing absorbable and non‐absorbable sutures for skin closure after any form of carpal tunnel decompression surgery in adults. DATA COLLECTION AND ANALYSIS: The unit of analysis was the hand rather than the patient. We performed meta‐analysis of direct comparisons to generate standardised mean differences (SMDs) with 95% confidence intervals (CIs) in pain scores and risk ratios (RRs) with 95% CIs for dichotomous outcomes, such as wound inflammation. The primary outcome was postoperative pain. Secondary outcomes included hand function, scar satisfaction, scar inflammation and adverse events (complications). We assessed the quality of evidence for key outcomes using GRADE. MAIN RESULTS: We included five randomised trials (255 participants). The trials were all European (UK, Republic of Ireland, Denmark and the Netherlands). Where quoted, the mean age of participants was between 48 and 53 years. The trials measured outcomes between one and 12 weeks postoperatively. Meta‐analysis of postoperative pain scores for absorbable versus non‐absorbable sutures at 10 days following open carpal tunnel decompression (OCTD) produced a SMD of 0.03 (95% CI ‐0.43 to 0.48; 3 studies, number of participants (N) = 137; I(2) = 43%); the SMD suggests little or no difference, but with a high degree of uncertainty because of very low‐quality evidence. At 10 days following endoscopic carpal tunnel decompression (ECTD), the SMD for postoperative pain with use of absorbable versus non‐absorbable sutures was ‐0.81 (95% CI ‐1.36 to ‐0.25; 1 study; N = 54); although the SMD is consistent with a large effect, the very low‐quality evidence means the results are very uncertain. Only the OCTD studies provided pain data at 6 weeks, when the SMD was 0.06 (95% CI ‐0.72 to 0.84; 4 studies; N = 175; I(2) = 84%), which indicates little or no evidence of difference, but with a high degree of uncertainty (very low‐quality evidence). The RR for wound inflammation using absorbable versus non‐absorbable sutures after OCTD was 2.28 (95% CI 0.24 to 21.91; N = 95; I(2) = 90%) and after ECTD 0.93 (95% CI 0.06 to 14.09; 1 study, N = 54). Any difference in effect on wound inflammation is uncertain because the quality of evidence is very low. One study reported postoperative hand function but found no evidence of a difference between suture types at two weeks (mean difference (MD) ‐0.10, 95% CI ‐0.53 to 0.33, N = 36), with similar findings at six and 12 weeks. Only the ECTD trial reported scar satisfaction, with 25 out of 28 people reporting a 'nice' result in the absorbable‐suture group, versus 18 out of 26 in the group who received non‐absorbable sutures (RR 1.29, 95% CI 0.97 to 1.72, N = 54). These findings are also very uncertain as we judged the quality of the evidence to be very low. All studies were at high risk of bias for most domains. No trials reported adverse events. AUTHORS' CONCLUSIONS: It is uncertain whether absorbable sutures confer better, worse or equivalent outcomes compared to non‐absorbable sutures following carpal tunnel decompression, because the quality of evidence is very low. Use of absorbable suture eliminates the need for suture removal, which could confer considerable savings to patients and healthcare providers alike. We need rigorously‐performed, non‐inferiority randomised trials with economic analyses to inform choice of suture.

Purpose Fractures of the lateral condyle of the humerus in children are a common injury. If displaced or unstable they may require surgical reduction and fixation with Kirschner wires (K-wires). K-wires are placed using either an open or closed technique. The decision to bury or leave the ends extending through the skin is surgeon-dependent and based on factors including post-operative infection risk, bony union and ease of wire removal. Methods We performed a systematic review and meta-analysis of non-buried versus buried K-wires for lateral condyle elbow fractures in children in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A comprehensive search strategy included Medline, Embase and CINAHL via NICE Evidence from database inception to June 2017. Two authors independently reviewed, included or excluded articles, extracted data and assessed for quality with the ROBINS-I tool. We performed direct comparison meta-analysis for all adverse events, post-operative infection and failure of bony union. Results Three studies were analysed comprising of 434 participants. There was a significantly reduced relative risk of adverse events in the non-buried group, equating to approximately 45% reduced risk (RR 0.55, 95% confidence interval 0.34 to 0.88). There were no significant differences in risk of post-operative infection or failure of bony union. All three cost-analyses in the included studies observed savings with non-buried K-wires. Conclusion Non-buried K-wires for lateral condyle elbow fractures convey a lower risk of adverse events and may be more cost-effective compared with buried K-wires. Non-buried K-wires do not appear to increase the risk of infection or failure of bony union. These findings are limited by a high risk of bias due to inherent methodological flaws in the design of included studies.

Long-term survival after esophagectomy is improving, and hence, quality of life (QOL) of these patients has become a priority. There has been extensive debate regarding the optimal site of surgical anastomosis (cervical or intrathoracic). We aimed to evaluate the impact of anastomotic site on long-term QOL postesophagectomy. Quality of life questionnaires (European Organisation for Research and Treatment of Cancer [EORTC] C-30 and OG-25) were sent to patients surviving over 3 years following esophagectomy. The data were analyzed by site of esophagogastric anastomosis: intrathoracic or cervical. EORTC C-30 data were compared against the reference population data. Of the patients, 62 responded (82%) with a median time postsurgery of 6.1 years (range 3-12 years). Patient demographics were comparable. There was no significant difference between cervical or intrathoracic anastomosis groups for functional or symptom scores, focusing on dysphagia (cervical = 8.8 vs. intrathoracic = 17.6, P = 0.24), odynophagia (cervical = 13.4 vs. intrathoracic = 16.1, P = 0.68) and swallowing problems (cervical = 8.1 vs. intrathoracic = 13.4, P = 0.32). There was no difference in overall health score between groups (cervical = 70.5 vs. intrathoracic = 71.6, P = 0.46). Overall general health score was comparable with the reference population (esophagectomy group P = 70.9 ± 22.1 vs. reference population = 71.2 ± 22.4, P = 0.93). There is no difference in long-term QOL after esophagectomy between patients with a cervical or intrathoracic anastomosis. Scores compare favorably with EORTC reference data. Survival after esophagectomy is associated with recovery of QOL in the long term, regardless of site of anastomosis and despite worse gastrointestinal-related symptoms.

Craniosynostosis has an incidence of 1 in 2000 to 2500 live births and may be corrected through several methods including total calvarial remodeling and frontal orbital advancement remodeling. Blood loss during craniosynostosis surgery can be substantial, ranging from 20% to 500% of total circulating volume with a high associated risk of transfusion-related adverse events. The authors performed a retrospective analysis of all patients undergoing surgery for craniosynostosis at a tertiary pediatric craniofacial center with a focus on blood loss and subsequent transfusion.The authors reviewed 40 patients with craniosynostosis16 years at a single-center. Data on perioperative blood loss and transfusion were obtained, including pre-, intra-, and postoperative hemoglobin, hematocrit, and use of tranexamic acid. The authors calculated estimated percentage of circulating red cell volume lost and transfused.The majority of patients had sagittal synostosis and underwent total calvarial remodeling (n = 20); the rest underwent frontal orbital advancement remodeling (n = 19) or lambdoid correction (n = 1). The average estimated volume red cell loss was 77% of circulating volume and 90% of patients received blood transfusion with an average 88.3% transfusion of circulating red cell volume. Longer operative time, younger age, and lower weight predisposed to50% blood volume transfusion (P = 0.032,0.005,0.005 respectively).This single-center observational study reports red cell volume loss and volume of transfusion in children undergoing surgical correction of craniosynostosis. Red cell volume loss was comparative to that in the literature and in this cohort longer operative time, younger age, and lower weight predisposed to50% blood volume transfusion.

Your recently published review by AA Sayampanthan into diabetic patients with burns trauma found that whilst they may suffer from higher rates of complication, diabetic patients do not have a longer length of stay (LoS) compared to non diabetic patients. Interestingly an analysis conducted at our ownregional burns unit found a different result, regarding LoS, when focusing on burns to the lower extremity, and may indicate a more complex patient cohort.

Fractures of the upper extremity are common with bones in the hand most frequently fractured. Hand fractures are typically seen in men of working age, distal radius fractures in an older population following a fall and supracondylar fractures in children.1 Kirschner wire (K-wire) fixation is the most common method of surgical fixation. One of the key decisions is whether to bury or not to bury the wire ends. Current popular opinion suggests that buried wires reduce infection rates. However, burying wires still retains a risk of erosion through the skin with subsequent pin site infection. It is also unclear whether a pin site infection of a non-buried wire affects outcomes and is significant risk factor for deep bone infection. The aim of this systematic review was to evaluate the current evidence to support decision-making as to whether K-wires should be buried or not buried following fracture fixation in the upper extremity with regards to post-operative outcomes.

Background Studies have suggested that contact between opposing mucosal surfaces in the nasal wall and cavity can be a target of the surgical treatment of migraines. Unfortunately, not enough is known about the role of nasal pathology in the pathogenesis of this condition. The co-existence of further rhinological disorders can be an impediment to defining the cause and effect of anatomical variants. The authors compared the MRI scans of migraine- and non-migraine patients (MPs and NMPs, respectively) to determine the prevalence of such mucosal contact points in order to extrapolate whether there is a significant association with migraines. Methods Coronal and axial MRI brain scans of 522 patients (412 migraineurs and 110 non-migraineurs) were analysed for the prevalence of anatomical variations of the nasal cavity, e.g. concha bullosa, septal deviations, mucosal swelling and contact points. Results The results showed no significant difference between MPs and NMPs patients for any of the parameters examined. Moreover, 87% MPs and 79% NMPs had at least one contact point. The most frequent contact point was between the middle turbinate and the septum, observed in 54% of MPs and 45% of NMPs. Conclusions Contact points with the nasal mucosa are highly prevalent in both MPs and NMPs. Although a contact point does not cause a migraine in the absence of the disease, the concomitant presence of migraine and contact points can trigger an attack, and therefore, it is necessary to differentiate or exclude a rhinological disorder in these patients.