Ilioinguinal nerve excision in open mesh repair of inguinal hernia--results of a randomized clinical trial: simple solution for a difficult problem?

BACKGROUND: Inguinodynia is the second most common complication occurring after inguinal hernia repair. This study was undertaken to evaluate the effect of ilioinguinal nerve excision, a concept previously proposed to be performed during open hernia mesh repair, on postsurgical pain and hyposthesia. METHODS: A double-blind randomized clinical trial was performed on 121 patients undergoing open anterior mesh repair of inguinal hernia in 1 center from April 2005 through June 2006. The ilioinguinal nerve was excised in half of the patients and preserved in the other half. Pain and hyposthesia at POD 1, 1 and 6 months after surgery, and 1 year after surgery was evaluated in both groups using a visual analog scale. Results were compared using chi-square analysis. RESULTS: Of the total number of 121 patients who entered the study, with an age range of 18 to 86 years (mean +/- SD 45 +/- 18), 115 (95%) were male. Sixty-one were in the nerve-excision group, and 60 were in the nerve-preservation group. One hundred patients were followed-up until the end of the first year. Using the visual analog scale to detect pain severity on postsurgical day 1, mean scores in the nerve-excision and nerve-preservation groups were 2.2 +/- .8 (range 1 to 4) versus 2.8 +/- .7 (range 2 to 4.5), respectively (P < .001). At 1 month after surgery, these scores were .7 +/- .7 (range 0 to 3) versus 1.5 +/- .7 (range 0 to 3.5), respectively (P < .001). Between 6 months and 1 year after surgery, median scores of zero were detected in both groups. After postsurgical day 1, the median score of hyposthesia was near zero in both groups. Thirteen patients developed chronic inguinodynia (13%), 10 of whom were in the nerve-preservation group. Chronic postsurgical inguinodynia was seen in 6% of patients in the ilioinguinal nerve-excision and 21% of the patients in the ilioinguinal nerve-preservation group (P = .033). COMMENTS: Neurectomy decreases postsurgical pain after elective inguinal hernia repair. Although chronic inguinodynia was less frequent in our study than reported by many previous studies, it is still wise to recommend ilioinguinal neurectomy in patients undergoing anterior inguinal hernia mesh repair.     

Prophylactic antibiotics for clean, non-implant plastic surgery: what is the evidence?

Use of prophylactic antibiotics in clean surgery is widespread, but their timing and selection is often based on convention and personal and local departmental preferences. There is insufficient robust evidence on which to base such decisions prophylactic antibiotics; plastic surgery; antibiotics; postoperative infection; surgical site infection.     

Retroperitoneal sarcoma: Time for a change in attiude?

Background : Retroperitoneal sarcoma (RPS) is considered a disease with poor prognosis partly because of the difficulty with diagnosis at an early stage. This review assesses the current best practice principles for RPS and finds evidence suggesting a better outlook for appropriately managed cases. Recommendations are made for improving diagnostic certainty before laparotomy and inappropriate transperitoneal biopsy occur. Methods : A critical review of the English language literature was conducted using MEDLINE software and searching the terms ‘retroperitoneal sarcoma’ alone or in combination with ‘prognosis’, ‘surgery’ and ‘adjuvant therapy’. Conclusions : Retroperitoneal sarcoma is a rare disease but when appropriately managed the disease‐free survival can be improved and may even approach that of extremity soft tissue sarcoma. One of the greatest barriers to improving outcome is the misinterpretation of clinical signs and an over‐reliance on ultrasound diagnosis in pelvic presentations, or misinterpretation of clinical signs and/or computer tomography (CT) scans in abdominal masses. Physicians referring patients with a retroperitoneal mass should consider more frequently the less common differential diagnoses of an abdominopelvic mass including retroperitoneal sarcoma. This is especially true in circumstances where there is a circumscribed, predominantly solid tumour, with clinical or radiological signs of vascular or rectal displacement, ureteric obstruction and/or classic renal rotational displacement. The more frequent use of CT scans with intravenous and oral contrast with referral prior to inappropriate transperitoneal biopsy is recommended. In atypical cases where preoperative biopsy is necessary, extraperitoneal routes are preferable. Complete en bloc surgical excision at the first laparotomy is the treatment of choice in RPS. Macroscopic clearance may necessitate resection of adjacent viscera, neurovascular structures or abdominopelvic walls but, if achieved, may lead to long‐term survival depending on individual tumour biology.     

Hierarchy of evidence: a simple system for orthopaedic research?

To be able to make a sound recommendation for a treatment based on the best available evidence, it is necessary to follow specific steps in acquiring literature, appraising the study design and quality, and assessing the results. Evidence-based medicine is founded on the concepts of using best evidence, levels of evidence, and grades of recommendation, and aims to provide clinicians with standardized rules to help them appraise the validity of published research. A number of systems have been developed to categorize research studies into consistent levels of evidence. These systems are based primarily on consensus expert opinion, and have not been validated to any extent. The use of different systems does not allow for effective communication between users; there is a lack of accord even between users of the same system. The GRADE working group has devised a new rating system that attempts to address deficiencies seen within other systems.     

Versatility of lateral arm flap for hand reconstruction—a clinical experience

Background

The lateral arm free flap (LAFF) has several advantages in hand reconstruction due to multiple factors. We aimed to show the versatility of LAFF in treating hand defects.

Methods

A retrospective analysis of all LAAF for hand reconstruction carried out at our institutions between August 2006 and August 2012 was undertaken. Clinical records were reviewed with respect to patients’ age and gender, size and location of defect, type and size of flaps, and complications.

Results

Twenty-four hand defects were reconstructed using LAFF. These included 15 cutaneous flaps, 8 fascial flaps, and 1 osteocutaneous flap. All flaps survived well except for one case that developed arterial insufficiency and required anastomotic revision. Primary closure of the donor site was possible in all patients. No complications occurred during the healing procedure.

Conclusions

The free lateral arm flap is a versatile and reliable option for defect coverage at the hand for small- and medium-size defects. It can be raised as a cutaneous, fascial, or osteocutaneous flap. Several advantages favor the use of lateral arm flap in hand reconstruction. These include preservation of major arm blood vessels, its constant vascular anatomy, long pedicle, and low donor site morbidity.Level of Evidence: Level IV, therapeutic study.

     

How many patients do we need for a clinical trial? Demystifying sample size calculations

Determining the number of subjects required for a study is a critical component when planning a research project. An adequate number of patients are needed in order to be able to answer the research question of interest with a degree of certainty. In this paper, the information that is required for determining the sample size is described. The primary aim is to demystify the sample size section in published clinical trials. Some of the difficulties in determining the sample size correctly are also highlighted and some good practices recommended.     

Outcome models in peripheral nerve repair: Time for a reappraisal or for a novel?

Peripheral nerve injuries are still underestimated. The complexity of assessment of outcome after nerve injury and repair has been described by many authors. Furthermore, the outcome is influenced by several factors that depend on mechanisms in the peripheral as well as the central nervous system. Appropriate formulation of a global accepted postoperative clinical protocol for peripheral nerve repair in the upper extremity remains a subject of debate. The purpose of this review is to detail the current concepts of methods of evaluation after peripheral nerves repair. Finally, we discuss the most crucial factors that determine the final hand function and we consider the challenges that need to be addressed to create a realistic clinical protocol that reflects a prognostic importance.