MCS

Abstract:

Venous thromboembolic disease (VTED) is a devastating complication following lower extremity total joint arthroplasty. Various guidelines have been proposed for VTED prevention, the most prevalent being the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). Although there were disagreements in the previous guidelines, there has recently been concordance with the two organizations. Additionally, there are various new pharmacological agents and mechanical devices being utilized and developed for VTED prevention. Therefore, in this review we aim to: (1) evaluate the current ACCP and AAOS guidelines, (2) discuss new chemoprophylactic agents currently available, (3) report briefly on mechanical compression devices to prevent VTED in patients undergoing lower extremity total joint arthroplasty.

Authors:

Julio J. Jauregui, MD, Orthopedic Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland , Bhaveen H. Kapadia, MD, Orthopedic Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Samik Banerjee, MBBS, MS (Orth.), MRCS (Glasg.) , Orthopedic Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Jeffrey J. Cherian, DO, Orthopedic Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Co-Director, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Rajit Chakravarty, MD , Resident, Drexel University College of Medicine, Department of Orthopaedic Surgery, Philadelphia, Pennsylvania

PMID:  24700231

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Abstract:

The modern generations of cementless hip arthroplasty implant designs are based on the precise fit and fill of components within the native bony geometry of the proximal femur and the acetabulum for improved implant longevity. Variations exist based on a number of population demographics such as age, gender, body mass index, and ethnicity. Recently, establishment of comprehensive electronic computerized tomographic databases from a diverse population worldwide have been key innovations in the field of implant development. This technology provides a potential improvement compared to historical techniques of implant design and manufacturing which involved limited trials on cadavers. Segmentation of the computerized data to generate three-dimensional models allows precise and accurate measurements of anatomical structures and may provide better understanding of anthropometric variations that occur among individuals. Evidence- and population-based computational analyses may provide a better tool for designing orthopaedic implants that deliver a better fit for a more diverse patient population. Moreover, these population-based databases can also validate new designs by means of virtual implantation and analysis on specific or large groups of bones within the database. The aim of this paper is to describe a three dimensional modeling and analytical technology and to review the various applications of this technology in relation to hip arthroplasty.

Authors:

Samik Banerjee, MBBS, MS, (Orth), MRCS (Glasg), Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Department of Orthopaedic Surgery , Sinai Hospital of Baltimore , Baltimore, Maryland, Ahmad Faizan, PhD, Principal Engineer,, Stryker Orthopaedics Inc., Mahwah, New Jersey, Jim Nevelos, PhD, Director , Hip Research, Stryker Orthopaedics Inc., Mahwah, New Jersey , Stefan Kreuzer, MD, Associate Professor , Department of Orthopaedic Surgery,, University of Texas Health Sciences Center , Houston, Texas, Rainer Burgkart, MD, Professor , Clinic of Orthopaedics and Sports Orthopaedics, Klinikum r.d. Isar, Technische Universität München , München, Germany, Steven F. Harwin, MD, Chief, Division of Adult Reconstruction and Total Joint Replacement, Department of Orthopaedic Surgery, Mount Sinai Health System, Beth Israel Medical Center, New York, New York, Michael A. Mont, MD, Director, Rubin Institute for Advanced Orthopedics , Center for Joint Preservation and Replacement , Department of Orthopaedic Surgery, Sinai Hospital of Baltimore , Baltimore, Maryland

PMID:  24574016

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Abstract:

The routine use of drains in surgery has been dogmatically instituted in some disciplines. Orthopaedic surgery is one such sub-speciality. The use of postoperative closed suction drainage in total hip arthroplasty (THA) has become increasingly controversial with multiple randomised control trials performed to assess the benefit to outcome in THA. The hypothesis of this systematic review is that closed suction drainage does not infer a benefit and increase transfusion requirements of primary total hip arthroplasty patients. A systematic review and meta-analysis was conducted adhering to the PRISMA guidelines. A search of the available literature was performed on PubMed, Cochrane Central Registry of Controlled Trials, MEDLINE (OVID) and EMBASE using a combination of MeSH terms and Boolean operators. All data analysis was performed using the Cochrane Collaboration’s Review Manager 5.1. Sixteen studies (n=2705) were included in the analysis. Post-operative closed suction drainage was found to increase total blood loss and blood transfusion requirements (p< 0.05). Surgical site infection demonstrated no significant difference between the two groups (p=0.82). No significant difference in haematoma formation between groups (p=0.19) was elicited. The routine use of closed suction drainage systems post primary hip arthroplasty is not supported by this meta-analysis. However, the heterogeneity between studies does limit the accuracy of the meta-analysis.

Authors:

Enda G. Kelly, MD, Surgical Trainee, Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland, James P. Cashman, MD, Consultant Orthopaedic Surgeon , Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland, Farrah H. Imran, MD, Consultant Plastic and Reconstructive Surgeon, Head of Plastic and Reconstructive Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia, Ronán Conroy, BA , Professor of Biostatistics , Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin. Ireland, John O’Byrne, MD, Professor of Orthopaedic Surgery , Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland

PMID:  24574017

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Abstract:

In comparison with standard surgical techniques robotic-assisted surgery has the advantages of increased surgical accuracy, reproducibility, optimization of component position, and improved patient outcomes in unicompartmental knee arthroplasty (UKA) and total hip arthoplasty (THA) procedures. The MAKO Tactile Guidance System (TGS; MAKO Surgical Corp, Fort Lauderdale, FL) facilitates robotic-assisted arthroplasty procedures currently implemented in many operating rooms. The benefits of this technology are evident, but have not been shown to improve patient outcomes and justify the added financial burden imposed. Further research is needed to determine if this technological advancement will translate into improvements in longevity and clinical outcomes.

Authors:

Steven D. Werner, DO, Adult Reconstruction Specialist, The Center for Orthopedic Research and Education, Sun City West, Arizona, Matthew Stonestreet, MD, Adult Reconstruction Fellow, The Center for Orthopedic Research and Education, Sun City West, Arizona, David J. Jacofsky, MD, Chairman, The Center for Orthopedic Research and Education, Phoenix, Arizona

PMID:  24574012

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Abstract:

The purpose of this study was to define the ability of a novel acetabular positioning device with 3D preoperative planning (AID) to improve acetabular component placement in total hip arthroplasty. Four surgeons placed the acetabular component in two Sawbones® models using three different methods: standard method, 3D planning method, and the AID method. The AID significantly decreased the mean deviation of actual acetabular component inclination from the preoperative plan when compared with standard and 3D planning methods (p = 0.003). Overall, AID reduced the number of malpositioned implants to 12.5%, compared with 87.5% in the standard method and 75% in the 3D planning method without use of the AID (p = 0.005). A clinical trial is needed to compare AID to standard surgical techniques.

Authors:

Anas Saleh, MD, Clinical Research Fellow, Bishoy V. Gad, MD, MS, MBA, Resident, Carlos A. Higuera, MD, Associate Staff, Alison K. Klika, MS, Research Program Manager, Joseph P. Iannotti, MD, PhD, Chair, Orthopaedic and Rheumatologic Institute, Wael K. Barsoum, MD, Vice-Chair, Orthopaedic Surgery, Chair, Surgical Operations, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio

PMID:  24526421

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Abstract:

3D printing is an emerging technology that is primarily used for aiding the design and prototyping of implants. As this technology has evolved it has now become possible to produce functional and definitive implants manufactured using a 3D printing process. This process, however, previously required a large financial investment in complex machinery and professionals skilled in 3D product design. Our pilot study’s aim was to design and create a 3D printed custom orthopaedic implant using only freely available consumer hardware and software. Standard CT scans were used to create a 3D surface render of a cadaveric radial head. This was then manipulated, mirrored, and converted into an implant, which was 3D printed in stainless steel using a consumer service. The model produced was an accurate mirror image replica of the patient’s original anatomy showing no significant statistical difference when the CT model was compared with the cadaveric model (p = 0.23) or when the 3D printed radial head model was compared with the cadaveric original (p = 0.42). Production from original CT scan took a total of 10 days, and the total cost including shipping was £32.

Authors:

Mr Mark Frame, MBChB, FRCS Glas, Tr & O, Orthopaedic Specialist Registrar Year 8, Western Infirmary , Glasgow, Scotland, Mr William Leach, MBChB, FRCS Ed, Tr & O, Consultant Orthopaedic Surgeon, Western Infirmary , Glasgow, Scotland

PMID:  24574013

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Abstract:

This section will complement other recent review articles of blood conservation in total hip arthroplasty. The purpose of this review was to provide a broad overview, as well as to evaluate the recent evidence on surgical intra-operative blood management strategies utilized for total hip arthroplasty. In this section, we specifically evaluated the use of bipolar sealants, patient positioning, wound compression, computer-assisted surgery, minimally invasive surgical approach, and cemented versus noncemented prostheses.

Authors:

Jeffrey J. Cherian, DO, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Bhaveen H. Kapadia, MD, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Samik Banerjee, MD, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Julio Jauregui, MD, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Kimona Issa, MD , Research fellow , Seton Hall University School of Health and Medical Sciences , Department of Orthopaedic Surgery , South Orange Village, New Jersey, Steven F. Harwin, MD, Chief of joint reconstruction, Beth Israel Medical Center, Adult Reconstruction and Total Joint Replacement Service, New York, NY, Michael A. Mont, MD, Director of Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD

PMID: 

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Abstract:

The substantial blood loss that can occur during total hip arthroplasty frequently requires allogeneic transfusions. Both allogeneic transfusions and post-operative anemia are causes of increased morbidity, cardiovascular risks, and length of stay. This anemia can also lead to decreased vigor, suboptimal rehabilitation, and lowered quality of life in patients undergoing total hip arthroplasty. The aim of this review was to analyze recent evidence on nonsurgical intra-operative blood management strategies utilized for total hip arthroplasty. Specifically, we evaluated the use of fibrin sealants, desmopressin, acute normovolemic hemodilution, hypotensive anesthesia, blood salvage, and peri-operative normothermia. No single strategy has been shown to provide superior results over another in reducing the need for allogeneic transfusions. However, a combination of the above blood management strategies may further result in reduced blood loss over one strategy. Larger prospective randomized studies comparing the individual strategies, as well as their combination, are needed to develop the best algorithm that can be the most effective and safe for intra-operative blood management in total hip arthroplasty.

Authors:

Jeffrey J. Cherian, DO, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Samik Banerjee, MD, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Bhaveen H. Kapadia, MD, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Guneet S. Sodhi, BS, Medical Student, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Kimona Issa, MD , Research fellow , Seton Hall University School of Health , and Medical Sciences , Department of Orthopaedic Surgery , South Orange Village, New Jersey, Steven F. Harwin, MD, Chief of joint reconstruction, Beth Israel Medical Center, Adult Reconstruction and Total Joint Replacement Service, Michael A. Mont, MD, Director of Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD

PMID:  24347481

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Abstract:

Total hip arthroplasty is increasing in incidence due to our aging population. However, this procedure has a high potential for increased blood loss, with allogeneic blood transfusions commonly used. However, due to potential transfusion-related risks such as immunosuppression or infections, attempts have been made to reduce the amount of blood loss and minimize transfusions. Therefore, our aim was to provide a broad overview of the widely used methods for reducing post-operative blood loss after total hip arthroplasty. These include antifibrinolytic agents, autologous blood transfusion drains, avoiding the use of drains, and modifications in drainage techniques. In addition, lowering the transfusion threshold is another method used to decrease the rates of allogeneic blood transfusion. Current evidence suggests that the use of some of these strategies—either alone, or in combination—may reduce the amount of blood loss and the need for allogeneic transfusions. However, further research is needed to create new, more standardized guidelines.

Authors:

Julio J. Jauregui, MD, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Kimona Issa MD, Research fellow , Seton Hall University School of Health , and Medical Sciences , Department of Orthopaedic Surgery , South Orange Village, New Jersey, Bhaveen H. Kapadia, MD, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Samik Banerjee, MD, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Steven F. Harwin, MD, Chief of joint reconstruction, Beth Israel Medical Center, Adult Reconstruction and Total Joint Replacement Service, New York, NY, Michael A. Mont, MD, Director of Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD

PMID:  24347484

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Abstract:

Total hip arthroplasty is associated with extensive blood loss, which is often corrected using allogeneic blood transfusions. However, Jehovah’s Witnesses often refuse allogeneic blood transfusions or certain types of autologous blood transfusions due to their religious beliefs. This may represent a tremendous challenge for the orthopaedic surgeon and their team. Performing a total hip arthroplasty on a Jehovah’s Witness patient requires a well-trained group of physicians willing to pre-operatively optimize the patient, attempt to minimize the blood loss during the surgery, adequately manage the post-operative period, and be aware of which of the life-saving strategies can be used in these patients during an emergency situation. Ultimately, physicians should be prepared to deal with marked blood loss and respect the patients’ wishes, values, and beliefs. This review focuses on studies where primary or revision total hip arthroplasty was performed in Jehovah’s Witness patients. Therefore, we will illustrate that with a prepared team and an optimized patient, it is potentially quite safe to perform total hip arthroplasties in Jehovah’s Witness patients.

Authors:

Julio J. Jauregui, MD, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Bhaveen H. Kapadia, MD , Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Samik Banerjee, MD, Research fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, Kimona Issa, MD , Research fellow , Seton Hall University School of Health , and Medical Sciences , Department of Orthopaedic Surgery , South Orange Village, New Jersey, Sherwin Su, MD, Orthopaedic surgery resident, Seton Hall University of Health , and Medical Sciences, Paterson, NJ, Steven F. Harwin, MD, Chief of joint reconstruction, Beth Israel Medical Center, Adult Reconstruction and , Total Joint Replacement Service, New York, NY, Michael A. Mont, MD, Director of Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD

PMID:  24347482

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Abstract:

The development of three-dimensional (3D) knee models and analytical tools from large databases of computerized tomographic data linked to patient demographics has led to the development of a fuller understanding of the amount of variation in the anatomy and morphology of the human knee and how this relates to clinical applications. In this study, we have aimed to review the spectrum of clinical application of three-dimensional modeling, which includes osteotomies and knee arthroplasties. More specifically, three-dimensional modeling has been used for: the assessment of tibial and femoral morphometry, the potential development of novel instrumentation for femoral resection, the evaluation of femoral condylar anthropometry, correlating mechanical and anatomical alignment, the assessment of the relationship of joint line and flexion, the extension and mechanical axis of the knee, and the evaluation of the relationship between medial tibial tubercle to the posterior aspect of the tibia. Three-dimensional modeling and analytical technology may provide insights into anthropometric variations in the knee and may assist in the future development of more patient specific instrumentation, implant positioning, and implant designs. It is hoped that such advances could improve patient satisfaction and long-term implant survivorship.

Authors:

Samik Banerjee, MBBS, M.S (Orth), MRCS (Glasg), Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Jerry D’Alessio, PhD, Director, Advanced Engineering, Stryker Orthopaedics Inc., Mahwah, New Jersey, Mark Kester, PhD, Senior Director Knee Research, Stryker Orthopaedics Inc., Mahwah, New Jersey, Steven F. Harwin, MD , Chief, Division of Adult Reconstruction and Total Joint Replacement, Department of Orthopaedic Surgery, Mount Sinai Health System, Beth Israel Medical Center, New York, New York, Michael Dunbar, MD, PhD, Division of Orthopaedics, Dalhousie University, Halifax, Nova Scotia, Canada, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland

PMID:  24700232

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Abstract:

Tendon augmentation grafts have the potential to facilitate the repair of massive or otherwise unrepairable rotator cuff tears. In our clinic, between 2009 and 2013, 25 patients underwent surgery to treat massive symptomatic rotator cuff tears with porcine dermal collagen patch. This study is a clinical and instrumental assessment of 9 patients with the longest follow-up. These patients were evaluated with Constant score, the American Shoulder and Elbow Surgeons Evaluation Form, ultrasound imaging, magnetic resonance imaging, and electromyography. The clinical evaluations have shown good outcomes. The magnetic resonance imaging results were comparable with those of the ultrasound scan. In all cases, we found covering of humeral head, centering of the humeral head, maintenance of the tropism of the supraspinatus, no appearance of fatty degeneration, no worse in cases with fatty degeneration. With the electromyographic examination a complete functional recovery was observed with the possibility of performing maximal contraction against resistance in all cases. We believe that porcine dermal collagen is effective as an augmentation graft in the treatment of chronic extensive rotator cuff tears, providing excellent pain relief with an improvement in active ranges of motion and strength.

Authors:

Stefano Giannotti, MD, Specialist in Orthopaedics and Traumatology, IInd Orthopaedic and Traumatologic Clinic, Marco Ghilardi, MD, Specialist in Orthopaedics and Traumatology, IInd Orthopaedic and Traumatologic Clinic, Giacomo Dell’Osso, MD, Specialist in Orthopaedics and Traumatology, IInd Orthopaedic and Traumatologic Clinic, Luca Magistrelli, MD, Specialist in Orthopaedics and Traumatology, IInd Orthopaedic and Traumatologic Clinic, Giulia Bugelli, MD, Resident in Orthopaedics and Traumatology, IInd Orthopaedic and Traumatologic Clinic, Frederica Di Rollo, MD, Resident in Orthopaedics and Traumatology, IInd Orthopaedic and Traumatologic Clinic, Giulia Ricci, MD, Specialist in Neurology, Neurologic Clinic, Rosanna Calabrese, MD, Specialist in Neurology, Neurologic Clinic, Gabriele Siciliano, MD, PhD, Associate Professor in Neurology, Neurologic Clinic, Giulio Guido, MD, PhD, Ordinary Professor of Orthopaedics , and Traumatology, IInd Orthopaedic and Traumatologic Clinic, University of Pisa , Pisa, Italy

PMID:  24526420

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Harvest Tech

Abstract:

Osteomyelitis is a bone infection by micro-organisms. Despite advances in antibiotics and operative techniques, osteomyelitis remains an orthopaedic challenge and expensive to treat. Antimicrobial therapy is adequate for the treatment of most cases of acute osteomyelitis of any type, provided that diagnosis is made early. The treatment of chronic osteomyelitis is operative followed by adjunctive antibiotic therapy. Apart from surgical debridement and systemic antibiotic treatment, local antibiotic treatment by using various antibiotic delivery vehicles is a preferred method by most surgeons. Antibiotic-loaded bone cement (polymethylmethacrylate, PMMA) is the most widely used material and represents the current standard as an antibiotic delivery vehicle in orthopaedic surgery. Despite that, there are some disadvantages or concerns about the use of antibiotic-loaded PMMA that have led to the use of bioabsorbable or biodegradable material. Although the number of clinical studies is small, it seems that antibiotic-loaded hydroxyapatite and calcium sulfate are safe methods for local antibiotic delivery. They deliver great amounts of antibiotics locally with serum concentrations in safe margins, they obliterate the dead space, and aid in bone repair, while there is no need for a second operation for their removal. The purpose of this article is to review the recent literature concerning osteomyelitis and local antibiotic treatment with special reference to bone graft substitutes as vehicles for local antibiotic delivery.

Authors:

Fani Lalidou, BSc, MSc, Postgraduate Student in Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece, George Kolios, MD, PhD, Professor of Pharmacology, Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece, Georgios I. Drosos, MD, PhD, Assistant Professor of Orthopaedics, Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece

PMID:  24504740

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Abstract:

This study aimed to investigate rupture rates following primary flexor tendon repair and to identify potential risk factors of rupture. Fifty-one patients with 100 flexor tendon injuries who underwent primary repair over a one-year period were reviewed. We collected demographic and surgical data. Causes of rupture were examined. Ruptured primary tendon repairs were compared with those that did not rupture. Univariate and multivariate analysis were undertaken to identify significant risk factors. Eleven percent of repaired tendons ruptured with a higher rupture rate noted in the non-dominant hand (p value = 0.009), in Zone II (0.001), and when more than 72 hours surgical delay occurred (0.01). Multivariate regression analysis identified repair in Zone II injuries to be the most significant predictor. Our rate of rupture of 11% was associated with delay in surgery, repair on non-dominant hand, and Zone II repairs. Careful consideration of these factors is crucial to reduce this rate.

Authors:

Mazin Saad. Ibrahim, MSc, MBChB, MRCS, Specialty Registrar, Birmingham Heartlands Hospital, Birmingham, The United Kingdom, Muhammad Asim Khan, MBBS, MRCS, Specialty Registrar, Brighton and Sussex University Hosptials NHS Trust, Brighton, the United Kingdom, Mai Rostom, MBBCh, MRCS, Clinical Fellow in Plastic and Reconstructive Surgery, Addenbrooke’s Hospital, Cambridge, The United Kingdom, Alastair Platt, MA, FRCS (plast), Consultant Plastic Surgeon, Castle Hill Hospital, Cottingham, East Yorkshire, The United Kingdom

PMID:  24526425

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