Indications for implant removal after fracture healing: a review of the literature

Introduction: The aim of this review was to collect and summarize published data on the indications for implant removal after fracture healing, since these are not well defined and guidelines hardly exist. Methods: A literature search was performed. Results: Though there are several presumed benefits of implant removal, such as functional improvement and pain relief, the surgical procedure can be very challenging and may lead to complications or even worsening of the complaints. Research has focused on the safety of metal implants (e.g., risk of corrosion, allergy, and carcinogenesis). For these reasons, implants have been removed routinely for decades. Along with the introduction of titanium alloy implants, the need for implant removal became a subject of debate in view of potential (dis)advantages since, in general, implants made of titanium alloys are more difficult to remove. Currently, the main indications for removal from both the upper and lower extremity are mostly 'relative' and patient-driven, such as pain, prominent material, or simply the request for removal. True medical indications like infection or intra-articular material are minor reasons. Conclusion: This review illustrates the great variety of view points in the literature, with large differences in opinions and practices about the indications for implant removal after fracture healing. Since some studies have described asymptomatic patients developing complaints after removal, the general advice nowadays is to remove implants after fracture healing only in symptomatic patients and after a proper informed consent. Well-designed prospective studies on this subject are urgently needed in order to form guidelines based on scientific evidence

Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

OBJECTIVE: To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND: Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS: The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS: Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION: We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG

Use of mastectomy in rural versus urban patients: the effects of medical community factors.

Abstract Abstract #5089 Background: Disparity exists in surgical treatment of breast cancer patients living in rural versus urban counties. Past studies evaluating this used patient level data. We examine county-level medical community factors that potentially impact the geographic variation of mastectomy versus breast-conserving therapy.&amp;#x2028; Methods: Data from 137,303 patients and 200 counties were analyzed combining the 2006 SEER and 2004 ARF (Area Resource File) databases. Inclusion criteria identified in SEER were: stage I, II, or III disease, female, diagnosis after 1992. Patients were linked to county level data from the ARF based on their county of residence. Medical community variables analyzed with ARF are seen in Table 1.&amp;#x2028; Results: A total of 9.58% of the patients reside in a rural county, and 59.90% of these received a mastectomy, compared to 44.92% of the urban patients. Multivariate analysis of the medical community factors was calculated by both land area and population with calculation by population accounting for the disparity in mastectomy use (Table 1). Of the medical community factors in this analysis, the screening hospital density was highly significant, accounted for the difference in rural versus urban mastectomy rates, and resulted in an increased likelihood of receiving mastectomy (OR 1.009, 95% CI 1.004-1.014). Bivariate analysis also revealed a higher density of screening hospitals in rural counties (57.62) than in urban counties (18.22).&amp;#x2028; Conclusions: Analysis using land area versus population to estimate availability of services suggests that disparity in the rural community is most affected by availability of providers and not to required travel distance. Density of screening hospitals was found to be the most important factor resulting in disparity between rural versus urban mastectomy rates. Rural counties have a higher density of screening facilities, yet they also have a higher mastectomy rate. This may represent a volume/quality issue that will require further investigation.&amp;#x2028; &amp;#x2028; Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5089.</jats:p