Systematic review: Early versus late dangling after free flap reconstruction of the lower limb.

INTRODUCTION AND AIMS: Dangling regimes after free flap surgery to the lower limb vary between centres and clinicians. There is currently no accepted gold standard. This review examines the evidence for early versus late post-operative dangling after free flap reconstruction of the lower limb. The secondary aim is to evaluate the regimes used. MATERIAL AND METHODS: Medline, Embase and the Cochrane library were searched for all studies on dangling or rehabilitation after free flap reconstruction in the lower limb (December 2015). All studies outlining a clear dangling regime were included. Data were extracted by two authors independently and analysed using the software package Review Manager (RevMan 5). All authors were contacted for further information. RESULTS: 197 patients were included from 8 studies: 1 randomized, 6 cohort and 1 case-series. Although some studies did not state the aetiology, of those that did; 42% were trauma, 31% oncology, 20% complex wounds and 7% infection. The majority of flaps were latissimus dorsi, 18% parascapular, 15% anterolateral thigh and the remainder was mixed. Forty-eight percent of patients dangled on post-operative day (POD) 7, 29% on day 6, 4% on day 5 and 18% on day 3, with varying regimes. A meta-analysis of comparable studies showed circulatory benefit after 4 days of dangling using tissue oxygen saturation as a measure. Four flap failures (2.0%) were reported. CONCLUSIONS: There is physiological benefit in post-operative dangling. A 3-day flap training regime is sufficient for physiological training. However, the optimal flap training regime remains unclear. It may be appropriate to start dangling as early as POD 3. More research is needed to determine the optimal time to start dangling and the regime.

Comparing the surgical timelines of military and civilians traumatic lower limb amputations.

The care and challenges of injured service have been well documented in the literature from a variety of specialities. The aim of this study was to analyse the surgical timelines of military and civilian traumatic amputees and compare the surgical and resuscitative interventions. A retrospective review of patient notes was undertaken. Military patients were identified from the Joint Theatre Trauma Registry (JTTR) in 2009. Civilian patients were identified using the hospital informatics database. Patient demographics, treatment timelines as well as surgical and critical care interventions were reviewed. In total 71 military patients sustained traumatic amputations within this time period. This represented 11% of the total injury demographic in 2009. Excluding upper limb amputees 46 patients sustained lower extremity amputations. These were investigated further. In total 21 civilian patients were identified in a 7-year period. Analysis revealed there was a statistically significant difference between patient age, ITU length of stay, blood products used and number of surgical procedures between military and civilian traumatic amputees. This study identified that military patients were treated for longer in critical care and required more surgical interventions for their amputations. Despite this, their time to stump closure and length of stay were not statistically different compared to civilian patients. Such observations reflect the importance of an Orthoplastic approach, as well as daily surgical theatre co-ordination and weekly multi-disciplinary meetings in providing optimal care for these complex patients. This study reports the epidemiological observed differences between two lower limb trauma groups.

The epidemiology and mortality of pretibial lacerations.

Pretibial lacerations are common injuries which have an underestimated mortality associated with their occurrence, and an under-appreciated morbidity associated with their treatment - they account for 5.2 out of every 1000 Emergency Department attendances in the United Kingdom, and occur mostly in the elderly. They are also increasingly being referred to plastic surgery units - the authors' department saw an increase from 58 referrals in twelve months in 2005/2006 to 113 referrals in six months in 2011. The Queen Victoria Hospital, East Grinstead, follows an evidence based and multi-disciplinary practice for the treatment of these injuries. The authors present the outcomes of patients referred to the hospital from the community and treated according to these guidelines, and compares the outcomes and mortality to a period prior to the introduction of this practise. The average time for skin grafted wounds to heal is found to be 59.8 days and for the donors it is 50.3 days, compared with an average time to healing of 123 days for those managed conservatively. The one month and one year mortality associated with these injuries is highlighted, as is the reduction in these figures following the adherence to the current treatment regime - prior to its introduction the 31 day mortality was 15%, and this was reduced to 4.3% by achievable changes in practice and treatment. Finally, the relevant extant research literature regarding pretibial lacerations is reviewed.

Home-made explosive found inside injured Afghan.

There is extensive literature on metal fragments from improvised explosive devices being embedded in patients but there are no reports describing the clinical and radiological appearances of embedded home-made explosive (HME). We present a case of partially detonated HME being found inside a patient's forearm. We discuss the medical management of the injury, the ongoing risk to the patient and surgical team associated with the explosive and the safe disposal of the substance.

So much for percentage, but what about the weight?

The use of resuscitation formulae for burns is advocated for A&E departments. Much care is taken to calculate the percentage of the burn, but this is then multiplied by an approximate weight. How accurate is this figure and should it be more carefully measured? Forty two sets of case notes of patients with resuscitation sized burns were reviewed. In 32, a weight was documented in the A&E notes. This was compared with the measured weight on arrival at the burn centre. In half the cases there was a greater than 5 kg difference and in nine patients over 10 kg of difference. The methods of patient weight assessment in 16 A&E departments were reviewed. The majority have only stand on scales. Three departments have sit on scales; however, if they were assessing the weight of a patient who is unable to sit they would need to ask the patient, relatives, or simply guess. Investment in weighing equipment should be encouraged if resuscitation formulae are to have any place in the A&E management of burn patients.

Treatment before transfer: the patient with burns.

OBJECTIVES: To review pre-burns centre management, including assessment, resuscitation, and transfer. METHODS: A retrospective analysis of the notes of all the UK patients admitted to the Burns Centre in 1998, who had a body surface area burn of over 15% in adults (10% in children). RESULTS: There were 31 patients, 21 adults and 10 children, and the average burn size was 32% (12-96%). Fourteen were overestimated (average of 9%) and 13 underestimated by 7.5%. Twenty nine received intravenous fluids, 18 specified a formula, but it was only applied correctly in 10. The average time to the Burns Centre from the burn was 10 hours, and the time for resuscitation and transfer, eight hours. Documentation was generally poor. CONCLUSION: There has previously been considerable variation in the standard of initial burn management and there have been problems with burn percentage assessment and resuscitation formula application. A new proforma has been introduced to tackle these issues.

External fixation of lower limb fractures in children.

Thirty-four tibial and femoral shaft fractures in 32 children between the ages of 3 and 15 years were treated by external fixation over a 5-year period. The indications were fractures occurring in association with other major injuries and failure of conservative treatment to maintain satisfactory reduction. There was one case of delayed union and one early refracture. The overall pin track infection rate was 6%, but the rate for the tibial pins (2.1%) was much lower than for the femoral pins (10.3%). Union was achieved at an average of 11.7 weeks in the femoral fractures and 10.0 weeks in the tibial fractures. The use of external fixation is recommended for childhood femoral and tibial fractures, particularly in children with multiple injuries.