Inter- and intrarater reliability of osteoarthritis classification at the trapeziometacarpal joint.

PURPOSE: To assess the reliability of the Eaton and Glickel classification for base of thumb osteoarthritis. METHODS: The interrater and intrarater reliability of this classification were assessed by comparing ratings from 6 raters using quadratic weighted kappa scores. RESULTS: Median inter-rater reliability ranged from kappa of .53 to .54; intrarater reliability ranged from kappa of .60 to .82. Using unweighted kappa interrater reliability was "slightly" reliable, and intrarater reliability was "fairly" reliable. Overall, the value of the intraclass correlation for all 6 raters was .56. CONCLUSIONS: This radiological classification does not describe all stages of carpometacarpal joint osteoarthritis accurately enough to permit reliable and consistent communication between clinicians. Therefore we believe it should be used with an understanding of its limitations when communicating disease severity between clinicians or as a tool to assist in clinical decision making.

A prospective case-control study to compare the sensitivity and specificity of the grind and traction-shift (subluxation-relocation) clinical tests in osteoarthritis of the thumb carpometacarpal joint.

The diagnosis of osteoarthritis of the thumb carpometacarpal joint is made predominantly by correlating examination findings with patients' symptoms and radiographs. The importance of clinical examination is enhanced due to the poor correlation between radiological severity of osteoarthritis of this joint and symptoms. Despite the importance of clinical examination findings, no previous studies have analyzed the traction-shift test nor compared clinical tests for this diagnosis. In this prospective case-control study the relative performance of the commonly used grind and traction-shift (subluxation-relocation) tests were compared in 30 patients and 30 unaffected controls. The traction-shift test had greater sensitivity (66.7%) and specificity (100%) than the grind test (30% and 96.7%, respectively), whilst also demonstrating superior positive (100%) and negative (75%) predictive value than the grind test (90% and 58%, respectively). Therefore, we believe this to be the superior clinical test for osteoarthritis of the carpometacarpal joint of the thumb.

Collagenase for Dupuytren's disease of the thumb.

Injectable collagenase is an alternative to surgical treatment for Dupuytren's disease. Previous studies have reported on the effectiveness of collagenase in finger contractures. This prospective study reports on the short-term safety and efficacy of collagenase treatment in five thumb and first web space Dupuytren's contractures. The thumb and first web space contractures were treated with injectable collagenase in four consecutive patients (five hands) with experience of previous surgical digital fasciectomy. The thumb contracture was measured by angle and span in two planes of thumb extension and abduction before injection and after manipulation. Collagenase treatment resulted in release of the contracture with a mean increase in thumb to index angle from 23° (10° to 35°) to 56° (45° to 60°) in extension and from 30° (10° to 50°) to 58° (50° to 65°) in abduction and a mean increase in span from 1.9 cm (1 to 3.5) to 3.9 cm (3 to 5) in extension and from 2.4 cm (1.5 to 3.5) to 3.9 cm (3 to 4.5) in abduction. All patients reported an increased range of movement and function and described collagenase therapy as preferable to surgery. In the short-term collagenase is an effective, well-tolerated and safe alternative to surgery for Dupuytren's disease of the thumb.

Randomized controlled trial of fibrin sealant to reduce postoperative drainage following elective lymph node dissection.

BACKGROUND: Excessive postoperative drainage following groin and axillary lymphadenectomy may be associated with a prolonged hospital stay and an increased complication rate. The use of fibrin sealant before wound closure may reduce postoperative wound drainage. METHODS: Consecutive patients undergoing elective groin or axillary lymphadenectomy were randomized to standard wound closure or to having fibrin sealant sprayed on to the wound bed before closure. Postoperative wound drainage, duration of drainage and complications were recorded, as were locoregional recurrence, distant metastasis and mortality. RESULTS: A total of 74 patients requiring 38 groin and 36 axillary dissections were randomized. The median postoperative wound drainage volume for the groin dissection cohort was 762 (range 25-3255) ml in the control group and 892 (265-2895) ml in the treatment group (P = 0·704). Drainage volumes in the axillary cohort were 590 (230-9605) and 565 (30-1835) ml in the control and treatment groups respectively (P = 0·217). There was no difference in the duration of drainage or postoperative complication rate between the treatment groups in both the axillary and groin cohorts. Local recurrence, distant metastasis and mortality rates did not differ between the treatment groups. CONCLUSION: There was no advantage in using fibrin sealant during elective lymphadenectomy in terms of reducing drainage output or postoperative complication rate.

Genetic screening of 202 individuals with congenital limb malformations and requiring reconstructive surgery.

BACKGROUND: Congenital limb malformations (CLMs) are common and present to a variety of specialties, notably plastic and orthopaedic surgeons, and clinical geneticists. The authors aimed to characterise causative mutations in an unselected cohort of patients with CLMs requiring reconstructive surgery. METHODS: 202 patients presenting with CLM were recruited. The authors obtained G-banded karyotypes and screened EN1, GLI3, HAND2, HOXD13, ROR2, SALL1, SALL4, ZRS of SHH, SPRY4, TBX5, TWIST1 and WNT7A for point mutations using denaturing high performance liquid chromatography (DHPLC) and direct sequencing. Multiplex ligation dependent probe amplification (MLPA) kits were developed and used to measure copy number in GLI3, HOXD13, ROR2, SALL1, SALL4, TBX5 and the ZRS of SHH. RESULTS: Within the cohort, causative genetic alterations were identified in 23 patients (11%): mutations in GLI3 (n = 5), HOXD13 (n = 5), the ZRS of SHH (n = 4), and chromosome abnormalities (n = 4) were the most common lesions found. Clinical features that predicted the discovery of a genetic cause included a bilateral malformation, positive family history, and having increasing numbers of limbs affected (all p<0.01). Additionally, specific patterns of malformation predicted mutations in specific genes. CONCLUSIONS: Based on higher mutation prevalence the authors propose that GLI3, HOXD13 and the ZRS of SHH should be prioritised for introduction into molecular genetic testing programmes for CLM. The authors have developed simple criteria that can refine the selection of patients by surgeons for referral to clinical geneticists. The cohort also represents an excellent resource to test for mutations in novel candidate genes.

Functional and oncological outcomes after limb-salvage surgery for primary sarcomas of the upper limb.

The surgical treatment of upper limb sarcoma poses an oncological and reconstructive challenge. Limb-salvage surgery aims to balance adequate excision margins for disease control and preservation of all important structures to retain maximum function. Reported here is an assessment of the functional and oncological outcomes of limb salvage surgery for primary sarcoma of the upper limb and limb girdle in 72 patients referred to a specialist musculoskeletal tumour unit over 9 years. All patients underwent excision of the sarcoma with reconstruction and adjuvant treatment as needed. Functional outcome was assessed using the Toronto Extremity Salvage Score (TESS) after discharge from hospital. The upper limb sarcomas treated by limb-salvage surgery achieved planned margins of excision in 85% of cases with primary surgery. This increased to 100% with re-excision, resulting in local recurrence in 15% and survival of 75% among those at 5 years or more after surgery, while retaining good to excellent function (TESS mean of 87 out of 100). A total of 38 patients completed TESS questionnaires and, as a single group, had a mean TESS of 87. Patient age, anatomical site of tumour and adjuvant treatment made no significant difference to TESS. Liposarcomas had a significantly better TESS than leiomyosarcomas, chondrosarcomas and malignant peripheral nerve sheath tumours. Oncological outcome was assessed in terms of excision margins achieved, local recurrence, re-excision and disease-free survival. Eight patients died of disease, all with high-grade primary tumours. Fourteen had local recurrence, four low-grade disease and the remaining high-grade disease. All four low-grade recurrences were successfully re-excised, as were five of the high-grade recurrences. The remaining five died of disease, with or without further recurrences. Consistently good functional results as measured by TESS were reported by responders, but high-grade disease and early recurrence were identified as predictors of recurrence and death from disease, respectively.

Tie-overs under pressure.

Dressings tied over skin grafts reduce the size of dead space, prevent haematoma formation, and immobilize the grafts [McCarthy, Plastic Surgery, 1990]. Their mechanism of action was thought to include the application of pressure to the bed and stabilization of the graft and dressing. A quantitative analysis of the pressure exerted by these dressings has never been reported [Wolf at al., Ann Plast Surg 40 (1998) 149]. This study measures the pressure exerted by tie-over dressings at the graft-bed interface and finds that no significant pressure is exerted.

Locking of the proximal interphalangeal joint of the little finger.

Locking of the metacarpophalangeal joints is well documented, but locking of other joints in the finger has not been described. We present a case of locking of the little finger proximal interphalangeal joint due to an osteophyte impinging on the extensor tendon.

Prevention of the parrot beak deformity in fingertip injuries.

The nail is supported by the dorsal tuft of the terminal phalanx. Following distal fingertip trauma, varying amounts of nail support may be lost resulting in the nail curving palmarwards. This curvature is dependent upon the degree of bony loss, the amount of remaining nail bed and the degree of scar contracture at the hyponychial-pulp interface. The parrot beak or hooked nail deformity is most commonly caused by tight closure of a fingertip amputation and excessive palmar tension at the hyponychial-pulp suture line. A simple technique using a hypodermic needle, that eliminates tension from the suture line at the fingertip pulp-hyponychial interface and prevents hooked nail deformity is described. This allows healing to take place without any palmarwards pull of the scar and a subsequent parrot beak deformity.

Direct measurement of cutaneous pressures generated by pressure garments.

Pressure garments are the mainstay of burn scar management despite limited scientific evidence. This study demonstrates a simple method of directly measuring the cutaneous pressures generated by a pressure garment. The results show pressure garments generate an increase in subdermal pressures in the range 9-90 mmHg depending on the anatomical site. Garments over soft sites generate pressures ranging from 9 to 33 mmHg. Over bony prominences the pressures range from 47 to 90 mmHg. This method is believed to be more representative of the pressures generated than the interpositional techniques that measure garment-skin interface pressure, as it avoids garment distortion, the interference effect of the measurement device (size, conformation, area) and directly measures subdermal pressures. The method should be useful for larger research projects on pressure therapy and also for clinical management of pressure garments in the treatment of hypertrophic scar.

Warm ischaemia time in a model for small bowel transplantation.

Intestinal transplantation is associated with high rates of mortality and morbidity. This paper details our initial experience with 82 heterotopic small bowel transplants based upon the original rat model described by Monchik and Russell (Surgery 70:693-702, 1971). A key issue associated with mortality was a warm ischaemia time of more than 40 min (P < 0.01). Sixty-eight percent of the recipients (44/65) survived for more than 24 hr when the warm ischaemia time of the donor bowel was reduced to less than 40 min. Investigators establishing an animal model of heterotopic small bowel transplantation should pay particular attention to the warm ischaemia time of the donor bowel.

Early use of pressure masks to avoid facial contracture during the pregrafting phase.

This article introduces the concept of early application of pressure therapy as a form of splinting in the pregrafting phase. It is based on the principles of (1) the use of pressure therapy to reduce contraction and hypertrophic scar formation and (2) the knowledge that most wound contraction occurs within the initial few weeks of healing. This idea has most application in facial burns, where wound contraction can be disfiguring and functionally disabling, and in situations where unavoidable delay in debridement and grafting may be present. The idea is illustrated with a case report.

Management of full thickness burns to lactating breasts.

A 19-year-old female sustained 8 per cent full thickness petrol flame burns to the neck, chest, breasts, upper abdomen and portions of the right upper limb. The patient had been breast-feeding until the time of the injury. Following assessment of the risks of potential complications such as engorgement, hyperprolactinaemia, mastitis, milk fistulae, glandular loss, scarring and nipple distortion, surgical tangential excision was delayed until bromocriptine produced cessation of lactation and breast involution occurred. This case report demonstrates that consideration of the potential problems in burns to the lactating breasts and prophylactic management can lead to successful healing and probable restoration of function.

Flushing the vessel ends: the effect on ischemic free flap survival.

During vascular anastomosis of experimental ischemic free flaps it is common to observe that stagnant blood in the vessel ends has clotted. A study was performed to investigate if flushing away the stagnant blood on division of the vessels would increase flap survival. Flushing did not influence flap survival. Clinically, clot is rarely seen, except in conditions of prolonged ischemia or damaged vessels. Current surgical practice does not involve flushing the vessel ends upon division of the vessels and this approach is affirmed by our results.