IV3000 semi-occlusive dressing use in simple and complex fingertip injuries: efficacy and affordability.

OBJECTIVE: This study aimed to explore the efficacy of the IV3000 semi-occlusive, transparent adhesive film dressing in the non-surgical management of simple as well as more complex fingertip injuries. METHOD: In this qualitative study, patients with fingertip injuries were prospectively recruited and treated conservatively with the dressing between 2015 and 2017. Inclusion criteria included any fingertip injury with tissue loss and patient consent for non-surgical treatment consistent with the study protocol. Exclusion criteria included injuries needing surgical intervention for tendon injury or exposure, joint dislocations, distal phalangeal fractures requiring fixation, bone exposure, isolated nail bed lacerations and any patients eligible for surgical repair who did not wish to be managed conservatively. RESULTS: A total of 64 patients took part in the study. The patients treated with the dressing were asked to rate functional outcome, of whom 40 (62.5%) patients reported the outcome as 'excellent', 19 (29.7%) as 'satisfactory', five (7.8%) as 'indifferent' and none (0%) as 'unsatisfactory'. A reduced pulp volume at completion of healing was felt by 21 (32.8%) patients, but all patients were 'satisfied' with the aesthetic appearance of their fingertips at final clinical review. Average healing time was 4.5 weeks across the group, with the average time for return to work being just under one week. We estimate a 60% reduction in cost with the conservative versus the surgical management option. CONCLUSION: This study showed that, for participants, the IV3000 dressing was an affordable and effective option for the conservative treatment of simple fingertip injuries and in the management of more complex fingertip injuries.

Establishing local diagnostic reference levels for mini C-arm use in upper limb surgery - A step towards national audit.

AIMS: Under the Ionising Radiation Medical Exposure Regulations, hospitals using fluoroscopy and image intensifiers should monitor doses from exposures using ionising radiation. There is a need for national diagnostic reference levels to advise Orthopaedic and Plastic surgeons on safe screening times and radiation doses for patients having upper limb surgical procedures. METHODS: Retrospective study of all patients who underwent upper limb surgical procedures requiring intra-operative mini C-arm image intensifier use at our hospital between 2013 and 2019. This included results from three machines in different rooms. Procedures were classified as closed and open procedures. RESULTS: Information on a total of 2910 procedures over 6 years (June 2013 to June 2019) were obtained. 133 procedures with incomplete data and 4 cases of lower extremities were excluded. 1719 closed procedures had a median dose area product of 0.48 cGycm2 and median screening time of 7 s, compared to 1054 open procedures, with a median dose area product of 1.88 cGycm2 and median screening time of 28 s. National diagnostic reference levels are set at the third quartile and indicate the difference between good and poor practice. For diagnostic reference levels, we suggest a dose area product of 0.82 cGycm2 and a screening time of 11 s for closed procedures and a dose area product of 3.07 cGycm2 and screening time of 40 s for open procedures. Public Health England state that national diagnostic reference levels should be derived from multiple patients, radiology rooms and hospitals. Our data meets the first two criteria and is an initial step in establishing national diagnostic reference levels for upper limb mini C-arm use. CONCLUSIONS: This large audit reports results, which, with further work across multiple hospital sites, should lead to establishing national diagnostic reference levels for mini C-arm fluoroscopy for upper limb Orthopaedic procedures.

"Reply - 313 Dermatome-Induced Lacerations: Incidence, Management, and Preventative Measures. April 2018, Volume 39, Issue Suppl 1, Page S126."

We would like to suggest the use of a simple and relevant mnemonic ("STSG") for the safe use of powered dermatomes to harvest split thickness skin grafts. Safety checklists have been shown to be effective tools for improving patient safety in various clinical settings by improving compliance with good practice and reducing the incidence of adverse events.

Managing aesthetic referrals in NHS Scotland: Outcomes from 1122 patients in the East of Scotland.

The Adult Exceptional Aesthetic Referral Protocol (AEARP) encompasses a series of aesthetic procedures which, as they do not treat an underlying disease process, are not routinely available within the National Health Service. Provision of these services can only be provided on an exceptional basis. In this prospective study, we evaluated the referral process and outcomes of 1122 patients referred under the AEARP over a 3.5-year period. Referrals were screened by a vetting panel comprising of a plastic surgeon, clinical nurse specialist, and clinical psychologist. Following initial vetting, supported patients underwent psychological assessment. Patients supported by psychology were assessed in clinic, and if deemed clinically suitable, were offered surgery. Overall, 20% (225/1122) of referrals were supported for surgery. Following primary vetting, 57% (640/1,122) of referrals were supported, 40% (197/492) of referrals to clinical psychology were supported, and 65% (225/345) of the remaining cases referred for consultation were supported for surgery. Unsupported referrals included those not fulfilling the referral guidelines or those with contraindications. The AEARP is simple and effective to implement, and has been instrumental in streamlining the referral-to-outcome process in a centralised, transparent, and fair manner. It reduces a potential high number of clinic appointments where patients do not meet the aesthetic criteria and/or fail to attend - thereby helping to streamline other surgical pathways by improving clinic efficiency. Moreover, it aids referring clinicians and patient education around aesthetic issues including a holistic approach. Wide adoption of such standards may reduce waiting times, facilitate cost savings, and ultimately enhance patient outcomes.

A lateral tarsorrhaphy with forehead hitch to pre-empt and treat burns ectropion with a contextual review of burns ectropion management.

INTRODUCTION: Facial burns around the eyes and eyelid ectropion can lead to corneal exposure, irritation, dryness, epiphora, infection or visual loss. We undertook a review of the published articles describing management of eyelid burns as well as methods to treat or prevent ectropion. We describe early experience of a surgical technique that we have found to mitigate ectropion in facial burns with peri-ocular involvement. MATERIALS AND METHODS: Two illustrative cases with our surgical technique is described from our experience of three cases. We reviewed the literature using the PubMed and EMBASE databases using the search terms 'burn' and 'ectropion'. RESULTS: The literature review produced a total of 17 relevant papers. Treatment options for eyelid burns were varied and were invariably level 4 or 5 evidence. Various techniques were used to treat eyelid burns including the use of a full thickness skin graft with or without concurrent scar contracture release but also use of a local flap reconstruction with or without a tissue expander or release of the underlying muscle. Other techniques included canthoplasty, Z-plasty, forehead flaps, fat transfer, and tarsorrhaphy with full thickness skin grafting. In general, the focus of articles was therapeutic and reconstructive rather than pre-emptive/preventative management. PROCEDURE: We describe our early experience of a novel technique for temporary lateral tarsorrhaphy with forehead hitch which protexts the globe and counters the scar- and gravity-related ectropic effects on the lower eyelids. DISCUSSION: Facial burns pose a difficult problem to the burn surgeon, especially when the eyelids are affected, both directly or indirectly. The optimal surgical management of eyelid burns remains unclear and the literature base lies mainly in the domain of case series. We review the literature on this subject and tabulate our findings and also describe our contribution to this area with a method of lateral and lower lid elevator that we have found valuable.

The ortho-plastic approach to soft tissue management in trauma.

Fractures with associated soft tissue injuries, or those termed 'open,' are not uncommon. There has been much discussion regarding there management, with the guidance from the combined British Orthopaedic Association and British Association and Aesthetic Surgeons teams widely accepted as the gold level of therapy. We aim to discuss the current evidence about the initial management of this group of injuries, taking a journey from arrival in the accident and emergency department through to the point of definitive closure. Other modes of therapy are also reviewed.

The development and future of reconstructive and microvascular surgery of the hand.

The hand is often thought of as a key discriminator in what makes humans human. The hand is both intricate and fascinating in its design and function, allowing humans to interact with their surroundings, and each other. Due to its use in manipulation of the person's environment, injury to the hand is common. Devastating hand injuries have a profound, physical, psychological, financial and socially crippling effect on patients. Advances in operative techniques and improvements in microscopes and instruments allowed Malt &McKhann to perform the first successful arm replantation in 1962 [1]. This was followed by a myriad of autologous free flaps of varying composition, that were discovered after the mapping of the cutaneous blood circulation by Taylor and Palmer [2] and Mathes & Nahai's classification of muscle flaps [3] providing us with countless options to harvest and transfer healthy, well vascularised tissues into areas of injury. Since the late sixties, with the emerging subspecialty of microvascular reconstruction, surgeons have had the technical ability to salvage many amputated parts, even entire limbs. The measure of functional outcomemust incorporate the evaluation and severity ofthe initial injury and the subsequent reconstructive surgeries [4].

Flap decisions and options in soft tissue coverage of the lower limb.

THE LOWER EXTREMITIES OF THE HUMAN BODY ARE MORE COMMONLY KNOWN AS THE HUMAN LEGS, INCORPORATING: the foot, the lower or anatomical leg, the thigh and the hip or gluteal region. The human lower limb plays a simpler role than that of the upper limb. Whereas the arm allows interaction of the surrounding environment, the legs' primary goals are support and to allow upright ambulation. Essentially, this means that reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of reconstruction, the primary goals are based on the preservation of life and limb, and the restoration of form and function. This paper aims to review current and past thoughts on reconstruction of the lower limb, discussing in particular the options in terms of soft tissue coverage. This paper does not aim to review the emergency management of open fractures, or the therapy alternatives to chronic wounds or malignancies of the lower limb, but purely assess the requirements that should be reviewed on reconstructing a defect of the lower limb. A summary of flap options are considered, with literature support, in regard to donor and recipient region, particularly as flap coverage is regarded as the cornerstone of soft tissue coverage of the lower limb.