Topical negative pressure therapy: current concepts and practice.

Research into topical negative pressure therapy (TNPT) started in 1989 with Dr Louis Argenta and Prof Michael Morykwas of Wake Forest University School of Medicine in North Carolina, USA. In 1997, Morykwas and Argenta concluded that TNPT both enhanced granulation tissue formation and helped bacterial clearance, through the actions of negative pressure Armstrong and Lavery confirmed this in 2005, concluding that TNPT therapy was promoting the development of granulation tissue. Numerous other studies have proved that TNPT is beneficial for a myriad of other wounds including: sternotomy wounds, extensive de-gloving injuries, various soft tissue injuries prior to surgical closure, skin grafting, pressure sores, leg ulcers, sacral pressure ulcers, acute traumatic soft tissue defects, and soft tissue defects following rigid stabilisation of lower extremity fractures. This review aims to summarise the clinical and scientific concepts of TNPT and its future applications.

Clinical review: Volkmann's ischaemic contracture.

INTRODUCTION: Volkmann's ischaemic contracture is a devastating condition with serious motor and sensory functional implications for the affected limb. This clinical review outlines acute compartment syndrome and Volkmann's ischaemic contracture, their presentation, evolution and current management. AIMS: This up-to-date clinical review is aimed at both specialist and non-specialist healthcare professionals who can play a key role in the early recognition of signs and symptoms to allow prevention of the condition. METHODS: No Cochrane reviews are currently available regarding Volkmann's ischaemic contracture. Medline, EMBASE and Scopus databases were searched using the MeSH terms 'Volkmann's ischaemic/ischemic contracture' and 'compartment syndrome'. Current guidelines were referred to. DISCUSSION: Prevention is essential regarding Volkmann's ischaemic contracture. This can be achieved through careful observation of patients sustaining high-risk extremity injuries, notably, children with supracondylar fractures of the humerus, and immediate decompression if signs and symptoms of a compartment syndrome are present. Increased awareness amongst doctors of compartment syndrome is fundamental and will allow early recognition, clinical diagnosis and subsequent fasciotomy.

Intra-lesional steroid for the management of symptomatic Infantile Digital Fibromatosis.

BACKGROUND: Infantile Digital Fibromatosis (IDF) is a benign, often asymptomatic nodular proliferation of fibrous tissue occurring almost exclusively on the extremities. Conventional treatment has included radical surgery but this is associated with a high level of recurrence. Whilst some authors suggest a strictly conservative approach, this is unacceptable when lesions become symptomatic from pain, contracture formation or functional deformity METHODS: We present a retrospective analysis of 12 symptomatic lesions of which 7 were treated with a novel technique of intra-lesional steroid. From 2004-2009, a total of ten patients received treatment for symptomatic IDFs. Patients were followed-up for an average of 5 years 9 months (range 8-131 months). RESULTS: Corticosteroid was well tolerated with no significant complications and was associated with lower morbidity that compared with surgery. There was no significance difference between rate of recurrence (1/7 vs. 5/10) for those treated with corticosteroid than compared to those patients who underwent surgery (p = 0.3) but the study is underpowered. CONCLUSIONS: This is the first ever study to look at the role of intra-lesional steroid in the management of IDF. Whilst the majority of asymptomatic Infantile Digital Fibromatoses can be safely observed until natural resolution, intra-lesional corticosteroid is a safe and well-tolerated alternative to surgery for all symptomatic digital fibromatoses of infancy. We suggest it replaces surgery as first-line treatment but look forward to a large multicentre trial to allow comparison.

Mirror foot--a reflection on three cases.

INTRODUCTION AND AIMS: Mirror-foot abnormalities are distinctly uncommon entities and represent extreme forms of congenital duplication. We present a reflection on three different cases of mirror foot and discuss their surgical management. PATIENTS AND METHODS: The first patient had a right-sided mirror foot with a central great toe and three complete medial rays. The second patient had quadruplication of the left great toe ray. The third had a full complement of metatarsals associated with two extra complete rays placed medial to the great toe of the right foot. All patients underwent complex ray resection and concurrent reconstruction of the medial arch of foot. All three cases of mirror foot presented and were operated on in the pre-ambulatory period. RESULTS: All three patients recovered with good functional and aesthetic results. Follow-up duration ranged from 3 to 5 years. CONCLUSION: Surgical treatment of the mirror foot is less complicated than that of its upper limb equivalent. Essentially, there must be an initial surgical reduction in the number of digits, coupled with tendon transfers as necessary to maintain foot arches.

A modification of the Chinese island flap technique for simple incomplete syndactyly release.

This paper presents a modification of the technique described by Yao et al. using a vascular island flap based on a dorsal digital vessel, which allows transfer of the web proximally and retains the integrity of the web skin. The technique was used in nine patients, aged from 1 to 15 years at operation, with nine incomplete simple syndactylies. The results were assessed at a mean of 36 (range 5-60) months after surgery. No vascular compromise or web creep was noted. This technique enables transfer of web skin proximally in cases of simple, incomplete syndactyly, avoids the presence of scars in the web space and does not require skin grafts.

MRI 'magic angle' imaging of finger tendons.

The value of using the technique of magic angle MR imaging to demonstrate finger tendons is explored. Images of fresh frozen cadaveric specimens are presented and the structures that can be visualized in the finger are described. The results suggest that magic angle MR imaging may be a useful non-invasive technique of visualizing the details of the tendons and their surrounds in the hand.

Histological examination of the capsules surrounding Trilucent breast implants.

Following a statement by the UK Medical Devices Agency (MDA), soya-oil-filled Trilucent implants for breast augmentation were withdrawn from sale in March 1999. The most recent report on the toxicity of the Trilucent implant suggests that one of the breakdown products of the filler is an aldehyde with an explicit risk of genotoxic and teratogenic effects. Explantation of all these prostheses was advised by the MDA in June 2000. No guidance regarding capsulectomy was put forward by any publication. The operation of capsulectomy confers an increased morbidity compared with simple prosthetic replacement. This study looks at the capsules of 18 consecutive patients who had received Trilucent implants for cosmetic breast augmentation, and who had undergone explantation and capsulectomy. The mean duration of implantation was 3 years (range: 2 years to 4 years 9 months). The capsules were examined histologically. The significant features of all the capsules included a florid foreign-body type reaction, synovial metaplasia, a villous hyperplasia and the presence of refractile material within the substance of the capsule. It is postulated that the refractile material is filler material that has bled through the wall of the intact Trilucent implant, and as such would represent a potential genotoxic hazard. Until such time as this potential hazard has been investigated fully and a conclusion reached, we recommend acceptance of the increased morbidity, and the performance of capsulectomies when explanting Trilucent implants.

The effect of siberian ginseng (Eleutherococcus senticosus) on substrate utilization and performance.

It has been suggested that Eleutherococcus senticosus (ES), also known as Siberian ginseng or ciwuija, increases fat utilization in humans. The purpose of this study was to examine the physiological responses to supplementation with ES in endurance cyclists. Using a randomized, double-blind crossover design, 9 highly-trained men (28 +/- 2 years, VáO2max 57.3 +/- 2.0 ml á kg-1 á min-1) cycled for 120 min at '60% VáO2max followed by a simulated 10-km time trial. Diet was controlled, and ES (1,200 mg á day-1) or a placebo (P) were administered for 7 days prior to each of the two trials. Oxygen consumption, respiratory exchange ratio, and heart rate were recorded every 30 min, and rating of perceived exertion, plasma [lactate], and plasma [glucose] were recorded every 20 min during the 120 min of steady state cycling. There were no significant differences (p >.05) between the ES and P groups at any steady-state time interval or during the cycling time trial (ES = 18.10 +/- 0.42, P = 17.83 +/- 0.47 min). In contrast with previous reports, the results of this study suggest that ES supplementation does not alter steady-state substrate utilization or 10-km cycling performance time.

ACTH-producing pituitary cancer: experience at the King Faisal Specialist Hospital & Research Centre.

Pituitary gland is an uncommon site of a primary cancer. Of more than 600 cases of pituitary tumors seen at the KFSH&RC between 1975 to 1998 only 3 patients had primary pituitary cancer. We have previously reported a case of pituitary fibrosarcoma arising as a rare complication of external radiotherapy (ERT) for GH-secreting pituitary adenoma (PA) [1]. We report now 2 cases of ACTH-producing primary pituitary carcinoma (ACTH-PPC); their follow-up data provide information on the natural history of this cancer. Patient #1; a 46 year old lady with Cushing's disease (CD) presented with an enlarged right cervical lymph node (LN) 2 years after having undergone a partial hypophysectomy through transsphenoidal surgery (PHYPX/TSS) and ERT for an invasive pituitary tumor. Patient #2; a 26 year old man presented with CD and underwent bilateral adrenalectomy (ADx) and pituitary ERT. Thirty-nine months later he developed Nelson's syndrome and a PHYPX/TSS was performed. Incidentally discovered hepatic metastases in this patient and an excisional biopsy of the LN in patient #1 showed histological features very similar to the pituitary tumor, and they stained strongly positive for ACTH. Perinuclear spherical hyalinized cytoplasmic inclusions were seen in the LN biopsy that corresponded to bundles of type 1 microfilaments (specific for pituitary ACTH-producing cells) seen by electron microscopy. A whole body 18-Fluoro-2-Deoxy-D-Glucose positron emission (FDG-PET) scanning, showed an intense uptake in the neck mass. A trial of octreotide did not change the exceedingly high levels of ACTH in patient #2, further supporting the diagnosis of ACTH-PPC. The clinical course of 102 months prior to his demise showed continued progression of the primary and the metastatic tumor. Patient #1, is alive at 15 months follow-up; hypercortisolemia is controlled using ketoconazole. ACTH-PPC should be entertained in a patient with CD presenting with persistent cervical lymphadenopathy. The clinical course in our patients suggests that the emergence of PC may involve a proliferative continuum from a pre-existing PA to an invasive tumor, culminating in a carcinoma. Adjunctive events such as ERT/ADx may predispose to the evolution of PC in genetically susceptible individuals. Because ERT is an effective treatment for PA its use will continue; it is important to be aware of the possible complication of primary pituitary carcinoma.

The surface anatomy of the germinal matrix of the nail bed in the finger.

Nail spicules result from incomplete excision of the nail matrix of the finger. We report a histological study to delineate the surface anatomy of the nail matrix. Sections were cut longitudinally and transversely in 19 fingertips. The proximal midline extent of the nail matrix was measured and expressed as a ratio of the distance from the nail fold to the distal interphalangeal joint. In the lateral sections, the angle subtended between the midline vertical and the lateral extent of the nail matrix was measured. The mean ratio of the proximal extent was 0.55 in the midline and the lateral angular extent was 66 degrees. The authors recommend that excision of the nail matrix should be rectangular, extending to the midlateral lines and proximally to a point three-quarters of the distance from the nail fold to the distal interphalangeal joint crease.