Free fibula flap to achieve bone union after congenital pseudoarthrosis of the forearm in neurofibromatosis: Technical report based on 3 cases, and literature review.

Congenital pseudarthrosis of the forearm bones (CPFBs) is rare, with only 106 reported cases, and is frequently associated with neurofibromatosis (NF). Approximately 5% of patients with NF develop pseudarthrosis, and 50% of patients with pseudarthrosis have NF. Achieving bone union is difficult in congenital pseudarthrosis. Many methods have been attempted, including casting, internal fixation with or without grafting, and electrical stimulation, but failure is frequent. Free vascularized fibular flaps (FVFs) have been used to bridge long bone defects since 1975 and in tibial pseudarthrosis since 1979. In CPFB, FVF is more successful than other methods in achieving union and is the current treatment of choice. Here, we presented three cases of forearm pseudarthrosis treated with FVF, reviewed the literature on CPFB, and discussed some technical aspects of FVF treatment. Three cases of congenital pseudoarthrosis were treated with free fibula flaps, diagnosed at ages of 7 years (ulna), 15 months (radius), and 9 years (radius and ulna). Two flaps were stabilized with intramedullary wires and latterly, one with compression plates. One persistent nonunion received revision nonvascularized bone grafting and plating. All patients achieved union by 11 months after index surgery. Reconstruction with vascularized fibula is the treatment of choice because it offers the highest published union rates and good functional results. Complete resection of the affected bone and stable fixation, latterly with compression plates are critical to success. Surgery is technically demanding, and complications are common. Secondary surgery may be required, but outcomes are favorable. LEVEL OF EVIDENCE: IV.

Digital papillary adenocarcinoma: An important differential diagnosis for digital soft tissue masses.

Digital papillary adenocarcinoma (DPAC) is a rare, aggressive cancer with significant metastatic potential which arises from digital sweat glands. We present a case of a DPAC managed with surgical excision and reconstruction with a reversed homodigital island flap. Level of evidence: V.

Results of syndactyly release using a modification of the Flatt technique.

The results of 144 congenital syndactyly releases over a 12-year period by a single surgeon using a modified Flatt technique (dorsal hourglass flap, interdigitating zigzag flaps, and full-thickness skin grafts) are analyzed considering the association of skin grafts and web creep. The mean follow-up was 5 years. There were seven cases of graft failure, only one of which developed web creep. Web creep occurred in 4.2% of web releases. The results suggest that avoiding longitudinal straight-line scars across the web space may be an important factor in avoiding web creep when performing the modified Flatt technique described.

The Fleur-de-lis DIEP-Introducing a 5th zone for DIEP reconstruction.

We present a case of breast cancer in the massive weight loss patient. In the light of the PIP implant scandal, the patient demanded an autologous reconstructive solution. We describe our surgical approach towards this unique problem and share our experience of performing a DIEP reconstruction using a fleur-de-lis pattern.

CT analysis of fat distribution superficial and deep to the Scarpa's fascial layer in the mid and lower abdomen.

INTRODUCTION: Mismatches in the thickness of subcutaneous fat at the level of the umbilicus and suprapubic region can result in an unsightly bulge and an unfavourable result following standard abdominoplasty. This problem can be avoided by thinning the abdominoplasty flap. This study was carried out to assess the thickness of the subcutaneous fat layer at the level of the umbilicus and the supra-pubic region. Measurements of full thickness fat and the depth of Scarpa's fascia separating superficial and sub-Scarpa fat layers were taken from the CT scans in 69 women; mean age 52 years (range 30-79). RESULTS: The thickness of the skin and abdominal wall fat was an average of 7 mm thicker (max 22 mm; p << 0.05). The thickness of the fat layer superficial to Scarpa's fascia was an average of 19 mm at mid abdomen and 22 mm in the lower abdomen (p << 0.05). The thickness of the fat layer deep to Scarpa's fascia was 14 mm in the mid abdomen and 5 mm in the lower abdomen (p << 0.05). In 55% of patients the difference in thickness of the mid abdominal and lower abdominal fat was greater than 5 mm, a difference that could lead to a noticeable mismatch and therefore an unfavourable outcome. CONCLUSIONS: Results of this study suggest that selectively thinning the fat layer deep to Scarpa's fascia would address potential mismatches and preserve the Scarpa's fascia layer in more than 50% of cases, therefore allowing wounds to be closed with an effective deep tension layer.

Pyrolytic carbon arthroplasty for the proximal interphalangeal joint: results after minimum 3 years of follow-up.

A retrospective study was undertaken to review the outcomes of a consecutive series of patients treated using pyrocarbon surface replacement arthroplasty by the same surgeon. We analyzed the results of this procedure in 24 proximal interphalangeal (PIP) joints in 19 hands of 16 patients. The minimum follow-up was 3 years. The study showed that pyrocarbon PIP joint replacements provided excellent pain relief and high patient satisfaction. More than two-thirds of patients subjectively rated postoperative range of motion and functional outcomes as better than preoperatively. Objective assessment showed a modest improvement in the active range of motion, which did not achieve statistical significance, although we did observe a statistically significant increase in passive range of motion. The results are encouraging for those surgeons who seek an alternative to silicone implant PIP joint arthroplasty in high-demand patients.

Cutaneous manifestation of silicone dissemination from a PIP implant--a case for prophylactic explantation?

The recent withdrawal of PIP (Poly Implant Prosthese, France) implants for breast augmentation enforced by the Medicines and Healthcare products Regulatory Agency (MHRA) on 31st March 2010 has ignited speculation into possible side effects relating to an unauthorized gel fill content. Local and migratory silicone granulomata and regional lymphadenopathy are well reported in the literature. Gel bleed from high cohesive gel implants with similar effect is also well known. However dissemination to sites distant from the breast manifest as cutaneous abnormalities in a patient implanted with a PIP product raises concern. We report such a case.

The partial excision greenstick (PEG) osteotomy: a novel approach to the correction of clinodactyly in children's fingers.

Closing wedge osteotomy is an accepted technique for correcting bony malalignment. This study reports the results of a novel osteotomy technique used in children's hands. Excision of a partial wedge generates a 'greenstick' type of fracture which can then be reduced and stabilised using only intraosseous wires. Eight consecutive patients who underwent surgery of this type between March 2003 and January 2008 were reviewed retrospectively. Union was obtained in all cases and there was good bone alignment and range of movement. No significant technique-related complications were encountered. This approach is a simple and effective way of correcting malalignment in the small bones of children's hands.

Telemedicine for acute plastic surgical trauma and burns.

Visual images can enhance communication over a distance. In the UK, plastic surgery provides services over large distances by a 'hub and spoke' model. Telemedicine could help to increase the efficiency of service for plastic surgery patients. Telemedicine, along with the impending Electronic Patient Record system could combine to improve communication, patient triage, record keeping, audit and could lead to a better quality of clinical care. Another benefit could be significant cost savings. We report our experience of the introduction of telemedicine to a Regional Plastic Surgery Service. Our first study compared assessments from images and patient examinations, which gave us confidence in the use of images [Jones SM, Milroy C, Pickford MA. Telemedicine in acute plastic surgical trauma and burns. Ann R Coll Surg Engl 2004;86:239-42]. We proceeded to a 10-week evaluation of all 973 referrals to our unit. We found that the system was used for a wide variety of injuries and for 42% of the 452 patients where the system was available. Initial resistance was overcome by the ease of use of the system, with both receiving and referring clinicians reporting benefits. The third phase was a 12-week prospective cohort study of 996 patients comparing the referrals with and without the telemedicine system. The system was available for 389 patients, and used for 243 patients (63%). The groups were analysed by a chi squared test and confidence interval calculation. We demonstrated a significant difference in the initial management of patients, with 10% more being booked directly to our Day Surgery Unit. There was a decrease in number of occasions when we were unable to accept a patient due to a lack of capacity. We found no change in the patients being managed with telephone only advice. We found that telemedicine is a valuable method of providing useful preliminary information in the referral process for injured patients and often significantly modifies their treatment and/or management plan. This has implications for the use of Information Technology resources and potentially the delivery of healthcare in relation to the management of injured patients.

Dorsal dimelia in patau syndrome: a case report.

We present a case of a child with Patau syndrome that exhibits features consistent with congenital palmar nail syndrome. The literature is reviewed and evidence presented to demonstrate that this is a defect in the dorso-ventral patterning of the limb and thus a form of dorsal dimelia. In order to differentiate this from other instances of ectopic nail tissue we suggest congenital palmar nail syndrome should be more specifically defined as duplicated nails, absent flexion creases, non-glabrous skin on the palmar surface, reduced movement at the interphalangeal joints and hypoplastic terminal phalanges.

Microvascular soft tissue reconstruction of the digits.

INTRODUCTION: Composite tissue loss to digits following trauma may require flap coverage. Local reconstruction techniques are popular but can result in a functional limitation at the donor site. Small free flaps though complex, may provide a superior alternative. METHOD: We retrospectively reviewed the case-notes of all patients who had a small free flap to a digit following trauma. The time period was 4 years (2000-2004). Sixteen patients with 18 digital free flaps were identified. These comprised of 10 venous flow-through flaps, one lateral arm flap, one great toe to thumb pulp transfer, three first web space flaps from the foot, one medial plantar flap and two free posterior interosseous flaps. All 16 patients were invited for clinical review at an out-patients clinic. Ten patients (11 flaps) attended follow-up. Standardised assessment of outcome in terms of scar quality at both the recipient and donor sites, sensibility, range of motion and function of the hand was completed. RESULTS: Overall the average follow-up period was 14 months, with 16 out of 18 flaps surviving. Of the patients that attended for clinical review, the majority recovered excellent function of the hand (quick-DASH--av. 5.7) with satisfactory aesthetics, minimal pain or limitations in range of motion. The flaps were all soft and durable. Ten flaps recovered protective but not discriminative sensation (only one flap was innervated). The three patients whose donor site was the first-web space of the foot developed significant hypertrophic scarring. CONCLUSION: Small free flaps provide an acceptable method of reconstructing digital defects. Venous flow-through flaps provided the best overall results in this series. The donor site for first-web space flaps is probably unacceptable.

Preoperative management of the amputated limb.

Little literature exists on storage and preparation of an amputated limb prior to transfer to a reconstructive plastic surgical unit for possible macroreplantation. This paper describes practical measures used to prolong ischaemia time allowing macroreplantation, tissue harvesting, or fashioning of a useful stump. A simple protocol is used to summarise these points.

Telemedicine in acute plastic surgical trauma and burns.

BACKGROUND: Telemedicine is a relatively new development within the UK, but is increasingly useful in many areas of medicine including plastic surgery. Plastic surgery centres often work on a hub-and-spoke basis with many district hospitals referring to one tertiary centre. The Queen Victoria Hospital is one such centre receiving calls from more than 28 hospitals in the Southeast of England resulting in approximately 20 referrals a day. OBJECTIVE: A telemedicine system was developed to improve trauma management. This study was designed to establish whether digital images were sufficiently accurate enough to aid decision-making. A store-and-forward telemedicine system was devised and the images of 150 trauma referrals evaluated in terms of injury severity and operative priority by each member of the plastic surgical team. RESULTS: Correlation scores for assessed images were high. Accuracy of "transmitted image" in comparison to injury on examination scored > 97%. Operative priority scores tended to be higher than injury severity. CONCLUSIONS: Telemedicine is an accurate method by which to transfer information on plastic surgical trauma including burns.

Free radial forearm adipofascial flaps raised through limited incisions.

Free radial forearm adipofascial flaps were used for limb reconstruction in four cases. The flaps were harvested through limited skin incisions with the aid of lighted retractors. The mean surface area was 96 cm(2). The donor sites and the transferred tissue healed satisfactorily in all cases. Although the dissection through limited incisions is slightly awkward and prolongs the operating time, the technique offers significant benefits in terms of donor-site morbidity and aesthetics.

Visual estimation of finger angles: do we need goniometers?

Seventy-one plastic surgeons and therapists, of varying levels of seniority and experience, were asked to examine a resin cast of an adult male hand and use estimation to measure the angles of the metacarpophalangeal and interphalangeal joints of each digit. Visual estimation by all subjects was inaccurate by a mean of approximately 25% (median percentage error 22, range 1-100). Consultants were the most accurate, whilst physiotherapists were the least. Regular goniometer users were no more accurate. However, hand surgery experience correlated with accuracy, as did a stated interest in hand surgery. Although visual accuracy improves with experience, it is still an inaccurate technique. We, therefore, recommend that goniometers should be used for measuring angles in hand surgery patients.

Introduction of a hand trauma day surgery operating list.

Due to a huge increase in hand trauma referrals to our busy plastic surgical unit, we introduced a dedicated half-day hand trauma day surgery (HTDS) list to try and reduce the pressure on inpatient beds and length of wait for surgery. We reviewed the first 101 cases treated on the HTDS list to determine whether this allowed adequate specialist treatment of these injuries and to assess outcome and complications rates. Only one patient needed admission following surgery and our complication rate compared favourably with that of patients admitted and treated in the standard manner. We conclude that a HTDS list is both an effective and efficient method of treating a wide range of hand injuries.

The first toe-to-hand transfer: a thirty-year follow-up.

In April 1968 the first successful free toe-to-hand transfer was performed by Mr. J. R. Cobbett at the Queen Victoria Hospital to reconstruct the thumb of a woodworker. Details of the case are discussed and the patient's current level of sensation, power and function are presented over 30 years following reconstruction.

Use of the homodigital adipofascial turnover flap for dorsal cover of distal interphalangeal joint defects.

The homodigital adipofascial turnover flap was originally described by Voche and Merle (1994) for dorsal cover of the proximal interphalangeal joint. We present three patients in whom this flap was used to cover dorsal defects of the distal interphalangeal joint, and describe an adaptation to allow greater flap mobility.

Distraction lengthening of the ulna in radial club hand using the Ilizarov technique.

Six children with radial club hand had distraction lengthening of the ulna using the Ilizarov technique at the mean age of 10 years. The mean lengthening achieved was 4.7 cm (46% of original ulna length). Complications included nocturnal pain, pin track infection and callus fracture or delayed union. Distraction lengthening of the ulna can enhance the ability to perform normal activities of daily living, such as reaching the perineum or driving a car, but complications are extremely common. The high rate of callus fracture in this series reinforces the need for regular radiographic review during distraction and suggests that after distraction it may take more than 4 weeks for satisfactory callus consolidation before removal of the fixator.