Biomechanical analysis of tendon turnover tenorrhaphy compared to direct repair and Pulvertaft weave.

The aim of the present study was to evaluate biomechanical properties of tendon turnover repair in comparison to direct repair and Pulvertaft weave. A total of 48 sheep flexor tendons were assigned to eight groups comprising single or double tendon turnover repair, tendon turnover segment (without tenorrhaphy), direct repair or Pulvertaft weave. Tensile strength, stiffness and failure mechanisms were evaluated with a 500 N load cell. Turnover repair showed no significant difference in tensile strength to direct repair. Failure in turnover repair occurred largely at the site of tenorrhaphy due to suture pull-through or suture rupture. the increase in cross-sectional area after turnover repair was similar to that after direct repair, but less than after Pulvertaft weave. Tendon turnover offers tensile strength similar to direct repair with no associated increase in bulk. It provides a biomechanically secure and quicker alternative to tendon grafting for reconstructing tendon defects, without secondary donor site morbidity.Level of evidence: V.

Fanconi Anemia: Examining Guidelines for Testing All Patients with Hand Anomalies Using a Machine Learning Approach.

BACKGROUND: This study investigated the questionable necessity of genetic testing for Fanconi anemia in children with hand anomalies. The current UK guidelines suggest that every child with radial ray dysplasia or a thumb anomaly should undergo further cost intensive investigation for Fanconi anemia. In this study we reviewed the numbers of patients and referral patterns, as well as the financial and service provision implications UK guidelines provide. METHODS: Over three years, every patient with thumb or radial ray anomaly referred to our service was tested for Fanconi Anemia. CART Analysis and machine learning techniques using Waikato Environment for Knowledge Analysis were applied to evaluate single clinical features predicting Fanconi anemia. RESULTS: Youden Index and Predictive Summary Index (PSI) scores suggested no clinical significance of hand anomalies associated with Fanconi anemia. CART Analysis and attribute evaluation with Waikato Environment for Knowledge Analysis (WEKA) showed no single feature predictive for Fanconi anemia. Furthermore, none of the positive Fanconi anemia patients in this study had an isolated upper limb anomaly without presenting other features of Fanconi anemia. CONCLUSION: As a conclusion, this study does not support Fanconi anemia testing for isolated hand abnormalities in the absence of other features associated with this blood disease.

"Fish Gill" Incisions for Severe Periorbital Surgical Emphysema Following Tension Pneumothorax - A Case Report and Review of the Literature.

BACKGROUND: Surgical emphysema refers to the presence of air within the subcutaneous space and is a known complication of chest drain insertion. Symptoms range from mild crepitus of the chest wall to the accumulation of air in the face and neck, which can ultimately result in cardiovascular compromise. OBJECTIVE: The aim of this article is to present a rare case of cervical, facial and periorbital surgical emphysema following chest drain insertion, and describes a novel use of 'fish gill' incisions in the palpebromalar groove with an associated review of the literature. CASE REPORT: A 68-year-old gentleman presented with acute dyspnoea due to a right-sided tension pneumothorax. Emergency decompression with a Seldinger chest drain resulted in persistent cervical, facial and periorbital surgical emphysema causing difficulty in movement, inability to open the eyes and progressive risk to cervical venous return. "Fish gill' incisions at the lateral-most edge of the palpebromalar groove, down to the level of the orbicularis oculi muscle, rapidly released air from the face and neck, alleviating discomfort, reducing venous compression and restoring vision. CONCLUSION: Cervical, fascial and periorbital surgical emphysema may be resolved with the use of "fish gill" incisions at the lateral palpebromalar groove and simple drains. To the best of our knowledge, this method has not been reported previously in the literature.

When should pelvic sentinel lymph nodes be harvested in patients with malignant melanoma?

BACKGROUND: Preoperative lymphoscintigraphy for sentinel node biopsy (SNB) combined with intra-operative gamma-probe detection often identifies nodes within the pelvis. This study investigates the role of pelvic SNB harvest. METHODS: Retrospective review of eighty-two stage I/II melanoma patients with primary tumour on the lower limb and trunk who underwent groin SNB, either inguinal or pelvic or both, over a three year period. RESULTS: Of the 82 patients, 19 had positive SNBs (24%), all of which were inguinal nodes. None of the 11 patients with pelvic nodes removed had a positive pelvic node. The median follow-up period was 18 months (SD: 10.8; range: 8-43). Although the complication rate was higher following pelvic SNB, the difference was not statistically significant (p > 0.5). The average operative time for an inguinal SNB was 92 min, and increased significantly to 134 min for a pelvic SNB (p < 0.0001). Lymphoscintigraphy of trunk and thigh melanomas identified individual tracks to be leading directly from the tumour to a pelvic node(s). However, when the primary tumour was located at or below the knee, pelvic nodes identified by lymphoscintigraphy appeared to be second level nodes. CONCLUSION: A lymphoscintigraphy protocol that includes dynamic images obtained in frequent intervals following injection of the radiotracer combined with thorough preoperative analysis of the lymphoscintigraphy scans and effective communication between the radiologist and the surgeon allows accurate identification of the primary tracks and prevent unnecessary harvest of second echelon pelvic lymph nodes. In patients with significant co-morbidities due consideration is required before harvesting pelvic sentinel nodes.