One stage placement of permanent implant compared to two stage tissue expander reconstruction.

With the advent of the skin sparing mastectomy, immediate breast reconstruction with placement of the definitive prosthesis at the time of mastectomy is possible. The question remains: does single-stage prosthetic reconstruction result in greater numbers of complications or rates of re-operation, compared to two-stage tissue expander reconstruction? A retrospective cohort study of a single centre?s experience with these techniques was carried out. From 2004 to 2012, 54 cases of immediate breast reconstruction with implant were identified, and 108 cases of immediate breast reconstruction using a tissue expander were identified. Gathered preoperative data included tumour, prior exposure to radiation, preoperative chemotherapy, smoking, and comorbidities. Complication rates, as well as the rate of secondary operations, were examined. There were no significant increased risks in the rate of post-operative complications (p = .910, odds ratio = 0.9) nor in the rate of re-operation (p = 0.421, odds ratio = 1.4) associated with the insertion of a definitive prosthesis at the time of skin sparing mastectomy. However, previously radiated breasts experienced a 100% rate of wound complications in our subset of 9 breasts that underwent one stage breast reconstruction with immediate final prosthesis placement. Our study suggests that patients with early stage disease can undergo single stage breast reconstruction without increased risk of complications nor need for secondary operations. While the mean time to completion of the reconstructive process is shortened by 5 months with the single stage technique, implant based breast reconstruction requires careful counseling and patient selection in radiated patients.

Evaluating an outreach service for paediatric burns follow up.

Complications following paediatric burns are well documented and care needs to be taken to ensure the appropriate follow up of these patients. Historically this has meant follow up into adulthood however this is often not necessary. The centralisation of burns services in the UK means that patients and their parents may have to travel significant distances to receive this follow up care. To optimise our burns service we have introduced a burns outreach service to enable the patients to be treated closer to home. The aim of this study is to investigate the impact of the introduction of the burns outreach service and within this environment define the optimum length of time needed to follow up these patients. A retrospective analysis was carried out of 100 consecutive paediatric burns patients who underwent surgical management of their burn. During the follow up period there were 43 complications in 32 patients (32%). These included adverse scarring (either hypertrophic or keloid), delayed healing (taking >1 month to heal) and contractures (utilising either splinting or surgical correction). Fifty-nine percent of these complications occurred within 6 months of injury and all occurred within 18 months. Size of burn was directly correlated to the risk of developing a complication. The outreach service reduced the distance the patient needs to travel for follow up by more than 50%. There was also a significant financial benefit for the service as the follow up clinics were on average 50% cheaper with burns outreach than burns physician. Burns outreach is a feasible service that not only benefits the patients but also is cheaper for the burns service. The optimum length of follow up for paediatric burns in 18 months, after which if there have not been any complications they can be discharged.

Systematic review of flexor tendon rehabilitation protocols in zone II of the hand.

BACKGROUND: Restoration of function following flexor tendon repair in zone II represents a difficult clinical problem. Despite many publications on rehabilitation methods, there exists no consensus as to which method is superior. This study was undertaken to determine which flexor tendon rehabilitation protocol provides the best outcome after surgical repair in zone II. METHODS: Electronic databases were searched for articles published between 1970 and 2009. The population included patients aged 5 years and older who sustained a flexor tendon laceration in zone II. The primary outcome was rupture rate. Secondary outcomes were range of motion and quality of life. The following protocols and their variations were considered: passive flexion and active extension protocols (Kleinert type protocols), controlled passive motion protocols (Duran type protocols), combination of the Kleinert and Duran protocols, and early active motion protocols. RESULTS: Seventy-nine articles were identified. Fifteen studies met the inclusion criteria. The mean rate of rupture was lowest in the combined Kleinert and Duran protocols (2.3 percent) and highest in the Kleinert protocols (7.1 percent). No statistically significant differences were found. The combined Kleinert and Duran protocols and the early active motion protocols exhibited the highest proportion of digits with excellent or good results using the Strickland and Buck-Gramcko systems. One study included a quality-of-life assessment-meaningful comparison was not possible. CONCLUSIONS: Both early active motion protocols and combined Kleinert and Duran protocols result in low rates of tendon rupture and acceptable range of motion following flexor tendon repair in zone II. Future studies should include quality-of-life measurements using validated scales.

Long-term anticoagulation in Kawasaki disease: Initial use of low molecular weight heparin is a viable option for patients with severe coronary artery abnormalities.

Patients with severe coronary artery involvement after Kawasaki disease (KD) require long-term systemic anticoagulation. We sought to compare our experience with thrombotic coronary artery occlusions, safety profile, and degree of coronary artery aneurysm regression in KD patients treated with low molecular weight heparin (LMWH) versus warfarin. Medical records of all KD patients diagnosed between January 1990 and April 2007 were reviewed. Of 1374 KD patients, 38 (3%) received systemic anticoagulation, 25 patients received LMWH from diagnosis onward, 12 of whom were subsequently switched to warfarin, and 13 received warfarin from onset. The frequency of thrombotic coronary artery occlusions was similar between drugs. Severe bleeding was more frequent in patients on warfarin, but minor bleeding was more frequent for patients on LMWH. Patients on warfarin were at greater risk of underanticoagulation or overanticoagulation (defined as achieving an anti-activated factor X level or an international normalized ratio below or above target level) than patients on LMWH (P < 0.05). Maximum coronary artery aneurysm z-scores diminished with time for patients on LMWH (P = 0.03) but not for those on warfarin (P = 0.55). This study suggests that LMWH is a potentially viable alternative for patients, especially young ones, with severe coronary artery involvement after KD.

Anatomical variations of the carpal tunnel structures.

There are many anatomical variations in and around the carpal tunnel that affect the nerves, tendons and arteries in this area. Awareness of these variations is important both during the clinical examination and during carpal tunnel release. The purpose of the present review is to highlight recognized anatomical variations within the carpal tunnel including variation in nerve anatomy, tendon anatomical variants, vascular anatomical variations and muscle anatomical variations.