Hemi-hamate arthroplasty outcomes: a single-centre experience.

This retrospective observational study evaluated outcomes after hemi-hamate arthroplasty. A palmar cortical step caused by the osteochondral graft was associated with reduced proximal interphalangeal joint range of motion compared to a flush palmar cortex at early follow-up (62° vs. 83°; p = 0.006).

Incidental finding of a hidden central polydactyly: A case report.

Congenital hand anomalies are common, and must always be considered as a differential diagnosis in patients with hand pathology. We report the case of a child who sustained a fingertip injury to highlight an unusual presentation of central polydactyly.

A comparison of the epidemiology of isolated and non-isolated hand burns.

Hand burns are common and treatment individualized, however given large volumes in some centers, pattern recognition may help optimize service provision. We performed a single center retrospective review from 2014 to 2018 of hand burns in patients aged 16 and over. Burns confined to the hands were considered isolated. We found 1163 patients (790 male, 68%), with 853 isolated (9% bilateral) and 310 non-isolated (35% bilateral) hand burns, and 12% were sustained in industrial workplaces. Most isolated burns received first aid (72%) and were scalds (41%) or contact (23%). Many presented to hospital by car (73%) and most were treated as outpatients (92%). Non-isolated burns were mainly flash (38%) or flame burns (25%, p < 0.01), with 66% given first aid, 49% used ambulances (p < 0.01) and 54% underwent hospital admission (p < 0.01). Non-isolated injuries had more full thickness involvement (p < 0.01), 13% were resuscitation burns and 10% received intensive care. Isolated and non-isolated burns are distinct clinical entities, as are unilateral and bilateral injuries. Isolated burns are usually unilateral scalds or contact burns, suited to outpatient treatment. Non-isolated burns are often flash or flame, bilateral, often needing ambulances, admission, and interventions. First aid can be improved, and consideration given to inpatient rehabilitation of bilateral hand burns.

Serum Inflammatory Markers and Amputations in Hand Osteomyelitis: A Retrospective Review of 146 Cases.

BACKGROUND: The diagnosis of hand osteomyelitis requires correlation of clinical, radiological, and microbiological findings. The role of serum inflammatory markers in diagnosing and prognosticating hand osteomyelitis remains uncertain. We sought to determine the utility of inflammatory markers in the diagnosis and follow-up of hand osteomyelitis, and their ability to predict outcomes, particularly amputation. METHODS: We retrospectively reviewed 146 patients diagnosed with hand osteomyelitis and with serum inflammatory marker levels measured after the onset of symptoms and within 14 days either side of diagnosis. Blood results at first presentation including white cell count (WCC), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and C-reactive protein (CRP) were reviewed, and associations with amputations assessed. Follow-up markers taken at 15 to 60 days from diagnosis were analyzed where available. RESULTS: Mean WCC and CRP at diagnosis were 9.2 (SD: 4.6) and 30.2 (SD: 42.4) respectively, compared with 8.2 (SD: 3.9) and 30.2 (SD: 42.4) at follow-up. At diagnosis, sensitivity of CRP was 74%, and WCC was 31%. Each marker had a low positive predictive value for amputation at diagnosis (<29%). A rise in CRP between diagnosis and follow-up was associated with an increased risk of amputation compared with a fall in CRP. The finding that WCC and CRP were both normal at diagnosis had a high negative predictive value against amputation (96%). CONCLUSION: C-reactive protein has a higher sensitivity than WCC, NLR, and PLR when used as a diagnostic adjunct in hand osteomyelitis. White cell count and CRP both within reference ranges at diagnosis was highly negatively predictive against amputation.

Partial myocutaneous gluteal flap for perineal reconstruction of extralevator abdominoperineal defects. A single surgeon series of 49 cases in 8 years, and a modification of the technique.

INTRODUCTION: Extralevator abdominoperineal excision (ELAPE) for low rectal tumours necessitates a reliable method of reconstructing the perineum. The senior author developed the partial myocutaneous gluteal (PMG) flap. We present 49 consecutive reconstructions with the refinement of the original procedure. METHODS: We conducted a retrospective observational review of patients undergoing ELAPE and PMG reconstruction from 2012 to 2019, with at least 1 year follow-up. The procedure was modified iteratively following our original series, to minimise perineal herniation, specifically by greater mobilisation of the inferior gluteus maximus muscle and separation of the muscle and fasciocutaneous components, allowing closure of the defect around the coccygeal remnant. Perineal herniation and wound complications were recorded. Laparoscopic and open resection techniques were compared, as were outcomes before and after modification of the flap. RESULTS: There were no flap failures in our cohort of 49 patients. Two patients (4%) required return to theatre acutely for perineal wound complications: one wound dehiscence and one flap-related haematoma. Five patients had evidence of perineal hernia, three prior to any modification of the flap and two following. Three had symptoms of which two required elective repair. The flap modifications were made in response to these cases. There were no significant differences in perineal outcomes for laparoscopic versus open, and before and after flap modification. CONCLUSIONS: Over the last 8 years, we have refined our perineal reconstruction technique following instances of perineal herniation and major wound dehiscence. We believe that the PMG flap provides robust and reliable option for the reconstruction of perineal extralevator abdominoperineal defects.

Free gracilis end-to-side microanastomosis to a peronea arteria magna: a case report.

BACKGROUND: Complex orthoplastic lower limb trauma in individuals with multiple injuries requires considerable resources and interdisciplinary collaboration for good outcomes. We present the first reported end-to-side free flap microanastomosis for lower limb trauma reconstruction involving a peronea arteria magna without radiographic collaterals. CASE PRESENTATION: A 55-year-old Caucasian gentleman involved in road traffic collision sustained an open tibial fracture on the anteromedial distal third of the left lower leg with local degloving and a subtotal right foot and ankle degloving. Both injuries were reconstructed with free tissue transfer. A left lower limb peronea arteria magna successfully received a free gracilis muscle flap by end-to-side microanastomosis and perfusion of the foot was preserved. This rare anatomical variant and its anatomy is reviewed, as well as a description of the suggested preoperative planning and technique for reconstruction. CONCLUSIONS: Successful free flap reconstruction may be performed to a lower limb with a peronea arteria magna recipient as the lone vessel supplying the foot in trauma, although preoperative counseling of the risks, benefits, and options are essential. LEVEL OF EVIDENCE: Level V, case report.

Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature.

INTRODUCTION: Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns. RESULTS: An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes. DISCUSSION: The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers. CONCLUSIONS: More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

Groin dissections in skin cancer: Effect of a change in prophylactic antibiotic protocol.

OBJECTIVES: To determine whether groin dissection surgical site infection (SSI) incidence changed with shorter post-operative antibiotic prophylaxis. BACKGROUND: Post-operative prophylaxis changed due to antimicrobial stewardship, from regular oral antibiotics until drain removal, to three intravenous doses. Both groups had a single intravenous dose at induction. METHODS: A prospective database of groin dissections for metastatic skin cancer was retrospectively reviewed for SSI according to Public Health England criteria. Eighty groin dissections in 79 consecutive patients were included: 40 had oral antibiotics until drain removal [mean 26±7 (range 19-36) days] and 39 had three post-operative intravenous doses. RESULTS: Longer prophylaxis was associated with lower SSI incidence [10 (25%) versus 21 (54%), odds ratio (OR) 3.50, 95% confidence interval (CI) 1.34-9.08, p = 0.009], fewer deep infections [5 (13%) versus 16 (41%), OR 4.89, 95% CI 1.57-15.13, p = 0.004], fewer readmissions for infection [5 (13%) versus 15 (38%), OR 4.38, 95% CI 1.40-13.65, p = 0.008], but similar seroma incidence [18 (45%) versus 16 (41%), OR 0.85, 95% CI 0.35-2.07, p = 0.72] and wound dehiscence [7 (18%) versus 5 (13%), OR 0.69, 95% CI 0.20-2.40, p = 0.56]. BMI ≥30 (n = 21) was associated with SSI, occurring in 13 of 21 (62%) (OR 3.859, 95% CI 1.34-11.10, p = 0.01). Median infection onset was 22 days (IQR 12-27) versus 17 (IQR 13-22), (p = 0.53). Multiple organisms were cultured in 21 of 31 (68%) patients with positive microbiological samples. CONCLUSIONS: SSI rates doubled with shorter prophylaxis; deep infections and readmissions for infection tripled. Obesity was independently associated with infection. Seroma and wound dehiscence incidence were unchanged. Infections mainly occurred in the third week after surgery and were polymicrobial.

Hand osteomyelitis in arterial calcification, diabetes mellitus and end-stage renal failure: a comparison of 210 cases over 12 years.

We present 210 patients with hand osteomyelitis in 246 rays over 12 years, including detailed analysis of 29 patients in this cohort with digital artery calcification evident on plain X-ray. Overall 71 patients had diabetes mellitus and/or end-stage renal failure, including 28 of 29 patients with calcification. In the calcification group, 17 patients had ipsilateral arteriovenous fistulae, five had steal syndrome and 15 had digital ulceration or skin necrosis. Compared with 181 controls, patients with calcification had more affected bones, polymicrobial infections, surgical procedures, phalanges and digits amputated and had higher mortality at 1 year (12 of 29) and 5 years (20 of 29), as a result of comorbidities. Absence of calcification in 43 patients with diabetes and/or end-stage renal failure was associated with better outcomes on all the above parameters. Early amputation to maximize disease-free survival may be appropriate for patients with hand osteomyelitis and arterial calcification.Level of evidence: IV.

A Rule of Thumb for Hand Burns: Categorization and Mapping of Proportional Surface Area Involvement.

Hand burns are common and often complex injuries, requiring referral to specialist centers. The patient's thumbprint is a rapid means of accurately assessing hand burn surface area. This study aimed to establish categories and evaluate sites of hand burn surface area in order to facilitate comparison of hand burns. Sixteen burns involving the hand and wrist among 14 patients referred to a burns center were retrospectively categorized by burn mechanism, burn thickness, and hand burn surface area. The burn surface area in the clinical record was compared with that calculated by the thumbprint method and the rule of thumb diagram. Burn surface area in the clinical record was either "1%" or "<1%" in 9 of 16 cases. In contrast, the surface area was <1 thumbprint (T) in six burns, two were between 1 and 5T, three were 5 to 10T, two were 10 to 20T, two were 20 to 50T, and one was greater than 50T. The median thumbprint burn surface area was 1.5T (range 0.20-80T), which corresponds to 0.05% TBSA. The hand areas with the highest burn frequency per unit area were the dorsum of the hand and dorsum of the index finger, with relative sparing of the palm and palmar surface of the digits. Hand burns surface area varies widely, and thumbprint evaluation with categories and mapping allows finer distinction between the surface area proportions and specific sites involved, even in a small series of hand burns.

Hand burns surface area: A rule of thumb.

INTRODUCTION: Rapid estimation of acute hand burns is important for communication, standardisation of assessment, rehabilitation and research. Use of an individual's own thumbprint area as a fraction of their total hand surface area was evaluated to assess potential utility in hand burn evaluation. MATERIALS AND METHODS: Ten health professionals used an ink-covered dominant thumb pulp to cover the surfaces of their own non-dominant hand using the contralateral thumb. Thumbprints were assessed on the web spaces, sides of digits and dorsum and palm beyond the distal wrist crease. Hand surface area was estimated using the Banerjee and Sen method, and thumbprint ellipse area calculated to assess correlation. RESULTS: Mean estimated total hand surface area was 390.0cm2±SD 51.5 (328.3-469.0), mean thumbprint ellipse area was 5.5cm2±SD 1.3 (3.7-8.4), and mean estimated print number was 73.5±SD 11.0 (range 53.1-87.8, 95% CI 6.8). The mean observed number of thumbprints on one hand was 80.1±SD 5.9 (range 70.0-88.0, 95% CI 3.7), χ2=0.009. The combined mean of digital prints was 42, comprising a mean of two prints each on volar, dorsal, radial and ulnar digit surfaces, except volar middle and ring (3 prints each). Palmar prints were 15 (11-19), dorsal 15 (11-19), ulnar palm border 3, first web space 2, and second, third and fourth web spaces one each. Using the surface of the palm alone, excluding digits, as 0.5% of total body surface area, the area of one thumbprint was approximated as 1/30th of 1%. CONCLUSIONS: We have demonstrated how thumbprint area serves as a simple method for evaluating hand burn surface area.

Laparoscopic sleeve gastrectomy for morbidly obese adolescents in Singapore.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) outcomes among adolescents and factors associated with adolescent obesity in Singapore were evaluated. METHODS: Prospectively collected data of patients aged 16-19 years who underwent LSG was retrospectively reviewed. A lifestyle questionnaire, Berlin and Epworth scores, and Patient Health Questionnaire-9 scores were collected. Preoperative anthropometrics, comorbidities, weight loss and body composition outcomes were recorded. RESULTS: Among 208 LSGs, 13 (6.3%) were performed on obese adolescents. Mean age and body mass index (BMI) at first presentation were 19.1 ± 0.9 (range 16.8-19.8) years and 46.2 ± 6.3 (range 36-57) kg/m2, respectively. There was family history of obesity (n = 7) and regular consumption of high-calorie drinks (n = 12). Most patients had comorbidities (n = 12), including hypertension (n = 5), asthma (n = 4), diabetes mellitus (n = 3), hernia (n = 3) and obstructive sleep apnoea requiring continuous positive airway pressure support (n = 3). At one year, excess weight loss was 64.3% ± 34.7% (range 21.8%-101.5%), while BMI and fat mass dropped to 31.2 ± 7.6 (range 23-40) kg/m2 and 17.4 kg, respectively. Pain score was 2/10 at 24 hours after surgery. Mean postoperative stay was 2.7 days. No complications or readmissions occurred. Remission of diabetes mellitus and hypertension was reported in two of three and four of five adolescents, respectively, within one year of surgery. CONCLUSION: LSG is a safe option for adolescents with good short-term weight loss outcomes and remission of metabolic comorbid conditions.

The success of sleeve gastrectomy in the management of metabolic syndrome and obesity.

The rapid reversal of diabetes, hypertension, hyperlipidaemia and obesity by surgical means has challenged accepted doctrines regarding the management of metabolic syndrome. Sleeve gastrectomy, which developed initially as a preparatory procedure for biliopancreatic diversion with duodenal switch, has seen an exponential rise in popularity as an effective lone laparoscopic bariatric procedure. Superior excess weight loss, a low complication rate, and excellent food tolerance, combined with a short hospital stay, have made this the procedure of choice for patients and surgeons across the globe. High volume centres nurture the ongoing development of experienced and specialized teams, pathways and regimens. Optimum surgical outcomes allow minimization of metabolic syndrome, reducing cardiovascular and cerebrovascular risk.

A retrospective review of the Dall-Miles plate for periprosthetic femoral fractures: twenty-seven cases and a review of the literature.

A retrospective review of the use of the Dall-Miles plate for periprothetic femoral fractures was performed at our institution. Twenty-seven fractures around a hip replacement were fixed using a Dall-Miles plate within 34 months. The mean age at operation was 74 (33-90) years. Twenty fractures were Vancouver B1, two B2, and five type C. Mean follow-up was 11 (2-41) months. Two fractured plates required revision and two fixations loosened, developing varus malunion. One malunion was related to deep infection. All four events occurred within six months of fixation. Two individuals were deceased within 3 months of surgery. Similar complications were evident in nine series published between 1990 and 2012. Increased incidence of periprosthetic femoral fractures is anticipated in a population with significant co-morbidities. Cortical strut allograft, iliac autograft and orthobiological supplementation remain options where non-union is anticipated.

Advancement and benefit of energy sealing in minimally invasive surgery.

Energy sealing has advanced rapidly in the last decade with many new devices becoming available. The rate and variety of advances in technology facilitate new and existing techniques, with ultrasonic shears and electrothermal bipolar graspers forming a vital but changing part of the modern surgeon's armamentarium. Advances including the combination of ultrasonic and bipolar systems, the addition of cutting blades, tissue impedance sensors, and electrode configurations with reduced lateral thermal spread have heralded new opportunities in laparoscopic and minimally invasive surgery. Reduced operating times, lower postoperative pain scores, and shorter length of stay are offset by the additional cost of such instruments. Reduced instrument exchange, improved smoke evacuation, and shorter surgeries by trainees with some devices are benefits that set the scene for further innovation in this vibrant sector.