Functional outcomes after single quadriceps muscle resection in patients with soft tissue sarcoma of the anterior compartment of the thigh.

BACKGROUND: Soft tissue sarcoma (STS) occurs most commonly in the anterior compartment of the thigh. Limb salvage surgery is the mainstay of treatment, however, resections frequently involve muscle sacrifice. This study determines the impact of a single quadriceps muscle sacrifice on daily living functions. This is to assist clinical decision-making relating to when a functional reconstruction should be offered over simple soft tissue coverage for these defects. METHODS: Patients who underwent single quadriceps resection as part of the management of STS between 2010 and 2020 were selected. Three functional tests were performed: Time Up and Go (TUG), Timed Up and Down Stairs (TUDS) and Toronto Extremity Salvage Score (TESS). The results were compared with age/sex matched healthy reference values and literature cohorts of lower limb STS patients. Correlations between the tests and age and follow-up duration were determined by the Spearman's test. RESULTS: The mean TESS, TUG and TUDS results of the 13 patients were 89.6%, 9.8 and 1.01 s/step, respectively. These scores were either similar or significantly better than the comparator values. The TESS score showed no statistical significance compared with patients with no muscle resection. TUG and TUDS scores showed significant positive correlation with each other (ρ = 0.885, P = <0.01) and with age (ρ = 0.646, P = 0.017 and ρ = 0.567, P = 0.043, respectively). CONCLUSION: This is the largest documented case series of single quadriceps resection for STS. The study suggests that this group of patients does not show a functional deficit and therefore does not require functional reconstruction.

Donor Side Preference in Maxillary Reconstruction With the Free Fibula Flap.

BACKGROUND: The implications on the choice of donor side when using the free fibula flap for reconstruction of unilateral maxillectomy defects has not been discussed in the literature so far. METHODS: A unilateral maxillectomy reconstruction was replicated using a 3D-printed skull model and fresh cadaveric dissections of left and right osteomyocutaneous fibula flaps for comparison. Detailed photo documentation was conducted to analyze and illustrate the anatomical differences of performing a reconstruction using the ipsilateral or contralateral sides and their relative benefits and risks. RESULTS: A more favorable lie of the septum and skin paddle and flexor hallucis longus muscle is attainable depending on which donor side is used and the planned direction of the pedicle. CONCLUSION: This study demonstrates why it is preferable to use the ipsilateral fibula if anastomosis is to the ipsilateral facial or neck recipient vessels, or the contralateral fibula where the contralateral recipient vessels are preferred.

Use of a bilayer biodegradable synthetic dermal matrix for the management of defects arising from necrotising fasciitis.

The aim of this article is to provide a brief overview of necrotising fasciitis, including causative factors, incidence, diagnosis and clinical outcomes. Various surgical treatment options are outlined, including methods of soft tissue reconstruction after wide excision of infected and necrotic tissues. The role of dermal matrices, including a synthetic biodegradable temporising matrix made of polyurethane, are described in terms of wound bed preparation, surgical application and clinical outcomes.

Use of the Derriford Appearance Scale 59 to assess patient-reported outcomes in secondary cleft surgery.

BACKGROUND: Secondary rhinoplasty, one of the final procedures in addressing the stigma of the cleft lip and palate (CLP), has both functional and aesthetic objectives. The way in which physicians evaluate outcomes in surgery concerning aesthetics is changing. Well-designed patient-reported outcome measures to assess health-related quality of life improvements attributable to surgery are increasingly being used. The Derriford Appearance Scale 59 (DAS-59) is currently the only available validated patient-reported outcome measure that assesses concern about physical appearance. METHODS: Twenty patients with CLP presenting between May 2009 and May 2013 for secondary rhinoplasty to Sunnybrook Health Sciences Centre (Toronto, Ontario) were recruited. DAS-59 measures were administered both preoperatively and at least six months after surgery. Pre- and postoperative measures were scored and compared. Item-by-item analysis of the measure was also performed. RESULTS: Total scores for this CLP group indicated greater concern about appearance than the general population. Across all subscales of the measure, there was a reduction in scores after secondary rhinoplasty suggesting less patient concern with appearance and a positive effect of surgery on patient quality of life. Item-by-item analysis suggested relatively few items in the measure were driving overall change in total scores. CONCLUSION: Comparison of pre- and postoperative scores with the DAS-59 in secondary cleft rhinoplasty suggests there is less concern with appearance after surgery. However, a small number of items within this generic scale contributing to this difference may suggest the need for a more patient specific measure for assessment of surgical outcomes in the cleft population.

HISTORIQUE: La rhinoplastie secondaire, l'une des dernières interventions pour corriger une fente labio-palatine (FLP), a des objectifs à la fois fonctionnels et esthétiques. La manière dont les médecins évaluent les résultats esthétiques après une chirurgie est en évolution. Ils utilisent de plus en plus des mesures de résultats bien conçues faites par les patients pour évaluer les améliorations à la qualité de vie liée à la santé découlant de l'opération. L'échelle d'apparence Derriford en 59 éléments (DAS-59) est la seule mesure validée de résultats déclarés par le patient pour évaluer les préoccupations relatives à l'apparence physique. MÉTHODOLOGIE: Les chercheurs ont recruté 20 patients ayant une FLP qui ont consulté au Sunnybrook Health Sciences Centre de Toronto, en Ontario, entre mai 2009 et mai 2013 pour subir une rhinoplastie secondaire. Ils ont administré les mesures de DAS-59 avant et au moins six mois après l'opération. Ils ont établi les scores des mesures préopératoires et postopératoires et les ont comparées. Ils ont également analysé chaque élément de la mesure. RÉSULTATS: Le score total de ce groupe de FLP s'associait à une plus grande préoccupation relative à l'apparence qu'au sein de la population générale. Dans toutes les sous-échelles de la mesure, les scores diminuaient après la rhinoplastie secondaire, ce qui laisse supposer que les patients se préoccupaient moins de leur apparence et que l'opération avait eu un effet positif sur leur qualité de vie. L'analyse de chaque élément indiquait que relativement peu d'éléments de la mesure suscitaient le changement des scores totaux. CONCLUSION: La comparaison des scores de la DAS-59 avant et après une rhinoplastie secondaire de la FLP indique une moindre préoccupation de l'apparence après l'opération. Cependant, peu d'éléments de cette échelle générique contribuent à cette différence, ce qui laisse croire à la nécessité d'utiliser une mesure plus précise pour évaluer les résultats chirurgicaux au sein de cette population.

Facial Fractures.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Demonstrate an understanding of some of the changes in aspects of facial fracture management. 2. Assess a patient presenting with facial fractures. 3. Understand indications and timing of surgery. 4. Recognize exposures of the craniomaxillofacial skeleton. 5. Identify methods for repair of typical facial fracture patterns. 6. Discuss the common complications seen with facial fractures. SUMMARY: Restoration of the facial skeleton and associated soft tissues after trauma involves accurate clinical and radiologic assessment to effectively plan a management approach for these injuries. When surgical intervention is necessary, timing, exposure, sequencing, and execution of repair are all integral to achieving the best long-term outcomes for these patients.

Changes in the management of deep sternal wound infections: a 12-year review.

BACKGROUND: Deep sternal wound infection (DSWI) is a rare but life-threatening complication following cardiac surgery associated with increased morbidity and mortality. Management of these patients has evolved over the years and can include sternal rewiring, mediastinal irrigation, negative-pressure wound therapy (NPWT) dressing or repair with flaps. We reviewed changes in our management of DSWI and outcomes. METHODS: Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, 5472 underwent cardiac surgery at St Vincent's Hospital, Melbourne, and 42 were identified as developing DSWI requiring re-operation between June 2002 and September 2014. Data were collected pertaining to risk factors for DSWI, management strategies and outcomes. Patients were compared from a period prior to NPWT dressing use (June 2002-February 2006, n = 14) and since the NPWT has been used regularly in the management of DSWI (from March 2006, n = 28). Patients were also compared based on the requirement for flap closure of their sternal wound. RESULTS: Because of the widespread use of NPWT dressings, there is a trend towards fewer sternal infections requiring flap closure (25 versus 42.8%) and less post-operative complications after definitive closure (7.1 versus 28.6%). Before and after widespread NPWT use, patients require similar number of re-operations before closure and have no significant differences in time to definitive closure or length of hospital stay. CONCLUSION: The use of NPWT dressings as a bridge to definitive closure may reduce the need for more burdensome flap reconstruction, does not delay definitive reconstruction or prolong hospital stay and may reduce post-reconstruction complications requiring re-operation.

Transection of inferior orbital fissure contents for improved access and visibility in orbital surgery.

BACKGROUND: Selective inferior orbital fissure (IOF) content transection for the purpose of surgical access to the posterior orbital floor is a technique that facilitates visualization of the posterior bony ledges of traumatic orbital floor defects. It also has potential advantages in achieving stable placement of reconstructive materials. Although not new, the surgical technique has not yet been described, and the morbidity of the technique has not been quantified. This article describes the procedure and assesses the morbidity specific to the division of related neural structures. METHODS: The technique and surgical anatomy are described and illustrated with intraoperative photographs. Postoperative assessment of neural structures relevant to the division of IOF contents is performed. These values are compared with the nonoperated side to evaluate the morbidity of the technique. RESULTS: The technique, which is consistently used by the senior author in the repair of orbital floor defects with very small posterior ledges or which extend to and involve the IOF, facilitates better visualization of the posterior ledge and posterolateral ledge in such cases. Surgical outcomes including facial sensation and lacrimal function on the operated side remain within the reference range and are not significantly different when compared with the contralateral nonoperated side. CONCLUSIONS: Selective IOF transection aids in the direct visualization of the posterior bony ledges in the repair of posterior orbital floor defects. It therefore may facilitate the placement of reconstructive materials on bony ledges circumferentially, providing stable reconstruction, potentially reducing implant-related complications without causing increased morbidity.

Asplenic fulminant sepsis secondary to a dog bite complicated by toxic epidermal necrolysis/Stevens-Johnson syndrome.

We report a case of asplenic fulminant sepsis in Australia following a dog bite which was complicated by toxic epidermal necrolysis/Stevens-Johnson syndrome (TENS/SJS). Capnocytophaga canimorsus, the infective organism, is a rare cause of septicaemia: a high degree of suspicion of this unusual organism and its early aggressive management is paramount. The diagnostic and management difficulties of TENS/SJS in the context of a patient with fulminant sepsis, DIC and on inotropes are also highlighted.

Quality of life after penile reconstruction using the radial forearm flap in adult bladder exstrophy patients - technique and outcomes.

BACKGROUND: Patients who have undergone reconstruction of bladder extrophy can have an extremely short penis, which can be functionally and psychologically debilitating. Penile reconstruction with the radial forearm free flap has the potential to provide these patients with improved genital appearance and sexual function. Quality of life after penile reconstruction is an important outcome measure in evaluation of the procedure. METHODS: We describe five patients who underwent total penile reconstruction with radial forearm free flaps and interview them with a quality of life questionnaire. RESULTS: Responses were overwhelmingly positive with regard to improved self-image as well as sexual function. CONCLUSIONS: This series supports the overwhelmingly positive change in quality of life to be gained with radial forearm free flap penile reconstruction for patients with an extremely short native penis in the adult exstrophy patient.

Eleven-year follow-up of cross-leg replantation for traumatic bilateral amputation.

The advent of microsurgery has allowed the replantation of traumatically amputated limbs. Replantation of a severed limb to the contralateral stump in bilateral traumatic amputation, however, is rarer, and criticisms include a prolonged hospital stay and complications. A 54-year-old man was caught in a paper-pulping machine and suffered bilateral lower limb amputation rendering his left lower leg unsalvageable. The right lower leg, after debridement however, was suitable for replantation to the left stump. This replantation was performed successfully. The patient was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. At 11-year follow-up the patient has a preference for his replanted leg in contrast to his contralateral prosthesis and has suffered no long-term complications. In addition, from a psychological perspective, he has experienced restoration of perceived body length with the cross-leg replantation.

Chemical injuries: the Tasmanian Burns Unit experience.

BACKGROUND: Chemical burns account for relatively few admissions to a burns unit. These injuries, however, deserve separate consideration because of their ability to cause continuing tissue destruction, their potential to cause systemic toxicity and the value of early treatment with copious lavage. Widespread inexperience in the treatment of chemical burns highlights the potential for greater levels of general awareness and knowledge. METHODS: A review of 31 patients with chemical injuries admitted to the Tasmanian Burns Unit at the Royal Hobart Hospital (RHH) was carried out for the years 1989-1999. RESULTS: The majority of patients were men aged 20-49 years (mean age: 32 years). Fifty-one per cent of injuries occurred in a domestic and 38% in an industrial setting. The more common aetiological agents were cement (25%), sulphuric acid (16%) and hydrofluoric acid (16%). The upper and lower extremities were involved in all but four patients and the mean total body surface area affected was 3.4%. The mean length of hospital stay was 9 days with a range of 1-30 days. Management of injuries consisted of either surgical or conservative treatment. The former included debridement and split-thickness skin grafting or primary closure and the latter of topical treatment with 1% silver sulfadiazine cream and appropriate dressings. CONCLUSION: Widespread inexperience in the treatment of chemical injuries highlights the potential for greater levels of knowledge. This is particularly apparent in the early management of these injuries.