A Five-Year Retrospective Analysis of Diagnostic and Treatment Data of Flexor Sheath Infections: Can We Accurately Predict the Presence and Severity of Infection Prior to Surgical Washout?

Flexor sheath infections (FSIs) are soft tissue infections affecting the hand, which, if mismanaged, can have devastating consequences. Clinical assessment is key to diagnosis, with many relying on Kanavel cardinal signs as an aid. To prevent unnecessary operative intervention and the associated post-operative combined patient and healthcare burden, it is key that patients with FSIs are correctly identified. It would also be useful to stratify severity of FSIs without surgical exploration. To date, there is no accepted method to assist clinicians in doing so. We retrospectively analysed data from a five-year period to see if we could identify pre-operatively (a) accurate predictors of FSIs and (b) severity of the FSIs. We established that only the presence of all four Kanavel cardinal signs significantly predicted the presence of an FSI. No other variable that was available prior to surgery could predict either presence or severity of infection.

Challenging the Orthodoxy of Mandibular Reconstructions Comparing Functional Outcomes in Osseous versus Soft Tissue Reconstructions of the Posterolateral Mandible.

BACKGROUND: Appropriate reconstruction of the posterolateral mandible remains controversial. Both osseous and soft tissues are vital components for an overall successful outcome and are often combined in complex defects. Their respective effect on oromandibular function in the reconstruction of different degrees of mandibular defects has been less evaluated. This study aimed to compare patient-perceived oromandibular function in osseous and soft tissue-only reconstructions following posterolateral mandibular defects, defined as limited or extended. PATIENTS AND METHODS: A 10-year retrospective review of consecutive patients undergoing mandibular reconstructions of the posterolateral mandible were identified. Limited defects were defined as reaching from the ipsilateral parasymphysis to anterior of the coronoid (sparing insertion of muscles of mastication). Extended defects were defined as reaching from the ipsilateral parasymphysis to posterior of the coronoid (sacrificing the muscle insertions). Functional outcomes were assessed using the University of Washington Quality of Life questionnaire, version 4. RESULTS: A total of 163 patients were identified, of which 41 patients had the particular posterolateral mandibular resections sought after. In 23 limited resections, there was no difference in functional outcome between osseous and soft tissue-only reconstructions. In 18 patients undergoing extended resections, osseous reconstructions demonstrated significantly better outcomes (p = 0.011). There were no significant differences in patient demographics between the groups. CONCLUSION: Our study highlights the interest of soft tissue-only reconstructions of the posterolateral mandible. Limited resections seem not to benefit from complex osseous reconstruction for adequate function. Conversely, there is a noteworthy positive impact on functional outcomes in extended posterolateral mandibulectomies reconstructed with osseous tissue, compared with soft tissue only. Although a larger study is needed to identify a stronger relationship, these preliminary results could aid reconstructive decisions, particularly when considering patient morbidity.

Intraoperative use of Mohs' surgery for the resection of major cutaneous head and neck cancer under general anaesthetic: Initial experiences, efficiency and outcomes.

BACKGROUND: Complete excision of high-risk extensive non-melanoma skin cancers in the head and neck is paramount to achieving loco-regional control. However, achieving clear margins still remains a significant challenge. Mohs' micrographic surgery (MMS) provides the most accurate method of intraoperative mapping and histological assessment of tumour margins. We have developed a technique combining MMS with reconstruction as a single-stage procedure performed under general anaesthetic. We present our experience and results. MATERIALS AND METHODS: Following regional skin cancer multidisciplinary team (MDT) discussion, patients considered appropriate for management as a single-stage combined procedure were referred for assessment. At surgery, a two-team approach was employed consisting of an MMS resection team and a reconstructive team, allowing simultaneous resection and elevation of any free tissue required for reconstruction. Outcome data were retrieved from a prospectively collated MMS database. RESULTS: Twenty-six cases were performed between January 2010 and January 2013. Fifty-eight percent of cases were basal cell carcinomas. Clear margins were achieved in 50% of cases following the first Mohs' layer. Free tissue reconstruction was required in 13 cases. Mean anaesthetic time was 445 min. Loco-regional control was achieved in 96% of patients, at a mean follow-up period of 29 months (range 11-50 months). CONCLUSIONS: This study shows that the combined single-stage MMS and reconstruction surgical model is safe, results in a low recurrence rate and improved patient care. It is a model that can be replicated in other tertiary skin cancer units.

The use of computed tomography for the estimation of DIEP flap weights in breast reconstruction: a simple mathematical formula.

BACKGROUND: Estimation of the volume of abdominal tissue is desirable when planning autologous abdominal based breast reconstruction. However, this can be difficult clinically. The aim of this study was to develop a simple, yet reliable method of calculating the deep inferior epigastric artery perforator flap weight using the routine preoperative computed tomography angiogram (CTA) scan. METHODS: Our mathematical formula is based on the shape of a DIEP flap resembling that of an isosceles triangular prism. Thus its volume can be calculated with a standard mathematical formula. Using bony landmarks three measurements were acquired from the CTA scan to calculate the flap weight. This was then compared to the actual flap weight harvested in both a retrospective feasibility and prospective study. RESULTS: In the retrospective group 17 DIEP flaps in 17 patients were analyzed. Average predicted flap weight was 667 g (range 293-1254). The average actual flap weight was 657 g (range 300-1290) giving an average percentage error of 6.8% (p-value for weight difference 0.53). In the prospective group 15 DIEP flaps in 15 patients were analyzed. Average predicted flap weight was 618 g (range 320-925). The average actual flap weight was 624 g (range 356-970) giving an average percentage error of 6.38% (p-value for weight difference 0.57). CONCLUSIONS: This formula is a quick, reliable and accurate way of estimating the volume of abdominal tissue using the preoperative CTA scan.

Reconstruction of large traumatic segmental defects of the femur using segmental allograft with vascularized fibula inlay.

Segmental defects of the distal femur following trauma pose a reconstructive challenge. A stable reconstruction capable of withstanding high forces while allowing early mobility is paramount. The Capanna technique of reconstruction combining allograft with vascularized bone graft provides such a construct and has been described for oncological resection. We describe a modified Capanna technique, the "inlay" construct. Three reconstructions were performed for distal femoral segmental loss following trauma. One patient had bilateral reconstructions. Bone defects measuring 11, 9, and 8 cm were reconstructed using a large segmental allograft and free fibular flap inlay assembly. Both patients made uneventful recoveries and achieved full weight-bearing without walking aids 6 months postreconstruction. Range of movement of each knee joint achieved at least 90 degrees of active flexion. We have shown that large segmental traumatic defects of the femur can be successfully reconstructed using segmental allograft with vascularized fibula inlay. This reconstruction provides early mechanical stability, protecting the fibula from fracturing and allowing axial loading of healing bone. The inlay assembly allows a large area of bony contact between allograft and vascularized bone, optimizing bony healing. It is a good alternative to other established techniques of managing significant segmental defects of the distal femur.

Management of chyle leak post neck dissection: a case report and literature review.

Chyle leakage post head-and-neck resection is a rare but potentially life-threatening complication. Management may be problematic and prolonged. Recently, thoracoscopic ligation of the thoracic duct has emerged as a promising technique to definitively treat this difficult problem. We present a recent case of a hemimandibulectomy, radical modified neck dissection and osseocutaneous fibular-free-flap complicated by a chyle leakage. The chyle leak was successfully treated with thoracoscopic ligation of the thoracic duct. In the light of our clinical experience and following a thorough literature review, we have proposed that complicated or high-output chyle leaks (>1000 ml day(-1)) should be treated with early thoracoscopic thoracic duct ligation.

Improvised External Fixation-a Modification.

A modification is presented to a commonly used type of improvised external fixator for hand fractures. Our modified fixator is easy to apply and allows fracture manipulation in three dimensions after application, before the cement sets.

Anatomical variation in deep inferior epigastric pedicles and implications for harvest of lower abdominal flaps.

The transverse rectus abdominis musculocutaneous (TRAM) flap based on the deep inferior epigastric artery is useful in head and neck reconstruction as it provides substantial skin and soft tissue cover, and allows volume to be replaced in large defects. A major advantage is the anatomical reliability of the deep inferior epigastric pedicle. We report a case in which neither rectus abdominis muscles had a blood supply from the deep inferior epigastric artery, which necessitated a change in the planned reconstruction. We review variations in the anatomical course of the artery and, although rare, stress the importance of reconstructive surgeons being aware of such variations.

Malignant melanoma and deep penetrating naevus--difficulties in diagnosis in children.

A 4-year-old boy presented to our department with a darkly pigmented lesion on the right side of his neck. It was excised and a diagnosis of deep penetrating naevus with atypical features was made. At 4-month follow-up our patient had developed a palpable cervical lymph node. Excision revealed malignant melanoma. We discuss our management and review the literature regarding DPN and melanoma of childhood.

Modulation of intracellular reactive oxygen species level in chondrocytes by IGF-1, FGF, and TGF-beta1.

Growth factors are important in the development, maintenance and repair of cartilage. The principal aim of this study was to test the capacity of three growth factors with established roles in cartilage, namely insulin-like growth factor (IGF)-1, fibroblast growth factor (FGF) and transforming growth factor (TGF)-beta 1, to alter intracellular reactive oxygen species (ROS) levels. Explants of articular cartilage from young, mature, and aged rats were pretreated with IGF-1, FGF, or TGF-beta 1 and intracellular ROS levels were quantified using the free radical sensing probe dihydrorhodamine 123 (DHR 123), confocal microscopy, and densitometric image analysis. Viability of chondrocytes following ROS stress and growth factor treatment was assessed using the live/dead cytotoxicity assay, and the activities of the antioxidant enzymes--catalase (CAT), total superoxide dismutase (SOD), and glutathione peroxidase (GPX)--were measured spectrophotometrically by decay of the substrate from the reaction mixture. The effect of IGF-1 on ROS levels in cultured human chondrocytes also was examined. In rat cartilage, FGF did not significantly affect ROS levels or antioxidant enzyme activity in any age group. TGF-beta1 significantly increased cellular ROS levels in mature and old cartilage whereas in marked contrast, IGF-1 significantly and age-dependently reduced ROS levels. IGF-1 also had a potent antioxidant effect on cultured human chondrocytes. Pretreatment of rat cartilage with IGF-1 significantly enhanced the activity of GPX, without altering the activity of SOD or CAT, and protected chondrocytes against ROS-induced cell death. TGF-beta 1 had no significant effect on the activity of the antioxidant enzymes. Despite promoting ROS production, TGF-beta 1 was not cytotoxic. We concluded that TGF-beta 1 exhibits an acute pro-oxidant effect in cartilage that is not cytotoxic, suggesting a role in physiological cell signalling. In marked contrast, IGF-1 is a potent antioxidant in mature and aged rat and human chondrocytes, protecting cells against ROS-induced cell death probably through the enhancement of the activity of the antioxidant enzyme GPX.