The ad hoc perforator flap for contracture release.

Release and autografting remains a mainstay of treatment of cutaneous and joint-associated contractures. However, owing to secondary contraction of grafts and the increase of children undergoing burn reconstructive surgery, recurrence of contractures is not uncommon. Locally available, well-vascularised tissue that will contract minimally and grow with the patient is the ideal for contracture release. Many 'predesigned' cutaneous flaps have been described, but use of these may involve tailoring a defect to fit a known flap. We introduce the concept of the 'ad hoc' perforator flap, an improvised island flap based on a perforator, innominate or otherwise, that happens to be adjacent to a particular soft-tissue defect and can be reliably raised on scarred skin. We carried out a retrospective analysis of all patients undergoing contracture release within our unit. Twenty-three ad-hoc perforator flaps in 20 patients were carried out between 2000 and 2005. Eleven of the 20 patients were children, and all but one case was subsequent to a burn injury. Fifteen of the 23 flaps were upper limb. In one case, a significant complication involving total flap loss occurred. Only one patient required a skin graft to close the flap donor site, and no patients required revisional surgery for contracture recurrence. The ad hoc perforator flap is a safe and simple technique for the management of contractures, and fulfils the ideal of well-vascularised tissue that can grow with the patient. The flap can be designed as required and, with experience, the concept is applicable not only to contracture release, but many other reconstructive scenarios.

Nineteenth century medical education for tomorrow's doctors.

Many of the ideas contained within the GMC's 'Tomorrow's Doctors' could be considered as old ideas reworked for modern medical education. Sir John Struthers, a pioneer in the field of medical education, touched on many of the issues in 'Tomorrow's Doctors' in his writings published over one hundred years ago. The study of the history of medicine, often neglected by members of our profession in the search for new ideas, is not only of interest, but is valuable to current and future medical education. History illustrates the mistakes of the past, but also helps highlight the successes and insights that remain applicable and relevant today.

Survey of clinicians' attitudes to the anatomical teaching and knowledge of medical students.

There is considerable and ongoing debate surrounding the teaching of anatomy to medical students, and the anatomical knowledge of those medical students once they graduate. Few attempts have been made to gather the opinions of clinicians on this subject. A questionnaire was sent to 362 senior clinicians in hospitals affiliated to the University of Aberdeen. A total of 162 replies were received, with this sample being representative of the population of hospital consultants. Our results indicate that the majority of clinicians feel that the current anatomical education of medical students is inadequate, and below the minimum necessary for safe medical practice. There is widespread support among clinicians for more vertical integration of anatomy teaching throughout the undergraduate curriculum.

Sir John Struthers MD FRCS Edin LLD Glasg: anatomist, zoologist and pioneer in medical education.

Sir John Struthers (1823--1899), a past president of the Royal College of Surgeons of Edinburgh and Regius Professor of Anatomy at the University of Aberdeen, was an accomplished scientist and medical educator. Much of his career was spent in shaping the medical curriculum of the nineteenth century. He was a strong proponent of a sound basic science education as preparation for a career in medicine, but was also central in developing more formal clinical teaching for medical students. His interest in comparative anatomy and evolution has provided a rich legacy of human and zoological specimens that remain of value in everyday teaching. Much of his work on educational theory and the place of basic sciences in the medical curriculum remains relevant to this day, and is of particular interest given the ongoing debate regarding the place of the basic medical sciences in the undergraduate medical curriculum

ABO blood groups and achilles tendon rupture in the Grampian Region of Scotland.

OBJECTIVE: To test whether the association between blood groups and Achilles tendon rupture (ATR) reported in some Scandinavian countries and in Hungary was present in our region. METHODS: We studied 78 patients treated at Aberdeen Royal Infirmary from 1990 to 1996, and compared their distribution of ABO blood groups with that found in 24.501 blood donors typed at the Blood Transfusion Centre during the same period. RESULTS: Overall, 47 of 78 (60%) of patients with an Achilles tendon rupture belonged to blood group O, compared with 51% of the population as a whole. Only 22 (28%) of the Achilles tendon rupture patients belonged to blood group A, whereas 35% of the general population were members of this group (NS). The A/O ratio was 0.47 for the tendon rupture patients, compared with 0.68 for the general population (NS). CONCLUSIONS: We could not demonstrate any significant association between the proportions of ABO blood groups and ATR in the Grampian Region of Scotland. The findings in other studies could be due to peculiarities in the distribution of the ABO groups in genetically segregated populations.

Tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type III collagen than tenocytes from normal achilles tendons. An in vitro model of human tendon healing.

Type I collagen is the main collagen in tendons; type III collagen is present in small amounts. Ruptured Achilles tendons contain a significantly greater proportion of type Ill collagen, which predisposes them to rupture. We used an in vitro model to determine whether tenocytes from Achilles tendons that were ruptured (N = 22), nonruptured (N = 7), tendinopathic (N = 12), and fetal (N = 8) show different behavior. Samples of Achilles tendon were digested with collagenase and the released tenocytes were collected. Primary tenocyte cultures were established and subsequently cultured onto glass coverslips. Once a confluent monolayer was obtained, the cell populations were "wounded" by scraping a pipette tip along the surface. The cultures were further incubated for either 1, 4, 8, 12, 16, or 24 hours, and production of types I and II collagen was assessed by immunostaining. In cultures from ruptured and tendinopathic tendons, there was increased production of type Ill collagen. Athletic participation places excess stress on the Achilles tendon, which could potentially lead to areas of microtrauma within the tendon. These areas may heal by the production of type III collagen, which is an abnormal healing response. Accumulation of such episodes of microtrauma could resuit in a critical point where the resistance of the tissue to tensile forces is compromised and tendon rupture occurs.

Changing incidence of Achilles tendon rupture in Scotland: a 15-year study.

OBJECTIVE: To determine the incidence of Achilles tendon rupture in Scotland from 1980 to 1995. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Data were obtained from the National Health Service Information and Statistics Division and analyzed in terms of age- and gender-specific incidence rates and time trends by age group. PARTICIPANTS: A total of 4,201 patients with Achilles tendon ruptures occurring during the study period. MAIN OUTCOME MEASURES: Calculation of incidence and of seasonality. RESULTS: The overall incidence of Achilles tendon rupture increased from 4.7/100,000 in 1981 to 6/100,000 in 1994, with a peak in 1986. In men, the incidence rose from 6.3/100,000 to 7.3/100,000. In women, the increase in incidence was more pronounced, from 3/100,000 to 4.7/100,000. In men, peak incidence rate occurred in the 30- to 39-year age group, whereas in women, the peak age-specific incidence occurred in those aged 80 years and older, with a steady increase after age 60. There was no evidence of a seasonality effect in the rate of occurrence of Achilles tendon rupture. A bimodal distribution of age at time of Achilles tendon rupture was noted. CONCLUSION: There was a significant increase in the incidence of Achilles tendon rupture during the period from 1980 to 1995. This reflects the increased incidence of the injury noted in other Northern European countries.