Continuous in situ targeted antibiotics for late cardiovascular implantable electronic device pocket perforation.

CIED infections are a dreaded complication associated with significant morbidity and mortality and the mainstay of treatment has traditionally been extraction. A recent cohort study suggested that continuous, in situ-targeted, ultrahigh concentrations of antibiotics (CITA) delivered into the CIED pocket may be a viable alternative to extraction in selected cases. We highlight two cases of device perforation which were successfully treated with this technique.

Saving the Exposed Deep Brain Stimulation Implant: A Comprehensive Review of Implant Extrusion and Reconstructive Options.

INTRODUCTION: Deep brain stimulation (DBS) for the treatment of Parkinson disease is susceptible to complications, such as hardware extrusion, most commonly at the scalp and chest. The authors describe their experience with the management of hardware extrusion and reconstruction with one of the largest single-institution experience and suggest an evidence-based treatment algorithm for the management of such cases. METHODS: A retrospective review of hospital records was performed to identify patients who underwent DBS-related surgery and reconstruction from January 2015 to April 2020. Management of these patients involved culture-directed antibiotics, local wound debridement, various forms of reconstruction, and hardware removal when indicated. RESULTS: Ninety-four patients with 131 DBS-related procedures were included. Twelve patients (12.8%) had hardware extrusion, of which 6 occurred primarily at the scalp and 6 occurred primarily at the chest. Primary closure of scalp wounds (odds ratio, 0.05 [0.004-0.71], P = 0.035) was negatively associated with treatment success. The type of reconstruction of chest wounds did not affect its success ( P = 0.58); however, none of them involved a new surgical bed, such as contralateral or hypochondrial placement. CONCLUSIONS: Hardware extrusion is a significant complication of DBS-related surgery. Management of extrusion at the scalp should involve the use of tension-free, well-vascularized locoregional flaps as opposed to primary closure. Implantable pulse generator extrusions at the chest can be managed with both primary closure and repositioning in a new surgical bed. Extruded DBS implants may be salvaged with appropriate reconstructive considerations, and the authors suggest an evidence-based treatment algorithm.

Application of real-time surgical navigation for zygomatic fracture reduction and fixation.

BACKGROUND: Inappropriate treatment of zygomatic fractures can reduce esthetic and functional outcomes. The aim of this study was to answer the research question: "Among patients with a unilateral zygomatic fracture, is the use of computer-assisted real-time navigation system during fracture reduction precise and accurate to create postoperative facial symmetry?" METHODS: Using a retrospective cohort study design, we enrolled a cohort of unilateral zygomatic fractures undergoing open reduction and internal fixation (ORIF) with the aid of the computer-based navigation system at Chang Gung Memorial Hospital, Taiwan, during January 2015 and March 2018. The predictor variable was the comparison before and after surgery. The main outcome variables included (1) two-dimensional (2D) reduction of the displacement at five anatomical landmarks: zygomaticofrontal, inferior orbital rim, zygomaticosphenoidal, zygomaticomaxillary, and zygomaticotemporal lines/buttresses and (2) three-dimensional (3D) differences on distances between zygomatic surface to the porion plane and the midpoint of zygomatic arch (ZA) to the mid-porion (MP) plane. The Wilcoxon signed-rank test was computed to compare between pre- and postoperative data, and a p-value less than 0.05 was considered statistically significant. RESULTS: The cohort comprised 24 subjects (50% females, 75% left-sided) with a mean age of 30.5 +/- 13.8 years. On 2D analysis, the significant fracture reduction was found: 4.78 vs. 1.22 mm, 1.78 vs. 0.40 mm, 3.50 vs. 0.07 mm, 3.06 vs. 0.55 mm, and 2.55 vs. 0.50 mm at zygomaticomaxillary, zygomaticofrontal, inferior orbital rim, zygomaticosphenoidal, and zygomaticotemporal landmarks. The 3D evaluations revealed the significant reduction of the differences between the left and right zygomatic surface to the porion plane (4.09 ± 2.12 vs. 0.46 ± 0.35 mm) and between the left and right ZA midpoints to the MP plane (4.89 ± 2.59 vs. 0.71 ± 0.44 mm) (p<0.001 for both 2D and 3D analyses). CONCLUSIONS: The results of this study suggest that the real-time surgical navigation system can effectively guide the ORIF of zygomatic fractures. Future research studies should focus on the learning curve and cost-effectiveness analysis of this technique.

Free-style Approach to the Pedicled Lower Medial Thigh Perforator Flap.

Soft tissue reconstruction around joints such as the knee requires a few additional considerations compared with other regions. The overlying skin must be pliable, with adequate distensibility to maintain the range of motion as a hinge joint, and ideally be replaced with "like-for-like" tissue to restore its delicate contour. The advent of perforator flaps has provided reconstructive surgeons with thin, pliable flaps conferring superior aesthetic results, good preservation of joint range of motion, and less donor site morbidity. Utilizing locoregional options also allows replacement with "like-for-like." We retrospectively reviewed lower medial thigh perforator flaps performed for traumatic and debrided infected knee wounds, using a free-style approach to flap harvest. The described technique was found to be reliable, with consistent anatomy. All flaps survived and successfully covered small- to medium-sized critical defects in healthy individuals and those with multiple comorbidities.

Combination therapy of oxidised regenerated cellulose/collagen/silver dressings with negative pressure wound therapy for coverage of exposed critical structures in complex lower-extremity wounds.

Complex wounds with exposed critical structures such as tendon and bone are a conundrum in wound management, especially in the setting where the patient is not a suitable candidate for flap surgery. While the individual use of negative pressure wound therapy (NPWT) and oxidised regenerated cellulose (ORC)/collagen/silver (PROMOGRAN PRISMA) dressing has been described in the literature, there are little data on the efficacy of their combined use. In this study, we describe a novel technique of combining the use of NPWT and ORC/collagen/silver dressings to manage complex wound beds as an alternative management option for patients not suitable for reconstructive flap surgery. This technique was performed in a series of 37 patients with complex lower-extremity wounds that were not healing with conventional NPWT alone. All patients had open wounds with exposed critical structures that were difficult to manage, such as exposed tendon, bone, deep crevices, and joint. Successful coverage of exposed critical structures was achieved in 89% of patients, and coverage was achieved within 28 days of combination therapy in 82% of these patients, without any complications. The novel technique of combining ORC/collagen/silver dressing and NPWT provides a useful option in the armamentarium of a reconstructive surgeon dealing with difficult complex lower-extremity wounds.

Biobrane dressing for paediatric burns in Singapore: a retrospective review.

INTRODUCTION: The ideal burn dressing for children should aim to alleviate pain, decrease length of hospital stay and minimise complications such as conversion and infection. The current literature is still inconclusive with regard to the gold standard burn dressing for the paediatric population. METHODS: We retrospectively reviewed children with superficial partial thickness burns admitted to our paediatric burns unit from January 2014 to April 2015. A total of 30 patients were included in our study, of whom 13 had Biobrane® dressing. The remaining 17 patients were treated with conventional silver foam dressing (i.e. Biatain® Ag) and served as matched controls. Long-term follow-up scar evaluation was carried out at an average interval of two years after injury. RESULTS: In the Biobrane group, the length of hospital stay was significantly shorter (Biobrane vs. silver foam: 4.76 ± 2.64 days vs. 8.88 ± 5.09 days; p = 0.01) and the infection rate was significantly lower (Biobrane vs. silver foam: 0% vs. 35.3%; p = 0.02). The Biobrane group had no hypergranulation or wound infection and did not require skin grafting. Long-term follow-up scar evaluation did not reveal any statistical difference between the patient groups at the two-year interval. CONCLUSION: Paediatric patients with partial thickness burns treated with Biobrane dressing had shorter hospital stay and lower incidence of infection compared to those treated with conventional silver foam dressing. Biobrane and silver foam dressings did not demonstrate any significant difference in terms of long-term scar outcomes over an average follow-up duration of two years.

The Rolling Earlobe Flap for Dilated Ear Holes Following Ear Gauging: A Novel Approach to Aesthetically Preserving Earlobe Soft Tissue Volume.

Patients are increasingly seeking repair of their earlobes following ear gauging. Research has shown that current repair techniques either excessively reduce the lobular volume or leave an obvious scar along the free edge of the earlobe. In our case series, we describe the use of a novel technique for repairing earlobes following ear gauging using a rolling earlobe flap that preserves the lobular volume and avoids leaving a scar on the free edge of the lobule. The procedure was performed on 3 patients (6 earlobes) who had defects from ear gauging that ranged from 3.0 to 6.5 cm. There were no postoperative complications of infection, wound dehiscence, flap necrosis, hypertrophic scars, or keloids, and all patients were highly satisfied with the postoperative results. This versatile technique allows for an aesthetically pleasing reconstruction of the lobule with the advantages of: the absence of a surgical scar on the free edge of the lobule, preserving the lobule volume, and presenting a highly customizable technique that allows lobules to be created with various shapes and volumes.

Rare Cause of Facial Palsy: Case Report of Tick Paralysis by Ixodes Holocyclus Imported by a Patient Travelling into Singapore from Australia.

BACKGROUND: Ticks are blood-sucking arachnids that feed on all classes of vertebrates, including humans. Ixodes holocyclus, also known as the Australian Paralysis Tick, is capable of causing a myriad of clinical issues in humans and companion animals, including the transmission of infectious agents, toxin-mediated paralysis, allergic and inflammatory reactions, and mammalian meat allergies in humans. The Australian Paralysis Tick is endemic to Australia, and only two other exported cases have been reported in the literature. CASE REPORT: We report the third exported case of tick paralysis caused by I. holocyclus, which was imported on a patient into Singapore. We also discuss the clinical course of the patient, the salient points of management, and the proper removal of this tick species. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increasing air travel, emergency physicians need to be aware of and to identify imported cases of tick paralysis to institute proper management and advice to the patient. We also describe the tick identification features and proper method of removal of this tick species.

Neurogenic heterotopic ossification after a stroke: diagnostic and radiological challenges.

Heterotopic ossification (HO) is the aberrant formation of ectopic bone within the soft tissues, of which the aetiology is usually either traumatic or neurogenic. Neurogenic HO is a known but uncommon complication that occurs after a cerebral or spinal insult. The condition may present with a spectrum of symptoms and is often difficult to diagnose clinically. Although different imaging modalities have been used to diagnose HO, clinicians and radiologists may occasionally encounter radiological features of HO that may mimic other disease conditions. We herein report a rare case of neurogenic HO occurring in the non-paretic limb of a patient, and the diagnostic and radiological challenges encountered.

Management of blunt traumatic thoracic aorta injuries with endovascular stent-grafts in a tertiary hospital in an urban Asian city.

BACKGROUND: Thoracic aortic injury from blunt trauma is a life-threatening condition with significant mortality and morbidity with open surgical repair. Endovascular means of treatment is emerging as an attractive and less invasive option. We report our experience with endovascular stent-graft repair for blunt traumatic thoracic aorta injury. METHODS: Between January 2003 and August 2009, six patients underwent endovascular repair of blunt traumatic thoracic aorta injury. Data from the medical records of these patients were analyzed. RESULTS: All patients had deceleration injury resulting in thoracic aorta pseudoaneurysm at the aortic isthmus just distal to the left subclavian artery. Four patients were motorcyclists who had been involved in road-traffic accidents and two had fallen from a height. The mean Injury Severity Score was 33.8 (range, 21-43). All procedures were performed within 48 hours of admission and technical success was 100%. Five patients (83.3%) had the left subclavian artery intentionally covered by the stent-graft to achieve adequate proximal landing zone. None of them had any left upper limb ischemic complications or cerebrovascular events after the procedure. One patient had preservation of the left subclavian artery because intraoperative vertebral angiogram showed a hypoplastic right vertebral artery. No other procedural complications, paraplegia, or deaths were reported. Mean follow-up was 18.8 months (range, 1.5-42 months). CONCLUSIONS: Our early experience of endovascular stent-grafting for blunt traumatic thoracic aorta injury suggests that this emerging technique is safe for treatment of such pathology in our inherently Asian population. Left subclavian artery may be sacrificed if adequate proximal landing zone is required for the stent-graft; and when vertebral angiogram was performed which did not show a dominant left vertebral artery.

Orofacial dystonia triggered by mouth closure.

Focal task-specific dystonia affects one part of the body, occurring only during the performance of a specific task. It usually affects the hand, though it can rarely affect the orofacial region. Treatment with oral medications and botulinum toxin (BTX) usually produces only modest benefit, owing to the complexity of the movements involved. We describe a patient with an unusual form of focal task-specific orofacial dystonia, manifested by asynchronous twitching of the right and left lower hemiface upon closure of the mouth and pursing of the lips. Injection of BTX produced complete resolution of task-specific dystonia for 4.5 months.