The Supraclavicular Artery Perforator Flap: A Comparative Study of Imaging Techniques Used in Preoperative Mapping.

BACKGROUND: The supraclavicular artery flap is an excellent flap for head and neck reconstruction. The aim of this study is to assess imaging techniques to define the precise vascular boundaries of this flap. METHODS: Six imaging techniques were used for supraclavicular artery mapping in 65 cases; handheld Doppler, triplex ultrasound, computed tomography angiography, magnetic resonance angiography, digital subtraction angiography, and indocyanine green angiography. We checked the site of the perforators, the course of a supraclavicular artery, and anatomical mapping of the supraclavicular artery. RESULTS: Handheld Doppler identified perforators' sites in 80% of the cases but showed no results for the course of the vessel. Triplex ultrasound identified the site of perforators in 52.9%, and partial mapping of the course of a supraclavicular artery in 64.7% of the cases. Computerized tomography angiography showed the site of perforators in 60%, and the course of supraclavicular artery completely in 45%, and partially in an additional 30%of the cases examined. Magnetic resonance angiography showed negative results for all parameters. Digital subtraction angiography showed the partial course of a supraclavicular artery in 62.5%, but showed no perforators. Indocyanine green angiography showed the site of perforators in 60% and a partial course of supraclavicular artery distal to perforators in 60%.Anatomical mapping of the vessel was possible with computerized tomography angiogram completely in 45%, and partially in 30%, and was also possible with indocyanine green angiography partially in 60%. CONCLUSION: Computerized tomography angiography showed best results in the mapping of the supraclavicular artery, but with an inability to define the perforator perfusion territories, and also with risks of irradiation, while indocyanine green angiography is a good alternative as it could precisely map the superficial course of the artery and angiosomes, with no radiation exposure.

Mechano-transduction effect of shockwaves in the treatment of lumbar facet joint pain: comparative effectiveness evaluation of shockwave therapy, steroid injections and radiofrequency medial branch neurotomy.

OBJECTIVE: Lumbar facet joints (FJ) is a common source of low back pain and contributes approximmately on one third of chronic low back pain. Medial branch radiofrequency neurotomy is considered as a gold standard in the treatment of facet joint pain. Corticosteroid injections have also presented effect in FJ pain. As an interventional procedures, they carry not-negligible risk of possible complications including infection, damage to nerve root or medial branch structures. Shockwave therapy (SWT) is a non-invasive method for treatment of various musculoskeletal disorders. Its effect is based on transduction of mechanical energy, transferred to cascade of various biochemical processes in target tissue. Its efficacy was proved in the treatment of different painful conditions. The efficacy of SWT was not yet studied in FJ pain. Aim of our work was to compare the efficacy of SWT against interventional treatment procedures - radiofrequency neurotomy and corticosteroid FJ injections. METHODS: A retrospective study was done on 62 selected patients with unilateral chronic lumbar facet pain. There were 32 women and 30 men, divided into SWT group, corticosteroid injections group radiofrequency group. Nociceptive and neuropathic pain intensity and severity of pain were measured. RESULTS: Shockwave therapy had shown better longterm results compared to FJ injections group and little inferior efficacy compared to RMBN. We did not observe any adverse effects and complications in SWT group. Moreover, in SWT and RMBN groups, significant longterm improvement in daily activities limitation, was observed. CONCLUSIONS: SWT appears to be a safe and perspective option in the treatment of FJ pain with negligible side effects.

Carpal tunnel syndrome caused by a fibrolipomatous hamartoma of the median nerve treated by endoscopic release of the carpal tunnel.

Fibrolipomatous hamartoma has up to now been considered a rare anomaly that most commonly affects the median nerve. Its pathogenesis is controversial. The magnetic resonance (MR) appearance is pathognomonic and precludes the necessity for a diagnostic biopsy. Its reported incidence is likely to increase as a result of the increased use of MRI. There is no definitive treatment, although carpal tunnel syndrome caused by fibrolipomatous hamartoma has been noted to respond to open release of the carpal tunnel. We describe a case of carpal tunnel syndrome caused by fibrolipomatous hamartoma of the median nerve that responded to a two-port endoscopic technique of release. Provided that a safe, distinct surgical plane can be established between the median nerve and the flexor retinaculum, the two-port technique of endoscopic release of the carpal tunnel is both safe and effective.

Analysis of wrist motion following vascularized bone graft to the proximal scaphoid.

PURPOSE: To determine whether there is any motion loss associated with the 1,2 intracompartmental supraretinacular artery (ICSRA) bone graft to the dorsal scaphoid. The null hypothesis is that placement of a vascularized bone graft in the dorsal scaphoid does not lead to a significant change in range of motion. METHODS: Seven fresh-frozen cadaveric upper extremities were examined. Simulated 1,2 ICSRA bone grafts were harvested and placed into a dorsal trough made in the proximal scaphoid. Wrist motion measurements were performed before and after 1,2 ICSRA bone graft implantation. RESULTS: There were no significant changes in wrist motion following 1,2 ICSRA bone graft implantation. CONCLUSIONS: Properly placed 1,2 ICSRA vascularized bone grafts for treatment of proximal scaphoid nonunions do not by themselves cause loss of wrist motion. CLINICAL RELEVANCE: Loss of motion following the treatment of proximal scaphoid nonunions with properly placed 1,2 ICSRA vascularized bone grafts are due to factors other than the bone graft itself.

Blastomycotic hand infections.

We report two cases of disseminated blastomycotic infections with involvement of the hand occurring in the absence of identifiable risk factors.

Factors that affect the clinical course of group A beta-haemolytic streptococcal infections of the hand and upper extremity: a retrospective study.

Group A beta-haemolytic streptococcus is a well-known cause of necrotising fasciitis, which is increasing in incidence and severity. More aggressive soft tissue infections of the hand and upper extremity caused by this organism have been noted in our plastic surgical unit, prompting a five-year retrospective study to find out which factors affect clinical outcomes. The records of 31 patients, 27 male and 4 female, with Group A beta-haemolytic streptococcal soft tissue infections with a mean (SD) age of 25 (12) years were reviewed. Twenty-seven infections followed injuries, while four were spontaneous. Six patients required more than two operations to clear the infection, and one required free tissue transfer for closure of the resulting soft tissue deficit. Of the variables age, number of cigarettes consumed daily, interval from the date of injury to the date of presentation, coexisting infection with Staphylococcus aureus, and grade of infection at presentation, only the last correlated with the patients' clinical course (p<0.001). Those patients with spontaneous infections with pre-existing medical conditions had a worse prognosis, requiring more operations and a longer stay in hospital. A multicentre prospective study would be useful to confirm these findings.

A 7-year experience in utilizing the latissimus dorsi myocutaneous flap for bilateral breast reconstruction.

Due to the benefits of prophylactic mastectomy in women at risk of breast cancer or recurrent disease, we have noted an increase in the number of women presenting for bilateral breast reconstruction. Current dogma stipulates that flaps of abdominal origin constitute the gold standard of breast reconstruction.However, women presenting for bilateral breast reconstruction may either have medical contraindications or be unwilling to undergo a procedure with a significant risk of donor site and/or flap complications. The latissimus dorsi musculocutaneous flap is an excellent flap in these circumstances. In the course of our experience in utilizing this flap, we have developed modifications in both the dissection and insetting of the flap that differ from earlier descriptions. Over the past 7 years, we have utilized the latissimus dorsi myocutaneous flap for bilateral breast reconstruction in 37 women with an acceptable complication rate and a high level of patient satisfaction.

A 12-year experience using the Brown two-portal endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a new paradigm in the treatment of carpal tunnel syndrome.

BACKGROUND: Compared with the open technique, endoscopic carpal tunnel release has a shorter postoperative recovery period but has been associated with an increased risk of iatrogenic injury. Because of morbidity of the open method, including painful scars, pillar pain, tendon adhesions, scar entrapment of the median nerve, chronic regional pain syndrome, and a longer postoperative recovery period, many patients have been treated nonoperatively to circumvent or forestall surgery, resulting in unrelieved median nerve compression and an increased risk of permanent nerve injury. METHODS: Inclusion criteria included a diagnosis of carpal tunnel syndrome based on history and physical examination and electrodiagnostic studies; failure of a short trial of conservative therapy; and advanced disease as evidenced by sensory, motor, or atrophic changes in the median nerve distribution. Exclusion criteria included prior surgery, wrist extension of less [corrected] than 40 degrees, mass within the carpal tunnel, Guyon's syndrome, and bony carpal tunnel abnormalities. Patients meeting these criteria were treated by the Brown two-portal endoscopic technique. RESULTS: A total of 14,722 patients were treated with the Brown endoscopic procedure. Eleven patients (0.07 percent) required conversion to an open procedure. There was one iatrogenic injury. Postoperative results were inversely related to the severity of the preoperative electrodiagnostic studies and the duration of symptoms regardless of the method of nonoperative treatment given. CONCLUSIONS: Operative decompression should be carried out promptly if symptoms have been present for 2 months or longer, as the occurrence of permanent nerve damage has been noted within this time frame. The authors advocate use of the two-portal endoscopic technique as previously described by Brown et al. for this purpose.

Single-cuff Bier's block in the forearm: factors affecting its efficacy and need for supplementation with local anaesthetics.

Bier's block in the forearm is a safe, effective, and reliable method of regional anaesthesia for operations on the upper extremity. We report 155 patients, of whom only 25 had residual sensation after placement of the block, that required additional local anaesthetic. The purpose of this study was to identify the factors responsible for the residual sensation using the single-cuff Bier's block technique. We recorded all those factors that we thought might have an influence. No patients required conversion to a general anaesthetic. The body mass index, the difference of the systolic and tourniquet pressures, and the site of incision were the three factors correlated with the need for additional anaesthesia.

Hot oil burns--a study of predisposing factors, clinical course and prevention strategies.

A 10-year retrospective study of hot oil scalds was conducted at the Yorkshire Regional Burns Centre from the years 1995-2004. The number of admissions was noted to have increased over this period. Peak occurrence was noted in the 1-5 and the 30-40-year-old age groups. The peak occurrence in adults was significantly older than that previously reported. Ninety-two percent of injuries in the 1-6-year-old age group were due to pulling a handle or cord of a container of hot oil. Older children had similar mechanisms of injury as adults. Injuries due to epilepsy, intoxication or assaults, were seen exclusively in the fourth to seventh decades of life. The total body surface area of adults and children were similar, i.e. 7.15 +/- 5.49% versus 7.23 +/- 6.87%. However, the incidence of full thickness injury in adults was over twice that observed in children, i.e. 67% versus 26%. Prevention of hot oil scalds requires adult supervision of young children. Product modification for fryers is helpful, but is not a substitute for adult supervision. Prevention of injury in adults requires the placement of adequate warning labels on hot oil cooking appliances as well as containers of cooking oil. In addition, adults should refrain from the consumption of alcoholic beverages when using hot oil cooking appliances or deep-frying.

Hot beverage burns: an 11-year experience of the Yorkshire Regional Burns Centre.

A retrospective study was performed at the Yorkshire Regional Burns Centre from 1994 to 2004 inclusive to determine the changes in treatment and clinical outcomes of patients admitted with hot beverage burns and the effect of changes in referral patterns over this period. Although children under the age of 3 years accounted for 77.5% of all cases of hot beverage scalds, this injury was represented in all age groups. Children from 1 to 2 years of age had the highest incidence of this injury. Changes in referral patterns over this period resulted in a decrease in the mean total body surface area of injury, an increase in the number of admissions and an increase in the time interval from injury to admission to the Burns Centre for this period. The total body surface area given by referring facilities was often times inaccurate, as reported previously by this Burns Centre. The introduction of Biobrane in 2002 was effective in reducing the length of hospitalisation for patients with superficial partial thickness burns. Hot beverage burns remain a significant public health problem deserving of continuing efforts to maintain public awareness.

A variant of Kaplan's accessory branch of the dorsal cutaneous branch of the ulnar nerve: a case report and review of the literature.

Kaplan's accessory branch is an aberrant branch of the dorsal cutaneous branch of the ulnar nerve that arises proximal to the styloid process of the ulna and courses ulnar to the pisiform. Variations of this anomaly have been described as having an end point of connection to the sensory branch of the ulnar nerve, to the motor branch of the ulnar nerve (rare), to the digital nerve at the level of the midhypothenar eminence, or to the proximal interphalangeal joint of the small finger or as running as an independent branch to the volar aspect of the small finger. We report a variant of Kaplan's accessory branch that coursed through the insertion of the flexor carpi ulnaris, a groove on the ulnar aspect of the pisiform, and connected to the ulnar nerve trunk proximal to its bifurcation into its motor and sensory branch. Based on the findings of the case presented and a review of the literature we offer a classification system for this anomaly.

Injury to the long thoracic nerve as a complication of neck dissection: a case report.

Injury to nerves by dissection of the neck is well recognised. A case report of injury to the long thoracic nerve follows, which has not been previously described.