Randomized feasibility trial of replacing or discarding the nail plate after nail-bed repair in children.

BACKGROUND: Nail-bed injuries are the most common hand injury in children. Surgical dogma is to replace the nail plate after repairing the nail bed. Recent evidence suggests this might increase infection rates and returns to clinic. The aim of this feasibility trial was to inform the design and conduct of a definitive trial comparing replacing or discarding the nail plate after nail-bed repair. METHODS: This study recruited participants from four hand units in the UK between April and July 2015. Participants were children under the age of 16 years with a nail-bed injury requiring surgery. They were randomized to either having the nail plate replaced or discarded after nail-bed repair. The follow-up method was also allocated randomly (postal versus clinic). Information was collected on complications at 2 weeks and 30 days, and on nail-plate appearance at 4 months using the Zook classification. Two possible approaches to follow-up were also piloted and compared. RESULTS: During the recruitment phase, there were 156 potentially eligible children. Sixty were randomized in just over 3 months using remote web-based allocation. By 2 weeks, there were two infections, both in children with replaced nail plates. The nail-replaced group also experienced more complications. There was no evidence of a difference in return rates between postal and clinic follow-up. CONCLUSION: Recruitment was rapid and nail-bed repair appeared to have low complication and infection rates in this pilot trial. The findings have led to revision of the definitive trial protocol, including the mode and timing of follow-up, and modification of the Zook classification.

St Andrew's COVID-19 surgery safety study: hand trauma.

INTRODUCTION: Adaptation is vital to ensure successful healthcare recovery during the COVID-19 pandemic. Hand trauma represents the most common acute emergency department presentation internationally. This study prospectively evaluates the COVID-19 related patient risk, when undergoing management within one of the largest specialist tertiary referral centres in Europe, which rapidly implemented national COVID-19 safety guidelines. MATERIALS AND METHODS: A prospective cohort study was undertaken in all patients referred to the integrated hand trauma service, during the UK COVID-19 pandemic peak (April-May 2020); all were evaluated for 30-day COVID-19 related death. Random selection was undertaken for patients with hand trauma who either underwent non-operative (control group) or operative (surgery group) management; these groups were prospectively followed-up within a controlled cohort study design and telephoned at 30 days following first intervention (control group) or postoperatively (surgery group). RESULTS: Of 731 referred patients (566 operations), there were no COVID-19 related deaths. Both groups were matched for sex, age, ethnicity, body mass index, comorbidities, smoking, preoperative/first assessment COVID-19 symptoms, pre- and postoperative/first assessment isolation and positive COVID-19 contact (p > 0.050). There were no differences in high service satisfaction (10/10 compared with 10/10; p = 0.067) and treatment outcome (10/10 compared with 10/10; p = 0.961) scores, postoperative/first assessment symptoms (1%, 1/100 compared with 0.8%, 2/250; p = 1.000) or proportion of positive tests (7.1%, 1/14 compared with 2.2%, 2/92; p = 0.349), between the control (n = 100) and surgery (n = 250) groups. CONCLUSION: These data support continued and safe service provision and no increased risk to patients who require surgical management. Such findings are vital for healthcare providers when considering service adaptations to reinstate patient treatment.

Differentiation of superficial-partial vs. deep-partial thickness burn injuries in vivo by confocal-laser-scanning microscopy.

OBJECTIVE: The current determination of burn depth is based both on a visual and clinical assessment. Confocal-laser-scanning microscopy (CLSM) enables in vivo histomorphological images. We hypothesized that CLSM can differentiate superficial-partial vs. deep-partial thickness burns on a histomorphological level. METHODS: Thirty-eight burn wounds in 14 patients were clinically divided in three groups from superficial (group 1), superficial-partial (group 2) to deep-partial (group 3) thickness burns. CLSM was performed with the Vivascope 1500 (Lucid Inc., Rochester, NY, USA) 24h after burn. The following parameters were assessed: cell size of the granular-layer, thickness of the basal-layer, minimal thickness of the epidermis and number of perfused dermal papillae. RESULTS: Superficial burns resulted in a significant increase of the cell size of the granular-layer and a higher increase of the minimal thickness of the epidermis as in superficial-partial thickness burns. The granular-layer in partial thickness burns was destroyed. Superficial burns had an increased thickness of the basal-layer; in superficial-partial thickness burns the basal-layer was partly destroyed with complete destruction in deep-partial thickness burns. In superficial burns the perfused dermal papillae were increased significantly, while decreased in superficial-partial thickness, and completely destroyed in deep-partial thickness burns up to a depth of 350 microm. CONCLUSIONS: In vivo confocal-laser-scanning microscopy can differentiate superficial-partial vs. deep-partial thickness burns on a histomorphological level.

Initial experiences using non-cultured autologous keratinocyte suspension for burn wound closure.

Early complete wound closure and thus reduction of excessive scar formation still represent a major clinical challenge in severely burned patients. A novel concept to cover large burn wounds consists of the application of non-cultured epithelial cell suspension within the first days. Herein, we report our experiences with three patients treated with CellSpray XP. According to the amount of cell suspension required, a skin biopsy was harvested and then processed in an external laboratory. Two days later the suspension containing autologous non-cultured keratinocytes was applied using an aerosol system. All wounds healed rapidly and virtually no signs of hypertrophic scarring were observed 6 months later.