Rupture Rates Between 2-Strand and 4-Strand Flexor Tendon Repairs: Is Less More?

The purpose of this study was to explore the difference in clinical outcome of 2-strand and 4-strand flexor tendon repairs in a single unit in adult population. A total of 109 complete divisions of a single flexor tendon were analyzed from 2016 to 2018 retrospectively. Thirty flexor tendons were repaired with 2-strand and 79 tendons were repaired with 4-strand technique. There was no significant difference in the complication rate including rupture, infection, and adhesions. These results support that 4-strand is not superior than 2-strand and that lower volume type of repair would be preferable.

A Novel Approach to Facial Reanimation and Restoration Following Radical Parotidectomies.

Background: Parotidectomies are indicated for a variety of reasons. Regardless of the indication for surgery, facial reanimation may be required because of facial nerve sacrifice or iatrogenic damage. In these cases, facial restoration performed concurrently with ablative surgery is considered the gold standard, and delayed reanimation is usually not attempted. Methods: A retrospective review of all patients who underwent parotidectomies from 2009 to 2022 in a single institution was performed. Indications, surgical techniques, and outcomes of an algorithmic template were applied to these cases using the Sunnybrook, Terzis scores, and Smile Index. A comparison was made between immediate vs. late repairs. Results: Of a total of 90 patients who underwent parotidectomy, 17 (15.3%) had a radical parotidectomy, and 73 (84.7%) had a total or superficial parotidectomy. Among those who underwent complete removal of the gland and nerve sacrifice, eight patients (47.1%) had facial restoration. There were four patients each in the immediate (n = 4) and late repair (n = 4) groups. Surgical techniques ranged from cable grafts to vascularized cross facial nerve grafts (sural communicating nerve flap as per the Koshima procedure) and vascularized nerve flaps (chimeric vastus lateralis and anterolateral thigh flaps, and superficial circumflex perforator flap with lateral femoral cutaneous nerve). Conclusions: The algorithm between one technique and another should take into consideration age, comorbidities, soft tissue defects, presence of facial nerve branches for reinnervation, and donor site morbidity. While immediate facial nerve repair is ideal, there is still benefit in performing a delayed repair in this algorithm.

Infection Rates for Open Distal Phalangeal Fractures Treated with Kirschner Wire: A UK Regional Hand Centre Experience.

Background: Phalangeal fractures are common in hand injuries which: comprising of 23% of all hand and forearm fractures. The current consensus is that focus of treatment should be on prompt irrigation and debridement to reduce infection risk. These infections are significant as they can lead to serious sequelae including osteomyelitis. The aim of this study was to determine the incidence of infection amongst patients with open fracture of distal phalanx who had been treated with K-wire fixation and the timing of their operative management compared to the UK national guideline. Methods: We performed a retrospective case-note analysis of the patients treated for open distal phalangeal fractures at a regional hands centre over the period of 12 months, and compared with the national guidelines. Data collected included patient demographics, mechanism of injury, length of time taken from injury to first washout, length of time K-wire remains in situ, and infection rate. Results: Half of the patients (n = 19) met the guideline and were treated with washout within the first 24 hours. Infection rates in this group was 11%. This compared with 26% in those patients that did not receive washout within 24 hours. Conclusions: This study demonstrates the difficulty in always meeting national guidelines and suggests key reasons for this. The authors propose a set of local, easily-achieved interventions to raise awareness and compliance with the national guidelines and reduce infection. Furthermore, it highlights the importance of carefully selecting cases that required percutaneous K-wire fixation.

Adverse Effects of Pregnancy on Keloids and Hypertrophic Scars.

There are many well-known risk factors for keloids and hypertrophic scars (HTS) including ethnicity, family history, and history of previous keloids or HTS. An association, which has been previously observed, exists between pregnancy and growth and worsening of keloid and HTS. This association is less well known amongst physicians and less documented in the literature. In this paper we discuss two cases of extreme worsening of keloid scars during pregnancy. We have also witnessed the transformation of a pre-existing scar into a keloid scar during puberty. We attribute this to the hormonal effects of pregnancy and puberty hormones which could potentially trigger the growth of pre-existing keloids and HTS. This may have an impact on many patients and we therefore recommend women and girls who have keloid and hypertrophic scarring be made aware of this potential effect.

Preoperative measurement of cutaneous melanoma and nevi thickness with photoacoustic imaging.

Photoacoustic imaging (PAI) is an emerging biomedical imaging technology, which can potentially be used in the clinic to preoperatively measure melanoma thickness and guide biopsy depth and sample location. We recruited 27 patients with pigmented cutaneous lesions suspicious for melanoma to test the feasibility of a handheld linear-array photoacoustic probe in imaging lesion architecture and measuring tumor depth. The probe was assessed in terms of measurement accuracy, image quality, and ease of application. Photoacoustic scans included single wavelength, spectral unmixing, and three-dimensional (3-D) scans. The photoacoustically measured lesion thickness gave a high correlation with the histological thickness measured from resected surgical samples ([Formula: see text], [Formula: see text] for melanomas, [Formula: see text], [Formula: see text] for nevi). Thickness measurements were possible for 23 of 26 cases for nevi and all (6) cases for melanoma. Our results show that handheld, linear-array PAI is highly reliable in measuring cutaneous lesion thickness in vivo, and can potentially be used to inform biopsy procedure and improve patient management.

Basic Surgical Skill Retention: Can Patriot Motion Tracking System Provide an Objective Measurement for it?

BACKGROUND: Knot tying is a fundamental skill that surgical trainees have to learn early on in their training. The aim of this study was to establish the predictive and concurrent validity of the Patriot as an assessment tool and determine the skill retention in first-year surgical trainees after 5 months of training. METHODS: First-year surgical trainees were recruited in their first month of the training program. Experts were invited to set the proficiency level. The subjects performed hand knot tying on a bench model. The skill was assessed at baseline in the first month of training and at 5 months. The assessment tools were the Patriot electromagnetic tracking system and Objective Structured Assessment of Technical Skills (OSATS). The trainees' scores were compared to the proficiency score. The data were analyzed using paired t-test and Pearson correlation analysis. RESULTS: A total of 14 first-year trainees participated in this study. The time taken to complete the task and the path length (PL) were significantly shorter (p = 0.007 and p = 0.0085, respectively) at 5 months. OSATS scoring showed a significant improvement (p = 0.0004). There was a significant correlation between PL and OSATS at baseline (r = -0.873) and at Month 5 (r = -0.774). In all, 50% of trainees reached the proficiency PL at baseline and at Month 5. Among them, 3 trainees improved their PL to reach proficiency and the other 3 trainees failed to reach proficiency. CONCLUSION: The parameters from the Patriot motion tracker demonstrated a significant correlation with the classical observational assessment tool and were capable of highlighting the skill retention in surgical trainees. Therefore, the automated scoring system has a significant role in the surgical training curriculum as an adjunct to the available assessment tool.

You've Got to Hand It to Them: Assessing Final Year Medical Students Knowledge of Hand Anatomy and Pathology.

BACKGROUND: Knowledge of hand anatomy and pathology is important for final year medical students as it frequently appears in examinations as a short case or in a written paper. Studies have shown that doctors in the Emergency Department have a deficient grasp of musculoskeletal anatomy secondary to a lack of dedicated teaching in medical school. METHODS: A questionnaire was handed out to 111 final year medical students. Students were asked to fill it out before and after dedicated upper limb teaching sessions during their rotation. The questionnaire consisted of an anatomical and pathological component. Students were tested on basic anatomy and pathology of several common upper limb conditions. RESULTS: There was a significant improvement in the medical students knowledge after the dedicated hand teaching. The identification of the carpal bones showed the most improvement overall. CONCLUSIONS: Basic musculoskeletal knowledge is essential to the practice of medicine. The majority of medical students gravitate towards a career in general practice or emergency medicine and good knowledge of upper limb anatomy is important. We have piloted a new interactive dedicated upper limb teaching module and have shown that there has been a significant improvement in students knowledge.

Evaluation of surgical training in the era of simulation.

AIM: To assess where we currently stand in relation to simulator-based training within modern surgical training curricula. METHODS: A systematic literature search was performed in PubMed database using keywords "simulation", "skills assessment" and "surgery". The studies retrieved were examined according to the inclusion and exclusion criteria. Time period reviewed was 2000 to 2013. The methodology of skills assessment was examined. RESULTS: Five hundred and fifteen articles focussed upon simulator based skills assessment. Fifty-two articles were identified that dealt with technical skills assessment in general surgery. Five articles assessed open skills, 37 assessed laparoscopic skills, 4 articles assessed both open and laparoscopic skills and 6 assessed endoscopic skills. Only 12 articles were found to be integrating simulators in the surgical training curricula. Observational assessment tools, in the form of Objective Structured Assessment of Technical Skills (OSATS) dominated the literature. CONCLUSION: Observational tools such as OSATS remain the top assessment instrument in surgical training especially in open technical skills. Unlike the aviation industry, simulation based assessment has only now begun to cross the threshold of incorporation into mainstream skills training. Over the next decade we expect the promise of simulator-based training to finally take flight and begin an exciting voyage of discovery for surgical trainees.