A double-blind, placebo-controlled randomised trial of intraparenchymal administration of local anaesthetic in elective breast augmentation.

INTRODUCTION: Several methods of controlling pain post-bilateral breast augmentation (BBA) have been described. BBA is frequently performed as a day case procedure; therefore, a simple effective method of controlling pain in the immediate post-operative period is desired. METHODS: We conducted a prospective, double-blinded, placebo-controlled randomised study of 20 women undergoing BBA. Women were randomly assigned to receive intraparenchymal infiltration intra-operatively prior to implant placement with either local anaesthetic (LA) (chirocaine) or normal saline. The primary outcome was post-operative pain scores immediately, and at 6 h. Our secondary endpoint was post-operative narcotic consumption. RESULTS: Twenty patients were included in this study. The average pain score in the immediate post-operative period was 3.4 in the control group versus 0.7 in the treatment group (p = 0.013). In 6 h post-operatively, the average pain score was 2.4 in the control group versus 0.9 in the treatment group (p = 0.03). Sixty-six percentage of patients in the control arm required post-operative opiates compared with 27% in the treatment group (p = 0.17) CONCLUSION: This randomised controlled trial demonstrates a technique of intraparenchymal infiltration of LA that significantly reduces post-operative pain scores after BBA.

The pruritus severity scale-a novel tool to assess itch in burns patients.

BACKGROUND: Pruritus assessment is difficult due to the varying subjective nature of the experience. There have been several validated tools described to quantify the severity of itch, however these tools fail to provide a comprehensive assessment or are too cumbersome and therefore lack usability. Our novel burn assessment tool, "The Pruritus Severity Scale" (PSS) allows for accurate quantification of itch components. The aim of this study was to assess its use in the burns population. METHODS: A prospective observational study was conducted on all patients over five years of age with a burn injury over a six month period. Patients underwent subjective evaluation of their itch as determined by two validated scores, the Visual Analogue Scale (VAS) and the Itch Man scale (IMS) and in addition to the PSS. The pruritus severity scale was correlated with the previously validated scoring methods using bi-variate correlations. RESULTS: Twenty-two patients were included in the study. The most common cause of injury was due to flame burn. The mean total body surface area was 6.5% (range: 1-26%). Both the IMS and the VAS positively correlated well with the PSS. The Spearman Coefficient for the PSS vs IMS was 0.81, R2 = 0.65 (P<0.05). The Spearman Coefficient for the PSS vs VAS was 0.87 (R2 = 0.76 (P<0.01)). There is a positive linear relationship between our novel scoring methods and the currently validated methods, indicating its validity as a burn assessment too. CONCLUSION: The Pruritus Severity Scale was shown to be an accurate, objective tool that was able to effectively record the patient's experience of itch. We believe that this novel score is quick, easy to use and allows for more comprehensive assessment than other short assessment tools.

Pedicled sural flaps versus free anterolateral thigh flaps in reconstruction of dorsal foot and ankle defects in children: a systematic review.

BACKGROUND: This systematic review compared free anterolateral thigh (ALT) flaps versus pedicled distally based sural artery (DBSA) flaps for reconstruction of soft tissue defects of dorsal foot and ankle in children. METHODS: A systematic literature search was performed to identify cases where an ALT or DBSA was used to reconstruct the dorsal foot in children. A total of 19 articles were included in the systematic review. RESULTS: Eighty-three patients underwent an ALT reconstruction and 138 patients underwent a DBSA reconstruction. Patients who had a DBSA were more likely to require grafting of the donor site (P<0.001). The size of ALT flaps was significantly larger than DBSA flaps (P=0.002). Subsequent flap thinning was required in 30% of patients after ALT and 12% of patients after DBSA reconstruction (P<0.001). Complications occurred in 11.6% of DBSA and 8.4% of ALT flaps (8.4%). CONCLUSIONS: Both flaps are valid options in reconstructing pediatric foot and ankle defects. Each flap has advantages and disadvantages as discussed in this review article. In general for larger defects, an ALT flap was used. Flap choice should be based on the size of the defect.

Paediatric Dupuytren's Disease in a Child of Indian Ethnicity: A Case Report and Literature Review.

Paediatric Dupuytren's disease is a very rare clinical entity. Dupuytren's disease has preponderance to older males of Celtic heritage. We present a case of Dupuytren's disease in an eight-year-old boy of Indian ethnicity who presented with a progressive flexion contracture of his right ring finger for a duration of six months. On examination, he had an isolated 60-degree flexion contracture of the proximal interphalangeal joint with thickening of the skin and subcutaneous tissues. This was consistent with Dupuytren's cord and contracture. He proceeded to theatre for a dermofasciectomy, with subsequent histological confirmation of Dupuytren's disease. We performed a review of the literature and identified 21 reported cases of Dupuytren's disease affecting the hand in the paediatric population. This is a rare report of Dupuytren's disease affecting a child of Indian ethnicity.

Collagenase Use and a Trap for the Unwary in Patients With Upper Limb Spasticity.

Collagenase has revolutionized the treatment of Dupuytren's disease. It acts by lysing collagen in Dupuytren's cords. It can also act on collagen in tendons, leading to tendon rupture. In this letter, we highlight caution where bowstringed flexor tendons were masquerading as Dupuytren's cords in a patient with upper limb spasticity. The initial plan was to inject the cords with collagenase; however, we proceeded with an open approach. If we had proceeded with our initial plan to inject the palpable cords with collagenase, tendon rupture would have been the likely outcome. We advise that administrators of collagenase proceed with caution in patients with upper limb neurological disorders, bearing in mind that bow-stringed flexor tendons can mimic Dupuytren's cords.

Recurrent Ameloblastoma Involving Fibula Neo-mandible: Management with Digital Planning and Reconstruction Using a Contralateral Free Fibula Flap.

Ameloblastoma is a locally aggressive tumor that most commonly arises in the mandible. It has a high rate of recurrence if inadequately excised. We report a case of a patient who developed recurrence of his ameloblastoma in his fibula flap mandibular reconstruction despite clear resection margins 23 years after resection. This is the first reported case of recurrent ameloblastoma in a neo-mandible reconstruction in the setting of negative margins. We discuss its surgical management using digital planning and reconstruction using a contralateral free fibula flap. Ameloblastoma is a locally aggressive entity that requires complete excision. Recurrence can even occur in the reconstruction, which can present a challenge to manage. Consideration should be given to repeat excision and second osseous flap reconstruction.

Idiopathic Carpal Spasm (Trousseau's Sign) After Intraoperative Arm Tourniquet Inflation in an Intubated Patient.

We present a case of a 38-year-old male who sustained a laceration from a knife to the volar aspect of his left index and middle fingers. He had clinical injury to his flexor digitorum profundus tendons to both digits. He underwent operative exploration and repair of the tendons under general anaesthetic. An arm tourniquet was inflated to allow for haemostasis in the operative field. A few minutes after inflation, the patient's hand went into carpal spasm. The tourniquet was deflated and the spasm resolved. Intraoperative serum calcium and carbon dioxide levels were normal. The operation proceeded with the tourniquet deflated. Postoperatively serum calcium and magnesium levels were within normal limits, as was serum vitamin D and parathyroid hormone levels. It has been reported that carpal spasm can occur with tourniquet use in the anxious patient due to hyperventilation and resultant metabolic alkalosis. This however is the first reported case of carpal spasm in the setting of tourniquet use and normal serum electrolytes and respiratory parameters in an intubated patient.

The Impact of Surgical Complications on Cancer Recurrence Rates: A Literature Review.

INTRODUCTION: The inflammatory response to a post-operative infection can increase the risk of tumour recurrence in cancer through the release of pro-inflammatory mediators. The aim of this study was review the literature to assess the relationship between post-operative complications and cancer recurrence. METHODS: We performed a literature review of the mechanism of such an association and looked at evidence in different cancer subtypes. RESULTS: A relationship has been identified for many cancer subtypes, and multiple theories have been proposed for the mechanism of this association. Methods to reduce post-operative complications may impact positively on cancer recurrence rates. CONCLUSION: This review demonstrates that wound complications after surgery can have significant implications for cancer patients. Strategies are required to minimize the risk of post-operative wound complications in patients undergoing cancer resection.

Dedicated general practitioner education sessions can improve diagnostic capabilities and may have a positive effect on referral patterns for common skin lesions.

INTRODUCTION: General practitioners (GPs) require the necessary skills to identify potentially malignant skin lesions and refer patients in an appropriate and timely manner. We examined the impact of a single consultant delivered education session to GP trainees on their diagnosis of common skin lesions. METHODS: A prospective analysis of baseline knowledge was assessed using a photographic questionnaire. A dedicated education session was delivered by a consultant plastic surgeon. Their knowledge was re-assessed after 3 months. RESULTS: There were 23 participants. Baseline ability to correctly diagnose skin lesions improved significantly at 3 months following dedicated teaching (baseline mean 30.2%, 3-month mean 65.9%, p = 0.001). All trainees recommended that dedicated skin education should be incorporated into GP training curricula. CONCLUSION: Dedicated education sessions on skin lesions can improve the diagnostic accuracy of GP trainees, and we suggest that they are incorporated into the GP training curriculum.

The Reverse Thomas Position for Thoracolumbar Fracture Height Restoration: Relative Contribution of Patient Positioning in Percutaneous Balloon Kyphoplasty for Acute Vertebral Compressions.

BACKGROUND: Standard positioning for percutaneous balloon kyphoplasty requires placing a patient prone with supports under the iliac crests and upper thorax. The authors believe that hip hyperextension maximises pelvic anteversion creating anterior longitudinal ligamentotaxis, thus facilitating restoration of vertebral height. METHODS: Radiographic imaging including pre-operative, post-positioning, post balloon tamp inflation and post-operative lateral radiographs were analysed for anterior and posterior column height, wedge angle of the affected vertebra and 3-level Cobb angle in patients with recent fractures of T11-L1. Fracture dimensions of the index vertebra were expressed as percentage of the analogous dimension of the referent vertebra. RESULTS: From a total of 149 patients, a full imaging sequence was available on 21 cases of vertebral compression fractures. The described positioning technique created a mean anterior column height increase from 68.3% to 75.3% with positioning (p = 0.15), increasing to 82.3% post balloon inflation. Average Cobb and wedge angle improvement of 4.7° (p = 0.004)and 3.6° (p = 0.002) from positioning along were also recorded. CONCLUSION: The Reverse Thomas Position is a safe and effective technique for augmenting thoracolumbar fracture height restoration in percutaneous balloon kyphoplasty.

An Appraisal of Inflammatory Markers in Distinguishing Acute Uncomplicated and Complicated Appendicitis.

BACKGROUND: It remains difficult to distinguish between complicated appendicitis (CAP) and uncomplicated appendicitis (UAP). There is a paucity of studies utilizing inflammatory markers to stratify the severity of acute appendicitis. This study aimed to evaluate and demonstrate the potential clinical utility of inflammatory markers as adjuncts in distinguishing CAP and UAP. METHODS: A comparative observational study was performed. Patients diagnosed with acute appendicitis were categorized as (a) complicated (necrosis, perforation, abscess) and (b) uncomplicated (inflamed, edematous). Hematological indices were combined to generate the following ratios: white cell lymphocyte ratio (WLR), white cell neutrophil ratio (WNR) and neutrophil lymphocyte ratio (NLR). Parameter accuracy was assessed using summary receiver operating characteristic (sROC) curves, classification and regression tree analysis and confusion matrix generation. RESULTS: On sROC analysis, neutrophils (area under the curve (AUC) 0.79, p < 0.001), WLR (AUC 0.79, p < 0.001) and NLR (AUC 0.79, p < 0.001) were the most accurate parameters in distinguishing CAP and UAP. White cell count (WCC; AUC 0.76, p < 0.001) and C-reactive protein (AUC 0.75, p < 0.001) were less accurate. WCC >12.25 (sensitivity 70%, specificity 68%) and NLR >5.47 (sensitivity 78%, specificity 70%) were the most accurate in identifying CAP. CONCLUSION: Inflammatory marker cutoff points can be generated and utilized to differentiate between UAP and CAP. This may be useful when deciding between conservative and operative management.

Focal intratendinous radiolucency: A new radiographic method for diagnosing patellar tendon ruptures.

BACKGROUND: Diagnosis of patellar tendon rupture is usually based on clinical history and examination. In equivocal cases, imaging may be required. Lateral radiograph is a simple and cost-effective method for prompt diagnosis. However, no specific radiological sign has been described. Rather than utilising patella alta as an indirect measure of patellar tendon rupture, we hypothesise that a focal intratendinous radiolucency is another reliable and accurate radiological sign for diagnosis. Sensitivity and specificity analysis was undertaken to evaluate the diagnostic value of this radiographic sign. METHODS: Lateral radiographs of mid-substance patellar tendon ruptures from 19 patients were analysed. These were then randomised with another 19 normal knee radiographs from age-matched patients to create a pool of 38 radiographs for interpretation. Six independent interpreters who were blinded to the diagnosis were requested to indicate whether rupture was present or absent based on the visualisation of a focal intratendinous radiolucency in the patellar tendon. The Insall-Salvati (IS), Caton-Deschamps (CD) and Blackburne-Peel (BP) ratios were measured in the same radiographs. Sensitivity and specificity for each of the radiographic measurements were calculated. Inter- and intraobserver correlations were reported in kappa statistics. RESULTS: The average sensitivity and specificity for focal radiolucency in the patellar tendon substance were 82.5% and 95.2%, respectively. Sensitivity and specificity for the IS ratio were 84.2% and 78.9%, for CD was 68.4% and 84.2% and for BP was 68.4% and 89.4% respectively. CONCLUSION: The presence of a focal intratendinous radiolucency in the patellar tendon is both accurate and reliable in diagnosing patellar tendon ruptures.

Diagnostic dilemmas due to fish bone ingestion: Case report & literature review.

INTRODUCTION: The diagnosis of abdominal complications due to fish bone ingestion is particularly difficult as the presentation may mimic common abdominal pathologies. PRESENTATION OF CASE: 65 year-old male presented with a two day history of right iliac fossa pain. He denied any nausea and vomiting. He had no systemic systems including fever, change in bowel habit. He had tenderness and guarding localized to the right iliac fossa. He had raised inflammatory markers. A CT scan of the abdomen was performed which showed fat standing in proximity to the terminal ileum, with the appearance of Crohn's disease. The clinical picture did not match the imaging and so the patient underwent a diagnostic laparoscopy. Findings included an acutely inflamed terminal ileum. A foreign body was identified piercing through at the small bowel wall at the terminal ileum. The foreign body was removed and revealed a fish bone. Intracorporeal sutures were inserted at the site of the microperforation. The patient was discharged well two days post operatively. DISCUSSION: Fish bone perforation is not a common cause of gastrointestinal perforation. Unfortunately the history is often non-specific and these people can be misdiagnosed with acute appendicitis & other pathologies. CT scans can be useful to aid diagnostics. It is not however fully sensitive in detecting complications arising from fishbone ingestion. CONCLUSION: Management therefore, should be based taking into account primarily the clinical picture & may necessitate diagnostic laparoscopy.

Metastatic ovarian carcinoma presenting as an incarcerated femoral hernia.

INTRODUCTION: Incarcerated femoral hernias usually contain a simple loop of bowel. Occasionally other abdominal structures may be found within the hernial sac. Rarely femoral hernias may contain metastatic tumour deposits. PRESENTATION OF CASE: We report the case of an 82 year old lady with a background of ovarian carcinoma, who presented with acute small bowel obstruction and an irreducible right groin mass. CT imaging revealed an incarcerated loop of small bowel within a femoral hernia sac. The patient proceeded to theatre for hernia repair. Upon opening the hernial sac an adherent incarcerated small bowel loop was discovered. Interestingly, the sac itself was lined with metastatic deposits, which were later histologically proven to be ovarian in origin. The sac was reduced and the hernia was repaired. The patient's post-operative course was uneventful. DISCUSSION: As abdominal wall hernias communicate with the abdominal cavity there is the potential for malignant cells to seed the peritoneal lining of the hernia sac. If the sac also contains bowel wall, this may become involved in the tumour mass. This may result in small bowel incarceration & obstruction. CONCLUSION: In cases, where there is a known intra-abdominal malignancy & the presence of an incarcerated hernia, there should be a high index of suspicion for the presence of tumour within the hernial contents.