A new concept for tuberosity repair in hemiarthroplasty for fracture: use of a clamp and underlying ledge to form a trapdoor.

BACKGROUND: Sutures are the most common method for tuberosity repair in hemiarthroplasty for fracture. Despite numerous suggested patterns, tuberosity repair remains a weak point leading to poor functional results. This study mechanically tested a new mechanism that avoids difficulties sutures may engender. The hallmark of the prosthesis is a "trapdoor" effect. Low-profile metallic clamps with undersurface stoppers are screwed across the tuberosity-tendon junction to an underlying ledge, creating a fixed metallic space. With cuff contraction, the tuberosities are too large to pull through this space. MATERIALS AND METHODS: Tests were carried out in line with the U.K. Human Tissue Authority regulations. Four-part fractures in 8 cadavers repaired with this method were subjected to simultaneous cyclic tension of 350N and passive glenohumeral motion for 8000 cycles. Both before and after machine stress, repairs were assessed by clasping each tuberosity with a forceps and attempting to displace it in a variety of directions. No movement was present before stressing. Any post-stress movement was considered a failure and recorded in millimeters. RESULTS: Six specimens after machine stress showed 0-mm movement (95% confidence interval, 34.9%-96.8%). Isolated movements of a single tuberosity occurred in 2 specimens. CONCLUSION AND DISCUSSION: The trapdoor completely withstood challenging elements of cyclic load and passive motion in 75% of cases. The device may represent an alternative to sutures.

Enhanced recovery for acute open lower limb fracture 'fix and flap'.

INTRODUCTION: Enhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following 'fix & flap', return to theatre, rate of successful flap salvage, flap failure and deep infection rates. METHODS: An observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases. RESULTS: 161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %. CONCLUSION: In isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

Is failure of tuberosity suture repair in hemi-arthroplasty for fracture mechanical?

BACKGROUND: Tuberosity suture repair in hemiarthroplasty for fracture carries risk of malunion giving poor results. Is failure mechanical or biochemical? We investigated the mechanical aspect with repetitive loading in cadaveric repairs. MATERIALS AND METHODS: Tests were carried out in line with U.K. Human Tissue Authority regulations. A 4-part fracture was created in 8 cadaver shoulders by osteotomizing the tuberosities. A standard hemiarthroplasty implant was cemented in at correct height and retroversion, and standardized repairs applied. Initial firmness of repair was confirmed by attempting to manually displace the tuberosities with a forceps in multiple planes. All pre-stress tests showed 0 mm movement. Repairs were then subjected to cyclical tension on the cuff musculature and simultaneous gleno-humeral motion for 8000 cycles. The tuberosities were reprobed with a forceps to record any movement. RESULTS: Defining repair failure as the ability to manually displace a tuberosity more than 3 mm, every specimen failed: 100% failure (exact 95% confidence interval 65.2-100% due to sample size). Movements of at least 1 cm were commonly observed. The sutures were loose but had never snapped. Sutures were noted to dig into the tendon and cut partially through bone. Collapse of cancellous bony volume led to looseness and migration of the sutures. CONCLUSION: Suture repair of tuberosities has mechanical weaknesses; failure may be a mechanical phenomenon.

Soft tissue coverage of the ankle: An algorithm for appropriate flap selection and the experiences of a newly established Major Trauma Network.

INTRODUCTION: Replication of the thin and pliable native skin around the ankle remains a challenge for plastic surgeons treating soft tissue defects in this region. Flap reconstruction constitutes the mainstay of management of such injuries. Subsequent management often entails revisional debulking surgery to permit normal footwear and an acceptable aesthetic outcome. In light of limited elective operating capacity throughout the covid-19 pandemic, we adopted an algorithm to inform reconstruction in such injuries and limit the need for revisional surgeries. This study presents this algorithm, which considers patient age, functional status, co-morbidities, body habitus and defect location. METHODS: Retrospective analysis of a prospectively maintained database of all patients undergoing lower limb soft tissue reconstruction over 21 months was performed. All flap-based reconstructions of ankle defects were included; direct closures and skin grafts were excluded. All trauma patients were managed via a combined orthoplastic approach as per BOA-BAPRAS standards. All patients had Computed Tomography Angiography prior to their definitive reconstruction. Lower Extremity Functional Scale (LEFS) scores were analysed for patients with over 12 months of postoperative follow up, where available. RESULTS: 71 flaps were performed in 69 patients. Open ankle fracture was the most common cause (86%); other indications included osteomyelitis and surgical wound dehiscence. Mean age was 50 (13-87 years) with a higher proportion of males to females (ratio 1.25:1). There were 26 pedicled flaps (18 Medial Plantar Artery and 8 Peroneus Brevis) and 45 free flaps (22 Anterolateral thigh, 11 Superficial Circumflex Iliac Artery Perforator, 11 Gracilis and 1 Medial Sural Artery Perforator). Mean follow-up is 13.6 months. There were three flap failures, and four patients subsequently underwent delayed below knee amputation despite successful soft tissue healing. For the patients with a minimum of 12 months follow up, LEFS scores with an average of 51% were achieved (range 15-88%). Four patients have been listed for revisional/debulking surgery. CONCLUSION: Although soft tissue defects around the ankle can be difficult to manage, with careful planning and addressing each patient individually, supported by an algorithmic approach, good functional and aesthetic outcomes can be achieved with low rates of secondary revision surgery.

Free flaps for lower limb soft tissue reconstruction - A systematic review of complications in 'Silver Trauma' patients.

BACKGROUND: There are 12.5 million people aged 65 years and older living in the UK. The annual incidence of open fracture is 30.7 per 10,000 person-years. In females, 42.9% of all open fractures occur in patients ≥ 65 years. METHODS AND MATERIALS: Preferred Reporting for Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study is registered with PROSPERO (CRD42020209149). The aim was to compare the complication profiles of free fasciocutaneous flaps and free muscular flaps in patients aged over 60 years undergoing lower limb soft tissue reconstruction following an open lower limb fracture. The search strategy based on strict inclusion criteria included PubMed, Embase and Google Scholar. RESULTS: 15 papers were identified, including 46 patients with 10 free fasciocutaneous flaps and 41 free muscle flaps. There were 3 complications in the fasciocutaneous group (30%) and 9 complications in the muscle group (22%). There was a total of 1 secondary procedure in the fasciocutaneous group and 4 in the muscle group. DISCUSSION: There is insufficient data to provide statistical comparison between free fasciocutaneous versus free muscle flaps for lower limb reconstruction performed in those aged over 60 years. This systematic review highlights evidence for the successful use of free tissue transfer in the older population following an open fracture injury and requiring lower limb reconstruction. There is no evidence to suggest the superiority of one tissue type over the other, with the inference that well vascularised tissue is the most significant factor impacting outcome.

Case Report: Revisiting the Internal Mammary Artery Perforator Flap: Salvage Option for Circumferential Pharyngo-Esophageal Defects.

Patients that present with pharyngeal strictures and pharyngocutaneous fistulas in the context of previous reconstruction and post-operative radiotherapy often report significant morbidity and reduction in quality of life. Reconstruction of such defects present a substantial clinical challenge requiring the importation of unirradiated vascularized tissue to facilitate healing in a friable, fibrotic, and vessel depleted tissue bed. The authors present a case report demonstrating an adaptation of the internal mammary artery perforator (IMAP) flap for reliable reconstruction of circumferential pharyngeal defects with primary tension free closure of the donor site. This technique avoids the use of free tissue transfer in a hostile, irradiated neck. The tubed IMAP flap is an excellent option, serving the purposes of reconstruction as well as addressing the patient's presenting issues of a chronic sinus and pharyngeal stricture inhibiting oral intake.

Measuring coagulation in burns: an evidence-based systematic review.

INTRODUCTION: Dynamic monitoring of coagulation is important to predict both haemorrhagic and thrombotic complications and to guide blood product administration. Reducing blood loss and tailoring blood product administration may improve patient outcome and reduce mortality associated with transfusion. The current literature lacks a systematic, critical appraisal of current best evidence on which clinical decisions may be based. OBJECTIVES: Establishing the role of different coagulation markers in burn patients, diagnosing coagulopathy, tailoring blood product administration and indicating prognosis. METHODS: Literature during 2004-2017 from the Cochrane Library, PubMed, Scopus, Medline and Embase was reviewed. Eligibility criteria included randomised controlled trials, systematic reviews, multi-/single-centre study and meta-analyses. Keywords searched were 'burns', 'blood coagulation disorders', 'rotem', 'blood coagulation' and 'thromboelastography'. The PRISMA flow system was used for stratification and the CASP framework for appraisal of the studies retrieved. RESULTS: In total, 13 articles were included after inclusion/exclusion criteria had been applied to the initial 79 studies retrieved. Hypercoagulation increases in proportion to the severity of thermal injury. Whole blood testing, using thrombelastography (TEG) and rotation thromboelastometry (ROTEM), was superior to standard plasma based tests, including prothrombin time (PT) and activated partial thromboplastin time (APTT) at detecting burn-related coagulopathies. CONCLUSIONS: Routine laboratory markers such as PT/APTT are poor indicators of coagulation status in burns patients. Viscoelastic tests, such as TEG and ROTEM, are efficient, fast and have a potential use in the management of burn patients; however, strong evidence is lacking. This review highlights the need for more randomised controlled trials, to guide future practice.

A novel method to correctly place the fasciotomy incision for decompression of the anterior and peroneal compartments of the leg.

UNLABELLED: Incorrectly placed fasciotomy incisions can lead to catastrophic complications in compartment syndrome. Two distinctly different techniques are widely practiced to decompress the anterior and peroneal compartments. In one technique the anterior compartment is decompressed directly, and then the peroneal via the inter-muscular septum, avoiding the peroneal perforators. The second technique relies on surface anatomy landmarks to place the skin incision immediately over the inter-muscular septum, and then the respective fascial envelopes are incised separately. A study in healthy active volunteers was conducted to explore the feasibility of a new technique for the placing the incision very accurately over the inter-muscular septum and so avoiding perforator vessels. Hypothesis The inter-muscular septum can be reliably identified using hand-held ultrasound, and confirmed with MRI. METHODS: Fourteen healthy active volunteers underwent hand-held ultrasound to identify the antero-lateral inter-muscular septum in the left lower limb, which was then marked using cod liver oil capsules. The positions of the anterior, septal and peroneal perforators were then identified using hand-held Doppler, and marked in the same way. MRI was then used to measure the relationship between the surface land marks, the septum (compared to its US position), and the relationship of the perforators themselves. RESULTS: Hand held ultrasound was successful in identifying the position of the inter-muscular septum in healthy volunteers, as confirmed on MRI scanning. The position and number of peroneal and anterior perforators proved very variable. Direct decompression of the anterior compartment would result in the loss of all anterior perforators in all subjects. Decompression with the skin incision over the inter-muscular septum would not jeopardise any peroneal muscular perforators. CONCLUSION: This new technique enables decompression both the anterior and peroneal compartments through an accurately placed incision, sparing the greatest number of perforators. Two brief case histories in which the technique was used are presented.

Long-term outcomes of microsurgical nasal replantation: review of the literature and illustrated 10-year follow-up of a pediatric case with full sensory recovery.

We present a case of successful artery only total nose replantation in an 18-month-old child, with 10 years of follow-up and full sensory recovery despite no nerve repair. The common absence of veins for anastomosis does not prevent successful replant, as demonstrated with the use of Hirudo medicinalis use in this unique case. We comprehensively review the literature of this rare and complex injury and advocate microsurgical replantation where possible over other methods of nasal reconstruction.

Basal cell carcinoma treated successfully with combined CO2 laser and photodynamic therapy in a renal transplant patient: a case report.

Renal transplant recipients are at significantly greater risk of developing skin malignancies due to combination immunosuppressive therapy. A significant number of patients present with lesions needing excision at multiple outpatient follow-up visits. For basal cell carcinoma, we have recently described how combining CO(2) laser with Photodynamic therapy greatly increases the efficacy of long-term tumour clearance compared with each modality alone. We present a case of a 66-year-old renal transplant therapy patient who repeatedly presents with new skin malignancies, in whom we treated successfully with Laser-Photodynamic therapy in a see-and-treat setting. This therapy offers patients the possibility of better cosmetic and functional results whilst obviating the need for repeated surgery. Other pre-cancerous lesions such as solar keratoses are prevalent in this patient group and respond extremely well to Photodynamic therapy monotherapy. We propose a regular clinic for renal transplant patients in a laser facility equipped with CO(2) laser and Photodynamic therapy, histopathology and punch-biopsy materials. This strategy allows simple and effective treatment of multiple lesions simultaneously, avoidance of numerous operations, avoidance of non-essential outpatient appointments that result in booking furthers visits for treatment, whilst facilitating diagnostic biopsies of potentially malignant lesions. We outline a care pathway for a see-and-treat clinic that implements this novel treatment modality improving the care of this unique patient population.