Graftless Syndactyly Release.

Syndactyly release aims to address skin deficits by resurfacing web spaces and sides of digits to allow independent digital motion while minimizing the risk of web creep and scar contractures. Conventional methods include the use of a dorsal and interdigitating flaps with full-thickness skin grafts. More recently, there have been several descriptions of "graftless" syndactyly release without skin grafts, thus avoiding a further (usually distant) donor site. However, the indications of when and when not to use these techniques remain unclear. In addition, the inevitable scarring from extra recruitment of local adjacent skin is perhaps underemphasized. In this article, we revisit the trilobed flap technique which serves to balance the amount of skin needed for resurfacing digits while minimizing local donor site scarring. The geometry and nuances of the flap inset are illustrated in detail to guide those embarking on this technique. The trilobed syndactyly release technique is a reproducible, safe, and reliable method for the release of simple syndactyly.

Successful Delayed Neurolysis of the Median Nerve in a Teenager 7 years After Supracondylar Fracture: A Case Report and Review of the Literature.

ABSTRACT: Supracondylar humeral fractures are the commonest elbow fractures in childhood, associated with a high rate of neurological complications. We present the case of a 14-year-old adolescent girl with persisting daily pain, lack of sensation, and strength to her left hand after a displaced supracondylar fracture 7 years earlier. At the time of the fracture, she underwent closed reduction and percutaneous Kirschner wire fixation. During revision surgery, half of the median nerve was found embedded in bone at the level consistent with the healed fracture site. Neurolysis of the fascicles adherent to the bone was performed. Postoperatively, the patient had complete recovery of sensation, reduced pain, and a 2.5-fold improvement of grip strength. This case shows that there is a role for delayed neurolysis in children.

Multidisciplinary management of anal intraepithelial neoplasia and rate of progression to cancer: A retrospective cohort study.

PURPOSE: To describe the regional burden of AIN and rate of progression to cancer in patients managed in specialist and non-specialist clinic settings. METHODS: Patients with a histopathological diagnosis of AIN between 1994 and 2018 were retrospectively identified. Clinicopathological characteristics including high-risk status (chronic immunosuppressant use or HIV positive), number and type of biopsy (punch/excision) and histopathological findings were recorded. The relationship between clinicopathological characteristics and progression to cancer was assessed using logistic regression. RESULTS: Of 250 patients identified, 207 were eligible for inclusion: 144 from the specialist and 63 from the non-specialist clinic. Patients in the specialist clinic were younger (<40 years 31% vs 19%, p = 0.007), more likely to be male (34% vs 16%, p = 0.008) and HIV positive (15% vs 2%, p = 0.012). Patients in the non-specialist clinic were less likely to have AIN3 on initial pathology (68% vs 79%, p = 0.074) and were more often followed up for less than 36 months (46% vs 28%, p = 0.134). The rate of progression to cancer was 17% in the whole cohort (20% vs 10%, p = 0.061). On multivariate analysis, increasing age (OR 3.02, 95%CI 1.58-5.78, p < 0.001), high risk status (OR 3.53, 95% CI 1.43-8.74, p = 0.006) and increasing number of excisions (OR 4.88, 95%CI 2.15-11.07, p < 0.001) were related to progression to cancer. CONCLUSION: The specialist clinic provides a structured approach to the follow up of high-risk status patients with AIN. Frequent monitoring with specialist assessments including high resolution anoscopy in a higher volume clinic are required due to the increased risk of progression to anal cancer.

Acute type A aortic dissection in-hours versus out-of-hours: A systematic review and meta-analysis.

OBJECTIVE: We sought to compare clinical outcomes in patients with acute type A aortic dissection that undergone surgical repair during in-hours (IH) versus out-of-hours (OOH). METHODS: An electronic literature search was done till March 2020 to include studies with comparative cohorts of IH versus OOH. Primary outcomes were 30-day mortality, stroke, and reoperation for bleeding; secondary outcomes were acute kidney injury, total hospital stay, and intensive care unit stay. RESULTS: Six articles with a total of 3744 patients met the inclusion criteria. Mean age was similar, 60 ± 12 versus 60 ± 13 in IH versus OOH (p = .25). Aortic root and total arch replacement were similar in both cohorts, 22% in IH versus 25% in OOH (risk ratio [RR], 1.10; 95% confidence interval [CI: 0.78, 1.55]; p = .58) and 29% in IH versus 32% in OOH (RR, 0.96; 95% CI [0.89, 1.04], p = .37) respectively. Reoperation for bleeding and stroke rate were similar, with 18% in IH versus 23% in OOH (RR, 0.89; 95% CI [0.73, 1.08]; p = .24), and 12% in IH versus 13% in OOH (RR, 0.83; 95% CI [0.66, 1.03]; p = .09) respectively. Thirty-day mortality was significantly lower in IH (RR, 0.81; 95% CI [0.72, 0.90]; p = .0001). CONCLUSION: There was higher 30-day mortality rate during OOH surgery, yet this difference diminished following sensitivity analysis. There were no significant differences in major postoperative outcomes. Therefore, operating on such cases should be decided on clinical priority without delay.