Targeted muscle reinnervation in managing post-amputation related pain: A systematic review and meta-analysis.

INTRODUCTION: Limb amputation can cause residual limb pain (RLP) and/or phantom limb pain (PLP). Although targeted muscle reinnervation (TMR) was initially introduced to facilitate the control of prosthetic limbs, it has been noted that these patients experience less pain and improved prosthetic functional outcomes. As a result, the use of TMR in managing neuroma-related RLP is increasing. The aim of this review is to assess the quality and strength of the evidence supporting the effectiveness of TMR in managing amputation-related pain. METHODS: Five different databases, including MEDLINE (PubMed), Scopus, Web of Science, Cochrane Library, and Embase, were searched from inception to March 2022. The protocol for this systematic review has been registered in the PROSPERO database (CRD42020218242). To be included, studies needed to compare pre- and postoperative pain outcomes or different techniques for adult patients who underwent TMR following amputation. Eligible studies also needed to use patient-reported outcome measures (PROMS) and be clinical trials or observational studies published in English. Excluded studies were case reports, case series, reviews, proof of concept studies, and conference proceedings. A meta-analysis was performed on studies that had similar intervention and control groups to examine treatment effects using a random-effects model. Studies were weighted using the inverse variance method, and a statistically significant p-value was considered to be less than or equal to 0.05. RESULTS: This review included five studies for qualitative analysis and four studies for quantitative analysis. Reviewed studies enrolled a total of 127 patients. The TMR group was compared with standard treatment at 12 months follow-up. The TMR group showed significantly better PLP as assessed by the numerical rating score RLP, and PLP assessed using Patient-Reported Outcomes Measurement Information System (PROMIS) also showed significantly lower pain intensity in the TMR group. CONCLUSION: There is limited evidence of good quality favoring TMR in reducing postamputation PLP and RLP pain compared with standard care. Randomized clinical trials are encouraged to compare the efficacy of different surgical techniques.

The perils of dressings: a cautionary tale of ischaemia.

A cohort of patients presented to Queen Victoria Hospital, UK, with iatrogenic toe ischaemia following application of a different, newly available post-procedure dressing with different properties to those usually used. This resulted in ischaemia with extensive skin and soft tissue damage, requiring debridement surgery and, in some cases, skin grafting. We aim to highlight the risk of morbidity from dressing application to the digits. This is a key learning skill for anyone who may either perform dressings or evaluate dressings on digits in the community and across multiple specialties in hospital. This article follows a thorough root cause analysis and addresses other possible causes of an acutely painful erythematous toe post-Zadek's procedure.

Our Definition of Propeller Flaps and Their Classification.

The term propeller flap was introduced for the first time by Hyakusoku to define an island flap, based on a subcutaneous pedicle hub, that was rotated 90 degrees to correct scar contractures due to burns. With the popularization of perforator flaps, the propeller movement was applied for the first time to a skin island vascularized only by an isolated perforator, and the terms propeller and perforator flap were used together. Thereafter, the surgical technique of propeller flaps evolved and new applications developed. With the "Tokyo consensus," we proposed a definition and a classification schema for propeller flaps. A propeller flap was defined as an "island flap that reaches the recipient site through an axial rotation." The classification included the SPP (SPP) flap, the perforator pedicled propeller (PPP) flap, and the supercharged PPP (SCP) flap. A recent update added a new category, the axial pedicled propeller (APP) flap. Here we propose our updated and comprehensive classification of propeller flaps, taking into account the previous classification and subsequent publications. Based on their vascular pedicle, we consider the following five types of propellers: (1) SPP flap, 2.PPP flap, its subtype (2a) SCP flap, (3) APP flap, (4) muscle propeller flap, and (5) chimeric propeller flap. The variables that can be taken into account in the classification are as follows: type of nourishing pedicle, degrees of skin island rotation, position of the nourishing pedicle, artery of origin of the pedicle, and flap shape.

The Role of Military Plastic Surgeons in the Management of Modern Combat Trauma: An Analysis of 645 Cases.

BACKGROUND: Plastic surgery has historically been linked to war. Between 2008 and the end of combat operations in Afghanistan in 2014, British military plastic surgeons formed part of the multinational military surgical team at the Role 3 Medical Treatment Facility, Camp Bastion, Helmand Province. The present study aimed to analyze the activity of these surgeons objectively and to determine the utility of their deployment. METHODS: Data were gathered prospectively from four periods (2009 to 2012). This coincided with different surgeons, types of combat activity, wounding patterns, and mission emphases for the hospital. Various metrics were employed. RESULTS: Plastic surgeons were involved in 40 percent of surgical cases (645 of 1654). This was consistent, despite changes in the predominant wounding mechanism and casualty population. One-third of cases involved the plastic surgeon as the lead or sole surgeon and two-thirds involved working with surgeons from other disciplines. Caseload by anatomical region was as follows: hand and upper limb, 64 percent; head and neck, 46 percent; lower limb, 40 percent; and trunk, 25 percent. A median of 1.75 body areas were operated on per patient. Involvement did not differ between patients wearing combat body armor when injured and those who were not. CONCLUSIONS: Plastic surgeons played a significant role in the management of modern military trauma. This reflects the types of injuries sustained and the expertise of military plastic surgeons complementing the skill set of the other surgical team members. The level of activity was independent of wounding patterns, suggesting that the specialty may be useful, irrespective of the nature of the conflict.

Evidence based management for paediatric burn: new approaches and improved scar outcomes.

Little evidence has been produced on the best practice for managing paediatric burns. We set out to develop a formal approach based on the finding that hypertrophic scarring is related to healing-time, with durations under 21 days associated with improved scar outcome. Incorporating new advances in burn care, we compared outcomes under the new approach to a cohort treated previously. Our study was a retrospective cross-sectional case note study, with demographic, treatment and outcome information collected. The management and outcome of each case was assessed and compared against another paediatric burns cohort from 2006. 181 burns presenting across a six month period were analysed (2010 cohort) and compared to 337 children from a previous cohort from 2006. Comparison of patients between cohorts showed an overall shift towards shorter healing-times in the 2010 cohort. A lower overall rate of hypertrophic scarring was seen in the 2010 cohort, and for corresponding healing-times after injury, hypertrophic scarring rates were halved in comparison to the 2006 cohort. We demonstrate that the use of a structured approach for paediatric burns has improved outcomes with regards to healing-time and hypertrophic scarring rate. This approach allows maximisation of healing potential and implements aggressive prophylactic measures.

The tertiary management of pretibial lacerations.

Pretibial lacerations remain one of the commonest yet most neglected conditions facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to have an approach to pretibial lacerations based on best available evidence, in order to optimize wound outcomes, but perhaps more importantly, to safeguard the general health of the vulnerable individual. We present an evidence-based approach to the tertiary management of these injuries and propose a treatment algorithm that we have utilized in our unit to successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner.

The "Tokyo" consensus on propeller flaps.

BACKGROUND: Over the past few years, the use of propeller flaps, which base their blood supply on subcutaneous tissue or isolated perforators, has become increasingly popular. Because no consensus has yet been reached on terminology and nomenclature of the propeller flap, different and confusing uses of the term can be found in the literature. METHODS: In this article, the authors report the consensus on the definition and classification of propeller flaps reached by the authors that gathered at the First Tokyo Meeting on Perforator and Propeller Flaps in June of 2009. Some peculiar aspects of the surgical technique are discussed. RESULTS: A propeller flap can be defined as an "island flap that reaches the recipient site through an axial rotation." The classification is based on the nourishing pedicle (subcutaneous pedicled propeller flap, perforator pedicled propeller flap, supercharged propeller flap), the degrees of skin island rotation (90 to 180 degrees) and, when possible, the artery of origin of the perforator. CONCLUSIONS: The propeller flap is a useful reconstructive tool that can achieve good cosmetic and functional results. A flap should be called a propeller flap only if it fulfils the definition above. The type of nourishing pedicle, the source vessel (when known), and the degree of skin island rotation should be specified for each flap.

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine.

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.

Pediatric superficial scald burns--reassessment of our follow-up protocol.

The most common pediatric burn injury is a superficial scald. The current follow-up protocol for such burns includes review of the patient at 2 weeks postinjury and then 2 months later. The authors decided to review the protocol to assess the need for this second follow-up. A retrospective study reviewed the case notes of patients younger than 16 years at the time of their injury presenting with a scald over 5% TBSA. The progress of healing and scar development up to 5 years follow-up was assessed. This study showed that scalds healing within 2 weeks following injury rarely became hypertrophic. A prospective study was performed over a 10-month period. All children who suffered a superficial partial-thickness scald injury were included. At the 2-week appointment, the need for further follow-up was predicted. The accuracy of this prediction was assessed 2 months later. This study showed that an experienced member of the burns team could reliably predict at 2-week appointment those children who could be safely discharged with no subsequent need for scar management. This study suggests that it will be safe to modify the follow-up protocol, reducing the number of clinic attendances.

The impact of recent legislation on paediatric fireworks injuries in the Newcastle upon Tyne region.

Despite the changes to the UK fireworks laws and considerable efforts in prevention, children are still being injured by fireworks. The UK is one of many countries that have altered their firework laws in recent years. We reviewed 54 firework-injured children over the last 10 years and assessed the impact of the two recent UK law changes. Our study outlines past British firework legislation and reviews the literature. In November 1996, there were three deaths in England, Wales and Scotland due to fireworks. The British Government introduced the Fireworks (Safety) Regulations of 1996/1997, primarily banning banger fireworks (known as bangers). We have not seen banger injuries in Newcastle since then. The Fireworks Act 2003 and the Fireworks Regulations 2004 limited the sale of fireworks to the 3 weeks surrounding bonfire night, and banned under 18s from purchasing or possessing fireworks. In our series, we noticed that, in 2004, 83% of children's firework injuries happened in the 3 weeks surrounding Bonfire Night. We conclude that legislation has had an impact, but stricter enforcement of the existing laws and further education of children and the general public into the dangers of fireworks is needed, as children are still being injured.

Evidence for the link between healing time and the development of hypertrophic scars (HTS) in paediatric burns due to scald injury.

The relationship between burn depth, healing time and the development of hypertrophic scarring (HTS) is well recognised by burn surgeons but is seldom mentioned in the published literature. We studied 337 children with scalds whose scars were monitored for up to 5 years. Overall HTS rates were found to be: under 10 days to healing=0%, 10-14 days=8%, 15-21 days=20%, 22-25 days=40%, 26-30 days=68% and over 30 days=92%. In the conservatively treated group the HTS rates are: under 10 days=0%, 10-14 days=2%, 15-21 days=20%, 22-25 days=28%, 26-30 days=75% and over 30 days=94%. If skin grafting is undertaken there is a much higher incidence of HTS in the 10-14 days group: 10-14 days=33%, 15-21 days=19%, 22-25 days=54%, 26-30 days=64% and over 30 days=88%. We conclude that there is a low risk of HTS formation in scalds healed before 21 days, and that surgery should be reserved for scalds likely to take more than 21 days to heal.