A Prospective Study to Examine Responsiveness and Minimally Important Differences (MIDs) for the CLEFT-Q Scales Following Three Cleft-Specific Operations.

The aim of this study was to examine internal responsiveness and estimate minimally important differences (MIDs) for CLEFT-Q scales.In this prospective cohort study, participants completed the CLEFT-Q appearance and health-related quality of life (HRQL) scales before and six months after cleft-related surgery.Seven cleft centres in Canada, USA and UK participated.Patients were ages 8-29 years with CL/P.Patients underwent rhinoplasty, orthognathic or cleft lip scar revision surgery.Internal responsiveness was examined using Cohen's d effect sizes (ESs) based on the following interpretation: 0.20-0.49 small, 0.50-0.79 moderate and ≥ 0.80 large. MIDs were estimated using two distribution-based approaches.Participants had a rhinoplasty (n = 31), orthognathic (n = 21) or cleft lip scar revision (n = 18) surgery. Most participants were males (56%) and aged 8-11 years (41%). Following rhinoplasty, ESs were larger for the nose (0.92, p = 0.001) and nostrils (0.94, p < 0.001) scales than for the face scale (0.51, p = 0.003). MIDs ranged between 6.2-10.4. For orthognathic surgery, larger ES was observed for the jaws scale (1.80, p < 0.001) compared with the teeth (1.16, p < 0.001), face (1.15, p = 0.001) and lips (0.94, p < 0.001) scales. MIDs ranged between 5.9-14.4. In the cleft lip scar revision sample, the largest ES was observed for the nose scale (0.76, p = 0.03), followed by lips (0.58, p = 0.009) and cleft lip scar (0.50, p = 0.043) scales. MIDs ranged between 6.4-12.3.CLEFT-Q detected change in key outcomes for three cleft-specific surgeries, providing evidence of its responsiveness. Estimated MIDs will aid in interpreting this PROM.

Outcome of reconstruction of cutaneous limb defects in dogs using hygroscopic "self-inflating" tissue expanders.

OBJECTIVES: To describe the placement of self-inflating tissue expanders and clinical outcomes in 12 consecutive cases of reconstruction of distal cutaneous limb defects in dogs. MATERIALS AND METHODS: Cases of distal cutaneous limb defect were divided into three groups based on the location of the placement of the self-inflating tissue expanders: Group A (n=4): on, or proximal to, the elbow and stifle; Group B (n=4): distal to the elbow or stifle and proximal to the carpus or tarsus; and Group C (n=4): distal to the carpus or tarsus. Owner satisfaction and clinical outcome were documented. RESULTS: Thirteen cases were originally included, but one was excluded because of incomplete follow-up. In one case, the self-inflating tissue expanders were removed before expansion started. A mean of five expanders were implanted per dog (range 2 to 9). Devices were removed after a mean of 24 days (range 13 to 42 days). Primary closure was achieved in eight of 11 cases, including all cases from Group A and 75% and 33% of cases from Groups B and C, respectively. All incompletely reconstructed defects or areas of wound dehiscence healed by second intention. Eight of 12 owners were satisfied. CLINICAL SIGNIFICANCE: Self-inflating tissue expanders can be used as an alternative for the reconstruction of limb defects in dogs in which direct primary closure would otherwise not be achievable. Defects below the carpus and tarsus are more challenging to treat with this method.

Sentinel node status predicts survival in thick melanomas: the Oxford perspective.

AIMS: To determine the prognostic value of SLNB in patients with thick melanoma in terms of overall survival (OS) and recurrence-free survival (RFS). METHODS: 136 patients with primary tumours (Breslow thickness ≥ 4.0 mm) underwent SLNB. OS and RFS were calculated and a multivariate Cox regression model used to determine the important prognostic factors for predicting OS and RFS. RESULTS: Median Breslow thickness was 5.5 mm and 60% were ulcerated. Median follow up was 4 years (95% CI = 4-5) with 54 patients having died at the time of analysis. 5-year OS for SLNB positive patients was 32%, compared to 78% for negative patients. The significant predictors of poorer OS were increasing age (p = 0.03), increasing Breslow thickness (p = 0.03) and SLNB positivity (p < 0.0001). 5 year RFS was significantly worse in the SLNB positive population compared to the negative patients (p < 0.0001); 27% versus 66% respectively. CONCLUSIONS: Patients with a thick melanoma and a positive SLNB have a significantly worse RFS and OS compared to those with a negative SLNB. Over three-quarters of patients with a negative SLNB survived five years. These findings have implications for the subpopulations included in adjuvant therapy trials and we advocate SLNB be recommended in patients with thick melanomas.

Randomized controlled trial of fibrin sealant to reduce postoperative drainage following elective lymph node dissection.

BACKGROUND: Excessive postoperative drainage following groin and axillary lymphadenectomy may be associated with a prolonged hospital stay and an increased complication rate. The use of fibrin sealant before wound closure may reduce postoperative wound drainage. METHODS: Consecutive patients undergoing elective groin or axillary lymphadenectomy were randomized to standard wound closure or to having fibrin sealant sprayed on to the wound bed before closure. Postoperative wound drainage, duration of drainage and complications were recorded, as were locoregional recurrence, distant metastasis and mortality. RESULTS: A total of 74 patients requiring 38 groin and 36 axillary dissections were randomized. The median postoperative wound drainage volume for the groin dissection cohort was 762 (range 25-3255) ml in the control group and 892 (265-2895) ml in the treatment group (P = 0·704). Drainage volumes in the axillary cohort were 590 (230-9605) and 565 (30-1835) ml in the control and treatment groups respectively (P = 0·217). There was no difference in the duration of drainage or postoperative complication rate between the treatment groups in both the axillary and groin cohorts. Local recurrence, distant metastasis and mortality rates did not differ between the treatment groups. CONCLUSION: There was no advantage in using fibrin sealant during elective lymphadenectomy in terms of reducing drainage output or postoperative complication rate.

Synthesis and properties of a novel anisotropic self-inflating hydrogel tissue expander.

The advent of self-inflating hydrogel tissue expanders heralded a significant advance in the reconstructive techniques available for the surgical restoration of a wide variety of soft tissue defects. However, their use in specific applications such as cleft palate surgery is limited on account of their isotropic expansion. An anisotropic self-inflating hydrogel tissue expander has been developed which markedly increases the potential indications for which this restorative tool may be employed. These include complex pediatric soft tissue reconstructions of the palate, nose, ear and digits. Anisotropic expansion in a hydrogel polymer network composed of methyl methacrylate and vinylpyrrolidone has been achieved by annealing the xerogel under a compressive load for a specified time period. By controlling the anisotropic processing conditions and composition we have been able to accurately tailor the ultimate expansion ratio up to 1500%. The expansion rate of the xerogel has also been significantly reduced by encapsulating the polymer within a semi-permeable silicone membrane. The structure and properties of the novel anisotropic hydrogel were characterized by attenuated total reflectance infrared spectroscopy, differential scanning calorimetry, thermogravimetric analysis and small-angle neutron scattering.

Congenital absence of flexor digitorum superficialis: implications for assessment of little finger lacerations.

Absence of flexor digitorum superficialis function in the little finger is a relatively common congenital anomaly that can complicate assessment of little finger injuries. We reviewed the prevalence of unilateral and bilateral absence of superficialis function in the published literature. In appropriate studies identified (1352 people), the anomaly was unilateral in 92 individuals (6.8%) and bilateral in 81 (6.0%). If superficialis function is absent in one little finger, the probability of absence in the opposite hand is 0.64. If superficialis function is present, the probability of absence in the other little finger is 0.02 (1 in 50). Absence of little finger superficialis function in one hand is therefore not a reliable indicator of this function in the opposite hand.

Poland syndrome with dextrocardia: case report.

Poland syndrome is a rare congenital condition presentingwith typical features including an absent costosternal head of pectoralis major andipsilateral brachysyndactyly. There are many clinical variations of the syndrome including rib defects, absence of shoulder girdle muscle and breast hypoplasia or agenesis. Dextrocardia is rarely associated with Poland Syndrome with only 22 cases being previously reported in the worldwide literature. Whereas 'classical' Poland syndrome is predominantly right sided, all cases associated with dextrocardia have been left sided. We report a further case of left sided Poland syndrome with dextrocardia which might have important implications for the understanding of the pathogenesis of this unusual condition.

Morbidity at the iliac crest donor site following bone grafting of the cleft alveolus.

We retrospectively analysed all cases of iliac crest bone graft harvest for secondary grafting of the cleft alveolus during an 11-year period. The case notes were reviewed and postal questionnaires sent to all patients. Of 73 consecutive patients, 57 (78%) were male, and the mean (S.D.) age at operation was 10 (1) years. A completed questionnaire was received from 72 patients (99%). The median stay in hospital was 3 days (range 2-5). The median time until the child could walk "normally" was 7 days (range 0-56). Thirty-seven patients (51%) had a postoperative limp, which resolved after a median of 7 days (range 3-56). There were two (3%) superficial donor site infections. The median length of scar was 60mm (range 40-100) and patient satisfaction was high, with a median visual analogue scale of 9/10 (range 2-10). Harvesting bone from the iliac crest for alveolar bone grafting is well tolerated by patients, has few important complications, and gives an aesthetically acceptable scar at the donor site.

Generation and propagation of a picosecond acoustic pulse at a buried interface: time-resolved x-ray diffraction measurements.

We report on the propagation of coherent acoustic wave packets in (001) surface oriented Al0.3Ga0.7As/GaAs heterostructure, generated through localized femtosecond photoexcitation of the GaAs. Transient structural changes in both the substrate and film are measured with picosecond time-resolved x-ray diffraction. The data indicate an elastic response consisting of unipolar compression pulses of a few hundred picosecond duration traveling along [001] and [001] directions that are produced by predominately impulsive stress. The transmission and reflection of the strain pulses are in agreement with an acoustic mismatch model of the heterostructure and free-space interfaces.

The open abdomen: aetiology, classification and current management strategies.

A new classification system has been devised for open abdominal wounds. This will help identify an appropriate management strategy, and indicate the associated morbidity and outcome. In all cases, early intervention is vital.

Late recurrence of dermatofibrosarcoma protuberans in the female breast: a case report.

The case presented is of a 39-year-old female who, at the age of 13 years, had had a "dermatofibroma" excised from her left breast. Twenty-six years later she developed an unsightly "stretched scar". Excision biopsy demonstrated a dermatofibrosarcoma protuberans (DFSP). This was managed by wide local excision, preservation of the nipple-areolar complex, and immediate reconstruction with a pedicled latissimus dorsi flap. Review of the original histology confirmed the presence of DFSP, revising the original diagnosis. Most DFSPs recur within 3 years of primary excision. Such prolonged latency prior to recurrence has not been previously described. This reinforces the need to educate patients regarding the importance of long-term scar surveillance following skin tumour excision.

Clinical experience with end-to-side nerve transfer.

A retrospective study was undertaken to determine the effectiveness of end-to-side nerve transfer. Twenty patients with peripheral nerve lesions of varying aetiology underwent 23 end-to-side nerve transfers over a 15-month period. The mean patient age was 30 years and 18 were male. The mean delay in presentation was 2.4 months. All underwent end-to-side nerve repairs and were reviewed in outpatients at regular intervals. Ten patients were lost to follow-up before 12 months and were therefore excluded from the study. The remaining ten patients, who had undergone 13 end-to-side procedures, had a mean follow-up period of 16 months. None demonstrated objective evidence of motor recovery at the end of the study period. Four patients had modest recovery of deep protective sensation, and two patients suffered a subtle degree of "donor" nerve morbidity. We have abandoned this technique in our centre in preference for standard nerve grafting techniques.

One in 13 'original' articles in the Journal of Bone and Joint Surgery are duplicate or fragmented publications.

Duplicate publication in orthopaedic journals may further an author's academic career but this is at the cost of both scientific integrity and knowledge. Multiple publications of the same work increase the workload of editorial boards, misguide the reader and affect the process of meta-analysis. We found that of 343 'original' articles published in the Journal of Bone and Joint Surgery in 1999, 26 (7.6%) had some degree of redundancy. The prevalence of duplicate publications in the orthopaedic literature appears to be less than that in other surgical specialties but it is still a matter of concern. It is the author's responsibility to notify the editor of any duality when submitting a paper for publication.

Malignant melanoma in South Africans of mixed ancestry: a retrospective analysis.

Little is known about the behaviour of melanoma in patients of mixed ancestry. A retrospective analysis of 844 consecutive patients presenting with melanoma over a 12-year period was performed. Forty patients (4.8%) were of mixed ancestry. The data evaluated included patient age, gender, delay in presentation, presenting stage, anatomical distribution, histology, management and outcome. The mean age at presentation was 52.8 years. Twenty-seven patients were female. The mean delay in presentation was 1.54 years. Seventy per cent of melanomas were confined to the extremities, of which one-third were plantar in origin. The most common histological variant, affecting 13 patients (32.5%), was acral lentiginous melanoma; 12.5% of patients presented with in situ (Stage 0) disease, 17.5% with Stage I disease, 22.5% with Stage II disease, 27.5% with Stage III disease and 7.5% with Stage IV disease. Twenty-seven patients (67.5%) remained alive at the end of the study after a median follow-up of 5.58 years, whilst 11 (27.5%) died after a median of 2.42 years. The median survival was 3.92 years. Although the histological type and anatomical distribution reflect the disease pattern of black populations, the overall 5-year survival of 74% is similar to that seen in white populations. An education programme is needed to improve melanoma awareness in mixed race populations.