Radiological evaluation before and after treatment with an osseointegrated bone-anchor following major limb amputation-a guide for radiologists.

Osseointegrated implants have been developed to allow direct skeletal fixation of a prosthesis as an alternative to traditional socket-fitted prostheses for patients who have suffered from a major limb amputation. The implants contribute to improvements in functional outcome and quality of life and radiological evaluation plays a crucial role in pre- and post-operative assessment. This article acts as a guide for radiologists who may be tasked with providing the radiological information required by surgeons and prosthetists. We also look at the radiological appearances of complications that may arise in patients treated with an osseointegrated implant. Plain X-rays are used to screen patients who wish to undergo treatment. Limb-length X-rays are then used to measure the length of any residual bone, and comparisons can be made with the normal side (if present). From this, decisions about the likely size of the implant and the need for further amputation can be made. CT scans enable accurate assessment of the medullary cavity and cortical thickness. Post-operatively, plain X-rays form the mainstay of the routine monitoring of the bone-implant interface. Potential complications include infection, aseptic loosening, mechanical fracture of the implant and periprosthetic fracture. Infection and aseptic loosening can be seen as a lucency at the bone-implant interface which (if left untreated) can lead to loss of the implant. Implant and periprosthetic fractures are radiographically obvious. Radiologists involved in the care of patients undergoing treatment with an osseointegrated implant should become familiar with the imaging requirements so they can contribute to optimal patient outcomes.

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair.

INTRODUCTION: Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial. METHODS AND ANALYSIS: WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates. ETHICS AND DISSEMINATION: Ethical approval was obtained from the London-City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks. TRIAL REGISTRATION NUMBER: ISRCTN identifier: 15052559.

Topical Transplantation of Bone Marrow Mesenchymal Stem Cells Made Deeper Skin Wounds Regeneration.

Current wound healing models generally employ full-thickness or irregular split wounds. Consequently, assessing the type of healing at varying wound depths and determining the deepest level at which wounds can regenerate has been a challenge. We describe a wound model that allows assessment of the healing process over a continuous gradient of wound depth, from epidermal to full-thickness dermal loss. Further, we investigate whether green fluorescent protein-labeled bone marrow mesenchymal stem cells (BM-MSCs/GFP) transplantation could regenerate deeper wounds that might otherwise lead to scar formation. A wound gradient was created on the back of 120 Sprague Dawley rats, which were randomized into the BM-MSCs/GFP and control group. These were further subdivided into 6 groups where terminal biopsies of the healing wounds were taken at days 1, 3, 5, 7, 14, and 21 post-operatively. At each observed time point, the experimental animals were anesthetized and photographed, and depending on the group, the animals euthanized and skin taken for rapid freezing, haemotoxylin and eosin staining, and vascular endothelial growth factor (VEGF) immunohistochemistry. We found the deepest layer to regenerate in the control group was at the level of the infundibulum apex, while in the BM-MSCs/GFP group this was deeper, at the opening site of sebaceous duct at hair follicle in which had the appearance of normal skin and less wound contraction than the control group (P value less than .05). The expression of VEGF in BM-MSCs/GFP group was higher than that in control group (P value less than .05). The number of vessels increased from 2.5 ± 0.2/phf of control group to 5.0 ± 0.3/phf of BM-MSCs/GFP (P value less than .05). The progressively deepening wound model we described can identify the type of wound repair at increasing depths. Further, topical transplantation of BM-MSCs/GFP significantly improved regeneration of deeper wounds from infundibulum apex (maximum depth of control group regeneration) to the opening site of sebaceous duct at hair follicle level.

Les modèles actuels de cicatrisation des plaies font généralement appel à des plaies pleine épaisseur ou de forme irrégulière. Il est donc difficile d'évaluer le type de cicatrisation à diverses profondeurs et de déterminer la profondeur maximale à laquelle les plaies se régénèrent. Les auteurs décrivent un modèle de plaie qui permet d'évaluer le processus de cicatrisation d'après un gradient continu de la profondeur de plaie, entre la perte épidermique et la perte dermique pleine épaisseur. Ils ont également examiné si la transplantation de cellules souches mésenchymateuses marquées de protéines fluorescentes vertes (BM-MSCs/GFP) peut régénérer des plaies plus profondes qui formeraient autrement des cicatrices. Les chercheurs ont créé un gradient de plaie sur le dos de 120 rats Sprague-Dawley divisés de manière aléatoire entre le groupe BM-MSCs/GFP et le groupe témoin. Ils ont ensuite subdivisé ces deux groupes en six groupes, dans lesquels ils ont prélevé des biopsies terminales des plaies en voie de cicatrisation les 1er, 3e, 5e, 7e, 14e et 21e journées après l'opération. À chaque journée d'observation, ils ont anesthésié et photographié les animaux expérimentaux et, selon le groupe, les ont euthanasiés et en ont prélevé la peau en vue de leur congélation rapide, de leur coloration HE et de l'immunohistochimie VEGF. Les chercheurs ont découvert que l'apex infundibulum était la couche la plus profonde à se régénérer dans le groupe témoin, mais que dans le groupe BM-MSCs/GFP, la régénération était plus profonde, à l'entrée du follicule pileux dans la glande sébacée, a repris l'apparence de la peau normale et se contractait moins que dans le groupe témoin (p<0,05). L'expression du VEGF dans le groupe BM-MSCs/GFP était plus élevée que dans le groupe témoin (valeur p inférieure à 0,05). Le nombre de vaisseaux observé était de 2,5±0,2/phf dans le groupe témoin et de 5,0±0,3/phf dans le groupe BM-MSCs/GFP (p<0,05). Le modèle de plaie de plus en plus profonde peut déterminer le type de réparation selon la profondeur. De plus, la transplantation topique de BM-MSCs/GFP améliore considérablement la régénération des plaies plus profondes, qui passe de l'apex de l'infundibulum (profondeur de régénération maximale dans le groupe témoin) à l'entrée du follicule pileux dans la glande sébacée.

A consecutive series of targeted muscle reinnervation (TMR) cases for relief of neuroma and phantom limb pain: UK perspective.

BACKGROUND: Studies have suggested that targeted muscle reinnervation (TMR) can improve symptoms of neuroma pain (NP) and phantom limb pain (PLP) in patients. OBJECTIVES: Our primary objective was to measure changes in NP and PLP levels following TMR surgery at 4-time points (baseline, 3, 6- and 12-months postoperatively). Secondary aims included identification of the character and rate of any surgical complications and patients' satisfaction with TMR. METHODS: A retrospective review of outcomes of 36 patients who underwent TMR surgery to treat intractable NP and/or PLP after major amputation of an upper (UL) or lower limb (LL) at a single centre in London, UK over 7 years. The surgical techniques, complications, and satisfaction with TMR are described. RESULTS: Forty TMR procedures were performed on 36 patients. Thirty patients had complete data for NP and PLP levels at all pre-defined time points. Significant improvements (p<0.01) in both types of pain were observed for both upper and LL amputees. However, there were varying patterns of recovery. For example, UL amputees experienced worsening of PLP in the first few months post-operatively whereas surgical complications were more common in LL cases. Patients were overwhelmingly satisfied with the improvements in their symptoms (90%). CONCLUSIONS: TMR surgery appeared to relieve both NP and PLP although the retrospective nature of this study limits the strength of this conclusion. However, complication rates were high, and it is crucial for surgeons and patients to fully understand the course and outcomes of this novel surgery prior to undertaking treatment.

Hard-wired Epimysial Recordings from Normal and Reinnervated Muscle Using a Bone-anchored Device.

A combined approach for prosthetic attachment and control using a transcutaneous bone-anchored device and implanted muscle electrodes can improve function for upper-limb amputees. The bone-anchor provides a transcutaneous feed-through for muscle signal recording. This approach can be combined with targeted muscle reinnervation (TMR) to further improve myoelectric control. METHODS: A bone-anchored device was implanted trans-tibially in n = 8 sheep with a bipolar recording electrode secured epimysially to the peroneus tertius muscle. TMR was carried out in a single animal: the peroneus tertius was deinnervated and the distal portion of the transected nerve to the peroneus muscle was coapted to a transected nerve branch previously supplying the tibialis anterior muscle. For 12 weeks (TMR) or 19 weeks (standard procedure), epimysial muscle signals were recorded while animals walked at 2 km·h-1. RESULTS: After 19 weeks implantation following standard procedure, epimysial recording signal-to-noise ratio (SNR) was 18.7 dB (± 6.4 dB, 95% CI) with typical recordings falling in the range 10-25 dB. Recoveries in gait and muscle signals were coincident 6 weeks post-TMR; initial muscle activity was identifiable 3 weeks post-TMR though with low signal amplitude and signal-to-noise ratio compared with normal muscle recordings. CONCLUSIONS: Following recovery, muscle signals were recorded reliably over 19 weeks following implantation. In this study, targeted reinnervation was successful in parallel with bone-anchor implantation, with recovery identified 6 weeks after surgery.

Functional Outcome After Reconstruction of Traumatic Soft Tissue Defects in the Lower Half of the Leg With Distally Based Medial Hemisoleus Muscle Flaps: A Case Series and Literature Review.

BACKGROUND: Data regarding donor-site morbidity, postoperative clinical course, and functional outcome after hemisoleus muscle flap reconstruction are rare. The aim of this study was to determine the clinical and functional outcome of distally based medial hemisoleus flaps used for the reconstruction of defects in the lower half of the leg. METHODS: Data regarding 31 patients who underwent medial hemisoleus flap reconstruction between 2011 and 2017 were analyzed retrospectively. Epidemiological data and data on clinical outcomes and complications were obtained from hospital records. Functional outcome data were recorded in 14 cases. RESULTS: All soft tissue defects were secondary to trauma; 90.3% were male and 9.7% were female. Mean age was 52 years (range, 16-77 years). Mean defect size was 48 ± 9.5 cm. Flap survival was complete in 29 patients and partial in 2 patients. The maximal plantar flexion force in the ankle joint of the operated leg was 78.1% (P < 0.05) compared with the unaffected side. Strength endurance was reduced by 16.5% (P < 0.05) in the operated leg compared with the unaffected side. CONCLUSIONS: Medial hemisoleus flaps should be included in the armamentarium for reconstruction of small to middle traumatic lower leg defects. They are quick to raise and inset and provide robust coverage. Although there is an objective reduction in plantar flexion and endurance, this did not translate into functional limitations in our group of patients. To our knowledge, this represents the largest case series to date of functional outcome of distally based medial hemisoleus flap reconstruction in lower limbs.

Assessing the augmented breast: a blinded study comparing round and anatomical form-stable implants.

BACKGROUND: Controversy persists as to whether round or anatomical form-stable breast implants provide the most aesthetically pleasing results, and there is a paucity of evidence comparing cosmetic outcomes of these two implants. A blinded study comparing aesthetic outcomes was conducted in an attempt to address this issue. OBJECTIVES: The authors compare aesthetic outcomes between round and anatomical form-stable breast implants. METHODS: Pre- and postoperative photographs of 60 consecutive patients undergoing breast augmentation (33 round, 27 anatomical) by a single surgeon were reviewed by 22 plastic surgeons. Photographs were graded on a modified Likert scale (1, poor; 4, excellent) for overall aesthetic result, upper pole contour, and natural appearance. The panel was asked to determine implant shape. RESULTS: Anatomical implants scored higher for upper pole contour: anatomical 2.80 (±0.44 - standard deviation) vs round 2.60 (±0.38). With regard to natural appearance and overall aesthetic results, anatomical implants scored higher: 2.89 (±0.42) vs 2.56 (±0.36) and 2.86 (±0.41) vs 2.72 (±0.37), respectively. None of these differences achieved statistical significance, and 62.7% of round and 49% of anatomical implants were correctly identified. There was no significant difference in the body mass index (BMI) between the 2 groups (P = .21). CONCLUSIONS: No significant difference (P > .05) in the general and specific cosmetic points between round and anatomical implants was demonstrated; many on the panel were unable to identify implant shape correctly. Both techniques seem to yield good cosmetic results. Clearly the decision on which implant to use must be made on an individual patient basis because many factors influence overall aesthetic outcome. Anatomical implants should not be assumed to produce a more natural result. LEVEL OF EVIDENCE: 4 Therapeutic.

Trends in tertiary breast reconstruction: literature review and single centre experience.

BACKGROUND: Autologous flap reconstruction can improve aesthetic results after failed implant reconstruction and be considered following previous failed autologous flap reconstruction. This study presents a review of the indications, motivation and outcomes of tertiary breast reconstruction. METHODS: A comprehensive literature review was conducted using Pubmed, Embase, Web of Science and Google Scholar. Articles were identified using key search terms and through citations. A single centre, retrospective, review of all patients who underwent autologous flap reconstruction following previous breast reconstruction between 2004 and 2010. Details on patient demographics, surgical outcomes and patient satisfaction were collected. RESULTS: Out of 580 autologous flap breast reconstructions, 31 patients had 36 tertiary breast reconstructions with an autologous free or pedicled flap. Indications for surgery included: capsule contracture with discomfort (n = 24), asymmetry (n = 8), extrusion of implant (n = 4), exposed implant (n = 1). and previous failed autologous flap reconstruction (n = 7). The mean age our cohort was 50.1 years, BMI of 26.1, 52.3% had radiotherapy (n = 19) and 51.6% had chemotherapy. We performed free DIEP(n = 22), LD with or without an implant (n = 11) and free TRAM flap (n = 3). 5 were bilateral procedures. Flap complications included total flap loss (n = 2), partial skin necrosis (n = 1) and fat necrosis (n = 1). Mean follow up time was 20 months. Overall satisfaction, excluding the two flap failures was good. LITERATURE REVIEW: Only small case series were published on tertiary breast reconstruction. More recent literature had larger patient samples. A total of 7 studies were identified, with a total of 532 flaps, following unsatisfactory or failed implant reconstruction. The Deep Inferior Epigastric Artery Perforator (DIEP) flap was the most favourable first choice for autologous tertiary reconstruction. Breast cancer was the commonest indication for primary surgery. Motivations for tertiary surgery included cosmesis (including asymmetry and shape), symptomatic capsule contracture and desire for a natural feel. A handful of studies explored the outcomes of autologous flaps following a previously failed flap. CONCLUSION: Autologous breast reconstruction for tertiary reconstruction can be performed successfully to improve cosmesis and physical discomfort following failed or unsatisfactory results from implant reconstruction or previous failed flap reconstruction. The goal is to excise scarred tissue, recreate the breast mound and the normal anatomical shape. It provides new skin and well vascularised tissue to facilitate healing, producing a more natural feel and aesthetic breast.

Obesity in mammaplasty: a study of complications following breast reduction.

BACKGROUND: Access to effective surgical treatments such as breast reduction is often restricted on the grounds of patient obesity. However, there is a lack of unambiguous data on the surgical risks of obesity in patients undergoing breast reduction. The aim of this study was to assess the relationship between patient obesity, as determined by body mass index (BMI), and surgical outcome following bilateral breast reduction (BBR). METHODS: Retrospective review of case notes was conducted for 306 patients who underwent BBR in our unit over a 5-year period. BMI, resection weight, smoking history, technique, complications and outcomes were determined from records of follow-up assessment. RESULTS: Overall complication rate was 53.9%, with multiple complications of 22.9%. A significant increase in complications after BBR with increasing BMI was identified (p = 0.019 any complication, p = 0.002 multiple complications). The effect of BMI on multiple complications was significant and independent of resection weight (p = 0.031) and reduction technique (p = 0.020). Smoking was associated with higher wound dehiscence and multiple complications. We developed a model for predicting risk of complications based on key variables. Despite higher complications, there was no significant difference in aesthetic outcome at follow-up between the BMI groups. CONCLUSIONS: These findings add to the body of evidence that obesity is associated with an increased risk of post-operative complications. This has implications for surgeons and healthcare payers. However the majority of complications were minor and aesthetic outcomes were satisfactory in the majority of cases. The use of a 'target' BMI as exclusion criteria should therefore be treated with caution.

Evidence-based burn care--An assessment of the methodological quality of research published in burn care journals from 1982 to 2008.

INTRODUCTION: The quantity and quality of research evidence in peer-reviewed burn care journals have never been evaluated. The aim of this study was to empirically assess the evidence available in this literature. METHODS: All studies published in Burns and Journal of Burn Care and Research between 1st January 1982 and 31st December 2008 were reviewed. Articles were tabulated according to their study design into the following groups: meta-analyses; randomised controlled trials; controlled trials; comparative studies and case series/reports. RESULTS: A total of 2215 original articles were evaluated, of which 67.0% were from Burns and 33.0% were from Journal of Burn Care and Research. There were 3 meta-analyses (0.1%), 179 (8.1%) randomised controlled trials, 56 (2.5%) controlled clinical trials, 715 (32.3%) comparative studies and 1262 (57.1%) case series/reports. Journal of Burn Care and Research published a higher proportion of randomised controlled trials than Burns (11.9% vs. 6.2%; p<0.001). There was no significant difference in the proportion of published controlled trials between the two journals (3.0% vs. 2.3%; p=0.333). Journal of Burn Care and Research published a higher proportion of comparative studies than Burns (27.9% vs. 41.4%; p<0.001). Case series/reports made up the highest proportion of articles in both Burns (63.6%) and Journal of Burn Care and Research (43.7%), with Burns publishing a higher proportion of these than Journal of Burn Care and Research (p<0.001). From 1982 to 2008, when articles from both journals were considered together there were significant increases in the proportion of randomised controlled trials (0 (0%) to 10 (9%); p<0.001) and controlled clinical trials (0 (0%) to 1 (1%); p<0.001). There were no significant changes in the proportion of comparative studies (11 (44%) to 28 (16%); p=0.846) or case series/reports (14 (56%) to 71 (65%); p=0.448). DISCUSSION: The burn care literature suffers from a relative shortage of high-quality evidence. More randomised controlled trials are warranted.

Descriptive and inferential statistical methods used in burns research.

BACKGROUND: Burns research articles utilise a variety of descriptive and inferential methods to present and analyse data. The aim of this study was to determine the descriptive methods (e.g. mean, median, SD, range, etc.) and survey the use of inferential methods (statistical tests) used in articles in the journal Burns. METHODS: This study defined its population as all original articles published in the journal Burns in 2007. Letters to the editor, brief reports, reviews, and case reports were excluded. Study characteristics, use of descriptive statistics and the number and types of statistical methods employed were evaluated. RESULTS: Of the 51 articles analysed, 11(22%) were randomised controlled trials, 18(35%) were cohort studies, 11(22%) were case control studies and 11(22%) were case series. The study design and objectives were defined in all articles. All articles made use of continuous and descriptive data. Inferential statistics were used in 49(96%) articles. Data dispersion was calculated by standard deviation in 30(59%). Standard error of the mean was quoted in 19(37%). The statistical software product was named in 33(65%). Of the 49 articles that used inferential statistics, the tests were named in 47(96%). The 6 most common tests used (Student's t-test (53%), analysis of variance/co-variance (33%), chi(2) test (27%), Wilcoxon & Mann-Whitney tests (22%), Fisher's exact test (12%)) accounted for the majority (72%) of statistical methods employed. A specified significance level was named in 43(88%) and the exact significance levels were reported in 28(57%). CONCLUSION: Descriptive analysis and basic statistical techniques account for most of the statistical tests reported. This information should prove useful in deciding which tests should be emphasised in educating burn care professionals. These results highlight the need for burn care professionals to have a sound understanding of basic statistics, which is crucial in interpreting and reporting data. Advice should be sought from professionals in the fields of biostatistics and epidemiology when using more advanced statistical techniques.

Burns surgery handover study: trainees' assessment of current practice in the British Isles.

INTRODUCTION: Effective handover of clinical information between working shifts is essential for patient safety. The aim of this study was to identify current practice and trainees' assessment of handover in the burns units of the British Isles. METHODS: A telephone questionnaire was conducted to trainee burns surgeons (at junior and senior grades) currently working at all 30 burns surgery units in the British Isles. Information regarding timing, location, duration, participation and quality of handover was collated anonymously. Trainees commented on satisfaction with current practice and its perceived safety. RESULTS: A 100% response from all 30 units was obtained. 23/30 units (76.7%) had junior to junior trainee handovers. 17/30 (56.7%) had senior to senior trainee handovers. 19/30 units (63.3%) reported that handover took place with more than one grade of doctor present (range 1-4 grades). 3/30 (10%) reported that handover was bleep-free. 3/30 (10%) had received formal training on good burns handover. 5/30 (16.7%) were working in a unit that operated a "burns surgeon of the week" pattern of emergency cover. Mean satisfaction level was 3.8 out of 5. Those working in "surgeon of the week" teams had significantly higher scores, 4.4 versus 3.68 (p=0.037). Other healthcare professionals were present at only 4/30 (13.3%) handovers. Overall 26/30 (86.7%) of trainees judged their current handover practice "safe" (100% in "surgeon of week" group and 84% in the remaining group, p=0.289). CONCLUSIONS: Effective handover remains a keystone in safe and effective communication between doctors. The study highlights areas for improvement in handover practice, including greater involvement of an integrated multidisciplinary team. Those working under the "surgeon of the week" pattern are more satisfied.

Superficial fascial system repair: an abdominoplasty technique to reduce local complications after caesarean delivery.

Abdominal incision complications are a major source of morbidity after caesarean delivery. Repair of the superficial fascial system may avert local complications after caesarean delivery by minimising tension to the skin and increasing the initial biomechanical strength of wound which has the potential to decrease early wound dehiscence and as a by-product correct suprapubic bulging.