Craniectomy with soft tissue reconstruction for locally advanced non-melanoma skin cancer of scalp with calvarial invasion: The Nottingham experience.

INTRODUCTION: Locally advanced non-melanoma skin cancer (NMSC) involving the periosteum or calvarium poses a clinical challenge for patients who are unfit for immunotherapy due to medical comorbidities and/or frailty. This case series aims to investigate outcomes for patients undergoing craniectomy and soft tissue reconstruction. METHOD: Patients who underwent craniectomy and soft tissue reconstruction for invasive NMSC with calvarium or periosteal invasion between 2016 and 2022 were included. Data, including demographics, operative details, and clinical outcomes, were gathered from Nottingham University Hospitals' digital health record and the histopathology electronic database. RESULT: Eight patients (average age: 78.4 years, 3 females 5 males) with significant comorbidities and varying degrees of periosteal or bone invasion fulfilled the inclusion criteria. Diagnoses included four squamous cell carcinomas, two basal cell carcinomas, and two pleomorphic dermal sarcomas. Five patients had a history of prior incomplete deep margin excision. The median sizes for soft tissue defect, tumor and bone defect size were 51.83 cm2, 34.63 cm2 and 42.25 cm2, respectively. Intraoperative complications included one dural tear. Four patients underwent local flap reconstruction and with split-thickness skin grafting, four patients underwent free flap reconstruction. Adjuvant radiotherapy was administered to three patients. Complications comprised partial graft loss in two and complete graft loss in one. There was partial flap loss in one case. One patient required subsequent parotidectomy due to regional progression before achieving disease control. All patients achieved lasting locoregional disease control (average follow-up 29.7 months). CONCLUSION: Craniectomy with soft tissue reconstruction proves to be a safe and effective treatment option in advanced NMSC of the scalp in patients unsuitable for immunotherapy due to frailty or medical co-morbidity.

Successful treatment of mixed depth flame burns using enzymatic debridement with Nexobrid™ in a patient with aggressive systemic sclerosis (scleroderma).

INTRODUCTION: Enzymatic debridement for mixed depth and full thickness burns is gaining recognition as an important technique available to the burns surgeon. Reductions in blood loss, the need for autologous skin grafting and the number of wounds requiring surgical excision are among the benefits of this evolving treatment modality. We present a case of successful treatment using enzymatic debridement of mixed depth flame burns in a young patient with systemic sclerosis (scleroderma). METHODS: A 24-year-old man with rapidly progressive limited cutaneous systemic sclerosis suffered approximately 6% mixed depth flame burns to the right leg including areas of likely deep partial thickness burn totalling approximately 2% total body surface area (TBSA). Enzymatic debridement using Nexobrid™ was performed under spinal anaesthesia in accordance with unit protocol. Pain was well controlled and at 4 h the Nexobrid™ was removed and replaced with saline-soaked gauze initially then simple dressings. After liaison with Rheumatology, he was also started on iloprost infusions over five days. He was discharged home on day 9 and completely healed by day 31. Scarring was minimal, the skin was soft and full, and pain-free range of movement of the right knee was maintained. DISCUSSION AND CONCLUSION: This case demonstrates the safety and effectiveness of enzymatic debridement of mixed depth burns in a patient with very compromised wound healing. Enzymatic debridement combined with iloprost infusion provided maximum preservation of viable dermis. The authors recommend that this treatment strategy is considered in similar cases.

Intraosseous ganglion cysts of the carpus: current practice.

Intraosseous cysts of the carpal bones are an infrequent cause of chronic wrist pain. The main body of work has investigated their occurrence in the proximal carpus, with limited incidence in the distal row. We review the current literature on the treatment of symptomatic carpal cysts following the report of a 17-year-old male with a 12-month history of progressive right wrist pain due to an intraosseous ganglion of the trapezoid. This review explores the pathology of carpal cysts, their varying presentation and current treatments.

Painless squeaking following cervical disc replacement: A case report.

BACKGROUND: We present a case of painless squeaking following cervical disc replacement which to our knowledge has not previously been reported in the literature. METHODS: A 45 year old gentleman presented with severe right sided C6 radiculopathy. He complained of more than 6 weeks of severe dysaesthesia in the right arm with pain radiating into the hand, thumb, index, middle and ring fingers. MRI confirmed severe impingement of C6 and C7 nerve roots. After trying a period of conservative treatment he underwent anterior cervical decompression with total cervical disc replacement of C5-6 and C6-7. RESULTS: Being a keen athlete he started running at 6 months post operatively. At his 12 month outpatient he presented us with an audio file containing squeaking from his neck. This was recorded immediately following a 9.5 mile hard surface run. The squeak got progressively less in intensity over 12 hours and disappeared after 24 hours. All instances of squeaking occurred after exercise where impact (running) or vibration (cycling) took place. This was first noticed 6 months post operatively when he restarted exercising. All episodes were completely painless. At his 18 month outpatient review the squeaking had reduced in frequency and intensity. At his 24 month review it had abated completely. CONCLUSION: The aetiology of this painless squeaking has been elusive and is likely to be multifactorial. However we hypothesise that the audible squeak associated with the prestige LP disc maybe related to specific design characteristics and needs further evaluation.