The unilateral perforator V-Y flap for fingertip reconstruction-a versatile technique.

Fingertip amputations are a very common form of injury seen in the emergency departments. Various techniques have been described for the management of these injuries including simple dressings, skin grafts, homodigital, heterodigital and regional flaps and also free flaps. We present our experience with 10 cases of unilateral V-Y flaps raised on a perforator vessel and advanced in a modified fashion to cover the entire tip with a single flap. The technique is quick and easy to perform under loupe magnification, has minimal donor site morbidity and achieves good results in terms of healing, hand function, sensory recovery, appearance and patient satisfaction.

'Hands up technique': An alternative surgical setup for Brachioplasty.

For routine brachioplasty, conventional intra-operative positioning involves abducted arms resting on two tables with the patient supine. This technique does not facilitate intra-operative comparison for symmetry and engages one assistant to hold the arm at all times. We describe a novel positioning technique for brachioplasty using Chinese finger traps and drip stands which is safe, easy to reproduce, obviates the need for a positioning assistant and facilitates symmetrical resection.

A multicentre, randomized, double-blind trial of the safety and efficacy of mannose-6-phosphate in patients having Zone II flexor tendon repairs.

The safety, tolerability and preliminary efficacy of mannose 6-phosphate in enhancing the outcome in Zone II flexor tendon repair was studied in a multicentre parallel double-blinded randomized controlled trial. Eight UK teaching hospitals were involved in treating repaired flexor tendons with a single intraoperative intrathecal dose of 600 mM mannose 6-phosphate, with follow-up over 26 weeks. A total of 39 patients (mannose 6-phosphate, n = 20; standard care, n = 19) were randomized. Seven were excluded from the safety and tolerability analysis because of intraoperative findings and eight were excluded due to early dropout (n = 4) or tendon rupture (n = 4), leaving 24 (mannose 6-phosphate, n = 13; standard care, n = 11) for assessment of total active motion. The safety, tolerability and other side effects were comparable between the groups. There was no significant difference between the two groups in the total active motion at Week 26. We concluded that mannose 6-phosphate, although safe and tolerable, had no beneficial effect on finger range of motion after Zone II tendon division.Level of evidence 1b.

Extensor indicis proprius opponensplasty - the burkhalter revisited.

The Extensor Indicis Proprius Opponensplasty although not widely exercised by hand surgeons has previously been shown to produce good results in the restoration of thumb opposition. Over the last 5 years the Extensor Indicis Proprius was selectively used in cases where the Flexor Digitorum Superficialis was unavailable or inappropriate. In a small case series operating on a total of six male patients with an average age of 32 and follow up of 12 months we have been impressed by the functional outcome and lack of donor site morbidity. The Extensor Indicis Proprius is expendable with minimal donor site morbidity, is of sufficient length and has an optimal line of pull to provide a superior mechanical advantage and a favourable torque when compared to Flexor Digitorum Superficialis.

A clinical analysis of Dupuytren's disease of the thumb.

Although Dupuytren's disease of the thumb was first described in 1833, the literature on this subject is limited to a few anatomical and clinical studies. This study examined the pattern of cords of Dupuytren's disease in 260 thumbs in 181 consecutive patients with evidence of disease relating to the thumb attending an out-patient clinic over a period of 36 months. Discrepancies in the literature are discussed in the light of the findings of this more detailed analysis and a simple but practical pictorial system for recording disease severity and detailing progression over time is presented.

Percutaneous trigger finger release: the 'lift-cut' technique.

One hundred and eighty patients with 240 trigger digits were treated by percutaneous release using a 'lift-cut' technique. All patients were reviewed at 3 months following release. Overall, 94% achieved an excellent or good result. Ten patients experienced recurrent symptoms and required a subsequent open release. There was no clinical evidence of digital nerve or flexor tendon injury. We recommend this technique as a safe and effective outpatient procedure.

Dupuytren's disease secondary to acute injury, infection or operation distal to the elbow in the ipsilateral upper limb--a historical review.

The aggregated total of 385 cases of Dupuytren's disease arising after acute or specific injury, operation or infection of the forearm, wrist or hand between 1614 and 2003 are documented, including a personal series of 52 cases. The history of this relationship is recorded and the medico legal implications of the association are discussed.

Immediate vulvar and vaginal reconstruction using the gluteal-fold flap: long-term results.

The gluteal-fold flap was used to reconstruct vulvar and posterior vaginal wall defects in 40 patients. This is a fasciocutaneous, islanded flap based on the internal pudendal artery and vein perforators. The flap is robust and has the advantage of being away from the pathway of carcinoma spread. In addition it has minimal donor-site morbidity as the scar is hidden in a natural crease.

Differences in morphology, cytoskeletal architecture and protease production between zone II tendon and synovial fibroblasts in vitro.

Fibroblast migration is an integral component of the processes resulting in the formation of restrictive adhesions in the injured tendon, especially in Zone II. Pre-requisites for cell migration are an intact cytoskeleton and an ability to biochemically degrade the extra-cellular matrix. The relative characteristics of fibroblasts from the fibro-osseus sheath (SC), the tissue surrounding the tendon in Zone II, and the endotenon (TC) with respect to morphology, cytoskeletal structure and ability to produce matrix metalloproteinases (MMPs) 2 and 9 were compared in vitro. It was found that SCs were larger in size and demonstrated greater amounts of intra-cellular alpha-smooth muscle actin (alpha-SMA) and intra-membranous vinculin. Filamentous actin (F-actin) fibres in SCs were more densely packed and concentrated, resulting in stress fibres. The SCs also produce greater amounts of MMP-2 and MMP-9 compared to TCs. These observations imply that SCs play an active role in adhesion formation and should be specifically targeted to inhibit or treat tendon adhesions.

Anomalous muscle of the wrist.

A case of an anomalous muscle found in the right wrist of a 52-year-old man during routine carpal tunnel decompression surgery is reported. The muscle was observed lying transversely across the carpal tunnel superficial and parallel to the flexor retinaculum. Its further definition was subsequently demonstrated by postoperative magnetic resonance imaging (MRI). No similar structure was detectable on MRI of the left wrist.

The flexor digitorum profundus "demi-tendon"--a new technique for passage of the flexor profundus tendon through the A4 pulley.

The flexor digitorum profundus (FDP) tendon may retract after avulsion or division in Zone 1. When treatment has been delayed, the oedematous tendon can be too swollen to pass freely through the A4 pulley. We present a new technique for dealing with this situation which depends on the "double-barrelled" nature of the distal part of the FDP tendon. One half of the tendon is excised longitudinally and the remaining "demi-tendon" is passed through the intact A4 pulley to allow tendon repair or re-attachment. This technique has been used in six cases in which passage of the FDP tendon through the A4 pulley would otherwise have been impossible.

Ear-lobe keloids: treatment by a protocol of surgical excision and immediate postoperative adjuvant radiotherapy.

There is no universally agreed policy for treating keloid scars of the ear lobe following piercing. We treated 35 patients (34 women) for high-risk ear-lobe keloids; the average age was 24 years (range: 16-44 years). All had failed to respond to prior treatment with massage and silicone, and corticosteroid injection. The keloids were excised extralesionally and the defects were closed with interrupted prolene sutures. The operative scar was covered with topical 2% lignocaine-0.25% chlorhexidine sterile lubricant gel under a transparent adhesive dressing. Adjuvant postoperative radiotherapy of 10 Gy, applied as 100 kV photons (4 mm high-voltage therapy (HVT) Al), was given within 24 h of surgery. All keloid scars were controlled at 4 weeks' follow-up. At 1 year, three out of 34 cases followed up had relapsed (probability of control: 91.2%). At 5 years, a further four out of the remaining 31 patients had relapsed (cumulative probability of control at 5 years: 79.4%). There were no cases of serious toxicity.

Reduction in matrix metalloproteinase production by tendon and synovial fibroblasts after a single exposure to 5-fluorouracil.

This study investigated the effect of treatment with 5min exposures to 5-fluorouracil (5-FU) on the production of matrix metalloproteinases (MMPs) by endotenon and synovial fibroblasts. Fibroblasts were grown from the flexor tendons of New Zealand White rabbits and were then exposed to varying concentrations (ranging from 0.25 mg x ml(-1)to 25 mg x ml(-1)of 5-FU for 5 min. The treated fibroblasts were suspended in a three-dimensional collagen lattice. The conditioned media from these collagen lattices were then analysed for MMP production using gelatin zymography on days 1, 3 and 7 after treatment. In the majority of cases this treatment produced a dose- and time-dependent reduction in total MMP production by both cell lines, specifically in the production of MMPs 2 and 9. This reduction was significant for most concentrations (P< or =0.01-P< or =0.05) when compared to phosphate-buffered-saline-treated controls. We conclude that 5-FU may reduce adhesions by limiting the migratory capacity of synovial fibroblasts (extrinsic healing).

Double tongue, intraoral anomalies, and cleft palate--case reports and a discussion of developmental pathology.

OBJECTIVE: Isolated cleft palate is the most common presentation of the nonsyndromic cleft lip/palate combinations and is multifactorial in etiology. We report two cases of children with clefts of the secondary palate coexistent with double tongue and in either case mandibular epulis or superiorly displaced salivary gland. RESULTS AND DISCUSSION: In each case, the palatal cleft correlated anatomically with the intraoral space-occupying lesion. The ratio of tongue volume to intraoral volume during palatogenesis is discussed with reference to the pathogenesis of cleft palate. These clinical cases propose the model of a unifying sequence of developmental events whereby deformation of palatal shelf elevation results in secondary palatal clefting.