Protocol for a feasibility, acceptability and safety study of the PICO device (negative pressure wound therapy) in acute paediatric burns.

INTRODUCTION: Negative pressure wound therapy (NPWT) in acute burn care may decrease the time to re-epithelialisation by more than 20%. Despite this, the perceived burden of use; including therapeutic, physical and financial, have limited the use of NPWT in acute burn care. This might be minimised by using the small, ultraportable, single-use NPWT device PICO as opposed to larger devices, which to date has never been studied in acute burn care. This research will; therefore, primarily assess the feasibility, acceptability and safety of PICO in paediatric burns. Secondary outcomes include time to re-epithelialisation, pain, itch, cost and scar formation. METHODS AND ANALYSIS: This protocol details a clinical trial methodology and is pre-results. This single site, prospective, pilot randomised controlled trial will be conducted in an Australian quaternary paediatric burns centre. Participants must be aged ≤16 years, otherwise well and managed within 24 hours of sustaining a burn that fits beneath a PICO dressing. Thirty participants will be randomised to one of three groups: group A: Mepitel and ACTICOAT, group B: Mepitel, ACTICOAT and PICO and group C: Mepitel, ACTICOAT Flex and PICO. Patient outcomes will be recorded at each dressing change to assess efficacy and safety outcomes until 3 months postburn wound re-epithelialisation. Surveys, randomisation and data storage will be undertaken via online platforms and physical data storage collated at the Centre for Children's Health Research, Brisbane, Australia. Analysis will be done by using StataSE 17.0 statistical software. ETHICS AND DISSEMINATION: Ethics has been obtained from Queensland Health and Griffith Human Research Ethics committees including a site-specific approval. These data will be disseminated via clinical meetings, conference presentations and peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12622000009718.

The feasibility of negative pressure wound therapy versus standard dressings in paediatric hand and foot burns protocol: a pilot, single-centre, randomised control trial.

INTRODUCTION: The goal of paediatric hand and foot burn management is hypertrophic scar and/or contracture prevention. The risk of scar formation may be minimised by integrating negative pressure wound therapy (NPWT) as an acute care adjunct as it decreases the time to re-epithelialisation. NPWT has known associated therapeutic burden; however, this burden is hypothesised to be outweighed by an increased likelihood of hypertrophic scar prevention. This study will assess the feasibility, acceptability and safety of NPWT in paediatric hand and foot burns with secondary outcomes of time to re-epithelialisation, pain, itch, cost and scar formation. METHODS AND ANALYSIS: This is a single-site, pilot randomised control trial. Participants must be aged ≤ 16 years, otherwise well and managed within 24 h of sustaining either a hand or foot burn. Thirty participants will be randomised to either standard care (Mepitel®-a silicone wound interface contact dressing-and ACTICOAT™-a nanocrystalline silver-impregnated dressing) or standard care plus NPWT. Patients will be reviewed until 3 months post-burn wound re-epithelialisation, with measurements taken at dressing changes to assess primary and secondary outcomes. Surveys, randomisation and data storage will be done via online platforms and physical data storage collated at the Centre for Children's Health Research, Brisbane, Australia. Analysis will be performed using the Stata statistical software. ETHICS AND DISSEMINATION: Queensland Health and Griffith University Human Research ethics approval including a site-specific assessment was obtained. The findings of this study will be disseminated through clinical meetings, conference presentations and peer reviewed journals. TRIAL REGISTRATION: Registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12622000044729, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381890&isReview=true , registered 17/01/2022).

Simulating the IMA Recipient Site for DIEP Flap Surgery: A New Model for Dynamic Microsurgery Simulation with Real-Time Respiration and a Pilot Study.

BACKGROUND: Breast reconstruction (BR) using autologous free flaps has been shown to have numerous psychosocial and quality-of-life benefits. Unfortunately, the microsurgical learning curve is quite steep due to some unique operative challenges. Currently, there is no realistic simulation model that captures real-life respiratory excursion and the depth of internal mammary vessels within the compact recipient site. The purpose of this study was to delineate intraoperative measurements of depth and motion, describe the resulting simulation model, and conduct a pilot study evaluating the simulator as an educational resource. METHODS: This is a single-center, ethics-approved study. For the intraoperative measurements, all consecutive patients undergoing free flap BR using internal mammary vessels as recipients were recruited. Patient and intraoperative factors as well as intraoperative measurements were recorded. A dynamic model was developed based on intraoperative parameters. For the pilot study, plastic and reconstructive surgery trainees were recruited to complete a hand-sewn internal mammary artery (IMA) anastomosis using the new simulator and completed objective questionnaires pre- and postsimulation. Subjective feedback was recorded and themes determined. RESULTS: Fifteen operative sites were analyzed. Flap pocket was found to be between 4 and 5 cm in depth with vertical excursion of 3.7 ± 1.0mm and a respiratory rate of 9 to 14 breaths/minute. Previous radiation, rib space, body mass index (BMI), blood pressure, heart rate, tidal volume, and respiratory rate showed no correlation to vessel depth/excursion. Laterality, rib space, BMI, radiation, vitals, and tidal volume had no correlation with vessel movement. Twenty-two trainees were included in the pilot. An increase in confidence and mixed results for anxiety was reported. CONCLUSION: This study reports a novel microsurgical simulation model that provides a realistic deep inferior epigastric perforator free flap BR IMA anastomosis experience. It replicates movement of vessels in situ with real-time respiratory excursion and similar physical structures of the internal mammary system. This model shows promising results for increased use in microsurgical education.

Suitability of Using the Hamate for Reconstruction of the Finger Middle Phalanx Base: An Assessment of Cartilage Thickness.

BACKGROUND: Osteochondral grafts are indicated for reconstructing the finger middle phalanx base when there is greater than 50% involvement of the articular surface and significant comminution. This study aims to compare the cartilage thickness of the distal surface of the hamate to the finger middle phalanx base to assess its suitability as an osteochondral graft. METHODS: A 3-dimensional laser scanner and computer modelling techniques were utilized to determine the cartilage thickness of the distal surface of the hamate, and finger middle phalanx base using cadaver specimens. The mean, maximum, and coefficient of variation (CV%; a measure of uniformity of cartilage distribution), as well as cartilage distribution maps were determined. RESULTS: The mean cartilage thickness of the hamate was 0.73 ± 0.08 mm compared to the average mean thickness of the finger middle phalanx base of 0.40 ± 0.12 mm. The maximum cartilage thickness of the hamate was 1.27 ± 0.14 mm compared to the average maximum of the finger middle phalanx base of 0.67 ± 0.14 mm. The CV% of the hamate was 27.8 ± 4.2 compared to the average CV% for the finger middle phalanx base of 26.6 ± 8.1. The hamate and finger middle phalanx base have maximum areas that were most frequently at or spanning the median ridge; however, this was more consistently observed with the hamate. CONCLUSION: The distal surface of the hamate is a suitable osteochondral graft with respect to cartilage thickness and distribution providing sufficient cartilage for reconstruction of the finger middle phalanx base.

HISTORIQUE: Les greffes ostéochondrales sont indiquées pour reconstruire la phalange médiane du doigt qui touche plus de 50 % de la surface articulaire et comporte une pulvérisation importante. La présente étude vise à comparer l'épaisseur du cartilage de la surface distale de l'os unciforme à la base de la phalange médiane du doigt (BPMD) pour en évaluer la pertinence comme greffe ostéochondrale. MÉTHODOLOGIE: Les chercheurs ont utilisé un lecteur laser tridimensionnel et des techniques de modélisation informatique pour déterminer l'épaisseur du cartilage de la surface distale de l'os unciforme et de la phalange médiane du doigt sur des spécimens cadavériques. Ils ont déterminé la variation moyenne, la variation maximale et le coefficient de variation (% CV; une mesure d'uniformité de la répartition du cartilage) de même que des cartes de répartition du cartilage. RÉSULTATS: L'épaisseur moyenne du cartilage de l'os unciforme était de 0,73 ± 0,08 mm par rapport à celle de la BPMD de 0,40 ± 0,12 mm. L'épaisseur maximale du cartilage de l'os unciforme était de 1,27 ± 0,14 mm par rapport au maximum moyen de la BPMD de 0,67 ± 0,14 mm. Le % CV de l'os unciforme était de 27,8 ± 4,2 par rapport à celui de la BPMD de 26,6 ± 8,1. Tant l'os unciforme que la BPMD ont des zones maximales sur la crête médiane ou qui recouvrent celle-ci, mais on l'observait davantage sur l'os unciforme. CONCLUSION: La surface distale de l'os unciforme est une greffe ostéochondrale pertinente qui assure une réserve d'épaisseur et de répartition du cartilage suffisante pour reconstruire la BPMD.

Patient-Reported Outcomes following Breast Conservation Therapy and Barriers to Referral for Partial Breast Reconstruction.

BACKGROUND: The purpose of this study was to evaluate the self-reported aesthetic outcome of breast conservation therapy in a generalized sample of patients, and to describe potential barriers to referral for partial breast reconstruction. METHODS: Consecutive breast conservation therapy patients completing radiotherapy over a 1-year period at a regional cancer center were identified. Eligible patients were contacted by means of mail/e-mail and invited to participate. Participants completed the BREAST-Q breast conservation therapy module along with a questionnaire examining feelings about breast reconstruction. Multiple regression analysis was performed using the satisfaction with breasts scale as the dependent variable. RESULTS: Surveys were completed by 185 of 592 eligible participants (response rate, 31.3 percent; mean age, 61 years) an average of 38 months after lumpectomy. The mean score for the BREAST-Q satisfaction with breasts scale was 59 of 100. Younger age (p = 0.038), lumpectomy reexcision (p = 0.018), and lumpectomy at a nonacademic center (p = 0.026) were significantly associated with lower satisfaction. Bra size, months from lumpectomy, and tumor quadrant/size were not significantly associated with satisfaction (p > 0.05). The most common statements regarding reconstruction were "I don't feel the need for it" (60.0 percent), "I don't like the thought of having breast implants" (22.7 percent), and "I don't want any more surgeon/doctor visits" (22.2 percent). Before lumpectomy, only 1.6 percent had a consultation for reconstruction, and only 22.7 percent were aware of this option. If offered, 33.1 percent of patients would have attended this consultation. CONCLUSION: There is an unmet demand for partial breast reconstruction, with an opportunity to advocate and increase awareness on behalf of patients undergoing breast conservation therapy.

A Qualitative Assessment of the Journey to Delayed Breast Reconstruction.

BACKGROUND: Canada has low immediate breast reconstruction (IBR) rates compared to the United States and Europe. Breast cancer survivors live with mastectomy defects sometimes for years, and this represents an area for improvement in cancer care. PURPOSE: This study qualitatively assessed (1) information provided about breast reconstruction at the time of cancer diagnosis among women seeking delayed breast reconstruction (DBR) and (2) referral practices for plastic surgery consultation for DBR. METHODS: Fifty-two consecutive patients seen in consultation for DBR at a single Canadian tertiary care centre completed questionnaires regarding their experience in seeking breast reconstruction. Seven semi-structured interviews were conducted to further explore themes identified through questionnaires. Questionnaire responses and interview transcripts were analyzed for recurring themes using standard qualitative techniques. RESULTS: A significant portion of women (43%) was interested in reconstruction prior to mastectomy, yet IBR was infrequently discussed (14%) or discouraged by their oncologic surgeons (33%). Common patient reasons for not pursuing IBR were referring physician objection and not having adequate knowledge. Women expressed wanting to discuss reconstruction at the time of cancer diagnosis. Half of the patients had attended another consultation, but the initial plastic surgeon either did not offer procedures for which these women were candidates or had prohibitively long surgical wait times. CONCLUSION: Lack of information about reconstructive options at the time of cancer diagnosis and perceived access barriers to plastic surgeons may contribute to underutilization of IBR in Canada. Access to breast reconstruction can be improved by reducing inefficiencies in plastic surgery referrals.

HISTORIQUE: Le taux de reconstructions mammaires immédiates (RMI) est faible au Canada par rapport aux États-Unis et à l'Europe. Les survivantes du cancer du sein vivent parfois avec une mastectomie pendant des années, ce qui représente un secteur à améliorer dans les soins du cancer. OBJECTIF: La présente étude était une analyse qualitative 1) de l'information transmise au sujet de la reconstruction mammaire au moment du diagnostic de cancer chez les femmes qui souhaitent une reconstruction mammaire tardive (RMT) et 2) des pratiques d'orientation vers une consultation en chirurgie plastique en vue d'une RMT. MÉTHODOLOGIE: Cinquante-deux patientes consécutives vues en consultation pour subir une RMT dans un seul centre canadien de soins tertiaries ont rempli des questionnaires sur leur expérience dans l'obtention d'une reconstruction mammaire. Les chercheurs ont organisé sept entrevues semi-structurées pour explorer les thèmes colligés grâce aux questionnaires. Ils ont utilisé des techniques qualitatives standards pour analyser les réponses aux questionnaires et les entrevues transcrites et relever des thèmes récurrents. RÉSULTATS: Avant la mastectomie, une forte proportion de femmes (43 %) souhaitait subir une reconstruction, mais leur chirurgien oncologue abordait rarement la RMI (14 %) ou la déconseillait (33 %). Les raisons fréquentes pour ne pas demander une RMI étaient l'objection du médecin traitant et le manque de connaissances suffisantes. Les femmes indiquaient vouloir parler de reconstruction au moment de leur diagnostic de cancer. La moitié des patientes avait participé à une autre consultation, mais le premier plasticien n'avait pas offert d'interventions auxquelles ces femmes étaient candidates ou présentait une trop longue liste d'attente avant l'opération. CONCLUSION: Le manque d'information sur les possibilités de reconstruction au moment du diagnostic de cancer et les obstacles perçus à l'accès aux plasticiens peuvent contribuer à une sous-utilisation de la RMI au Canada. Pour améliorer l'accès à la reconstruction mammaire, on peut réduire les inefficacités en matière de demande de consultation auprès des plasticiens.

Variation in Treatment Recommendations for Dupuytren Disease.

PURPOSE: To examine agreement on Dupuytren disease (DD) treatment recommendations in an international sample of hand surgeons. METHODS: A survey was developed to determine expertise in needle aponeurotomy, surgery, and collagenase injection to treat DD and to examine treatment recommendations for 16 case scenarios. Case scenarios were predeveloped using expert input. Each case represented a unique combination of 4 dichotomous variables including cord thickness, contracture severity, patient age, and joint involvement. Interrater reliability statistics were calculated and multinomial logistic regression modeling and analysis of variance were used to examine the impact of surgeon- and case-related variables on treatment recommendations. RESULTS: A total of 36 hand surgeons from 9 countries (mean experience, 17 years) participated. Average pairwise percent agreement and Krippendorff's alpha were 26% and .012, respectively. Predictors of a recommendation for surgery over multiple options were a total contracture of greater than 70°, a thick precentral cord, involvement of the metacarpophalangeal and proximal interphalangeal joints, and greater years in practice. A greater number of years in practice predicted recommendation for collagenase injection and the presence of a thick precentral cord predicted a recommendation for needle aponeurotomy. CONCLUSIONS: Little agreement exists on treatment recommendations for common presentations of DD in this sample. CLINICAL RELEVANCE: Further investigation into the sources of potential widespread discrepancies in the management of DD may improve the capacity to make evidence-based recommendations.

Construction and Setup of a Bench-scale Algal Photosynthetic Bioreactor with Temperature, Light, and pH Monitoring for Kinetic Growth Tests.

The optimal design and operation of photosynthetic bioreactors (PBRs) for microalgal cultivation is essential for improving the environmental and economic performance of microalgae-based biofuel production. Models that estimate microalgal growth under different conditions can help to optimize PBR design and operation. To be effective, the growth parameters used in these models must be accurately determined. Algal growth experiments are often constrained by the dynamic nature of the culture environment, and control systems are needed to accurately determine the kinetic parameters. The first step in setting up a controlled batch experiment is live data acquisition and monitoring. This protocol outlines a process for the assembly and operation of a bench-scale photosynthetic bioreactor that can be used to conduct microalgal growth experiments. This protocol describes how to size and assemble a flat-plate, bench-scale PBR from acrylic. It also details how to configure a PBR with continuous pH, light, and temperature monitoring using a data acquisition and control unit, analog sensors, and open-source data acquisition software.

Surgeon-Reported Needs for Improved Training in Identifying and Managing Free Flap Compromise.

Background This study examined the need for improved training in the identification and management of free flap (FF) compromise and assessed a potential role for simulated scenario training. Methods Online needs assessment surveys were completed by plastic surgeons and a subsample with expertise in microsurgery education participated in focus groups. Data were analyzed using descriptive statistics and mixed qualitative methods. Results In this study, 77 surgeons completed surveys and 11 experts participated in one of two focus groups. Forty-nine (64%) participants were educators, 65 and 45% of which reported having an insufficient volume of FF cases to adequately teach the management and identification of compromise, respectively. Forty-three percent of educators felt that graduating residents are not adequately prepared to manage FF compromise independently. Exposure to normal and abnormal FF cases was felt to be critical for effective training by focus group participants. Experts identified low failure rates, communication issues, and challenging teaching conditions as current barriers to training. Most educators (74%) felt that simulated scenario training would be "very useful" or "extremely useful" to current residents. Focus groups highlighted the need for a widely accepted algorithm for re-exploration and salvage on which to base the development of a training adjunct consisting of simulated scenarios. Conclusion Trainee exposure to FF compromise is inadequate in existing plastic surgery programs. Early exposure, high case volume, and a standardized algorithmic approach to management with a focus on decision making may improve training. Simulated scenario training may be valuable in addressing current barriers.

Developing Cognitive Task Analysis-based Educational Videos for Basic Surgical Skills in Plastic Surgery.

OBJECTIVE: To describe the development of cognitive task analysis (CTA)-based multimedia educational videos for surgical trainees in plastic surgery. DESIGN: A needs assessment survey was used to identify 5 plastic surgery skills on which to focus the educational videos. Three plastic surgeons were video-recorded performing each skill while describing the procedure, and were interviewed with probing questions. Three medical student reviewers coded transcripts and categorized each step into "action," "decision," or "assessment," and created a cognitive demands table (CDT) for each skill. The CDTs were combined into 1 table that was reviewed by the surgeons performing each skill to ensure accuracy. The final CDTs were compared against each surgeon's original transcripts. The total number of steps identified, percentage of steps shared, and the average percentage of steps omitted were calculated. SETTING: Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, an urban tertiary care teaching center. PARTICIPANTS: Canadian junior plastic surgery residents (n = 78) were sent a needs assessment survey. Four plastic surgeons and 1 orthopedic surgeon performed the skills. RESULTS: Twenty-eight residents responded to the survey (36%). Subcuticular suturing, horizontal and vertical mattress suturing, hand splinting, digital nerve block, and excisional biopsy had the most number of residents (>80%) rank the skills as being skills that students should be able to perform before entering residency. The number of steps identified through CTA ranged from 12 to 29. Percentage of steps shared by all 3 surgeons for each skill ranged from 30% to 48%, while the average percentage of steps that were omitted by each surgeon ranged from 27% to 40%. CONCLUSIONS: Instructional videos for basic surgical skills may be generated using CTA to help experts provide comprehensive descriptions of a procedure. A CTA-based educational tool may give trainees access to a broader, objective body of knowledge, allowing them to learn decision-making processes before entering the operating room.

Steroid injection and needle aponeurotomy for Dupuytren disease: long-term follow-up of a randomized controlled trial.

PURPOSE: To compare long-term outcomes and retreatment rates for patients with Dupuytren disease who underwent needle aponeurotomy (NA) combined with a series of triamcinolone acetonide injections or underwent NA alone as part of a prior randomized controlled trial. METHODS: During this follow-up study, 44 of 47 participants in the original study were examined as needed between 6 and 53 months from their initial procedure. Those who had not been reassessed within 18 months of the original NA were asked to return for follow-up. The average total active extension deficit (TAED) of previously treated joints was compared between groups 7 to 12, 13 to 24, 25 to 36, and 37 to 48 months following treatment. Timing of retreatment (if performed) was recorded. RESULTS: Forty-four participants returned for assessment an average of 4.8 times over 53 months. Mean TAED was significantly less in needle aponeurotomy triamcinolone injection patients at 6 months and between 13 and 24 months. Sixty-two percent of NA group patients and 30% of needle aponeurotomy triamcinolone injection patients returned for a second treatment on the same digit(s) (retreatment). This difference was not significant. Mean time to retreatment and mean TAED immediately prior to retreatment did not differ significantly between groups. Kaplan-Meier survival estimates demonstrated a significantly higher percentage of NA group patients expected to return for retreatment by 24 but not by 36 months. Younger age, more than one joint treated at the initial NA, and TAED severity throughout the follow-up period were associated with earlier retreatment. CONCLUSIONS: Serial triamcinolone injections combined with NA was associated with lower TAED for up to 24 months. A larger study would more accurately quantify the potential benefits of combining triamcinolone injections with NA for treatment of Dupuytren disease. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Dose optimization in cardiac x-ray imaging.

PURPOSE: The aim of this research was to optimize x-ray image quality to dose ratios in the cardiac catheterization laboratory. This study examined independently the effects of peak x-ray tube voltage (kVp), copper (Cu), and gadolinium (Gd) x-ray beam filtration on the image quality to radiation dose balance for adult patient sizes. METHODS: Image sequences of polymethyl methacrylate (PMMA) phantoms representing two adult patient sizes were captured using a modern flat panel detector based x-ray imaging system. Tin and copper test details were used to simulate iodine-based contrast medium and stents∕guide wires respectively, which are used in clinical procedures. Noise measurement for a flat field image and test detail contrast were used to calculate the contrast to noise ratio (CNR). Entrance surface dose (ESD) and effective dose measurements were obtained to calculate the figure of merit (FOM), CNR(2)∕dose. This FOM determined the dose efficiency of x-ray spectra investigated. Images were captured with 0.0, 0.1, 0.25, 0.4, and 0.9 mm Cu filtration and with a range of gadolinium oxysulphide (Gd2O2S) filtration. RESULTS: Optimum x-ray spectra were the same for the tin and copper test details. Lower peak tube voltages were generally favored. For the 20 cm phantom, using 2 Lanex Fast Back Gd2O2S screens as x-ray filtration at 65 kVp provided the highest FOM considering ESD and effective dose. Considering ESD, this FOM was only marginally larger than that from using 0.4 mm Cu at 65 kVp. For the 30 cm phantom, using 0.25 mm copper filtration at 80 kVp was most optimal; considering effective dose the FOM was highest with no filtration at 65 kVp. CONCLUSIONS: These settings, adjusted for x-ray tube loading limits and clinically acceptable image quality, should provide a useful option for optimizing patient dose to image quality in cardiac x-ray imaging. The same optimal x-ray beam spectra were found for both the tin and copper details, suggesting that iodine contrast based imaging and visualization of interventional devices could potentially be optimized for dose using similar x-ray beam spectra.

Primary orbital fracture repair: development and validation of tools for morphologic and functional analysis.

The purpose of this study was to develop and validate a technique for objective quantitative evaluation of outcomes of orbital reconstruction. Facial three-dimensional images were captured using a Vectra three-dimensional camera. Morphometric analysis was based on interactive anthropometric identification. The analysis was applied to a population of healthy adults (n = 13) and a population of patients following primary repair of unilateral orbital fractures (n = 13). Morphologic results following reconstruction were evaluated by identifying residual asymmetries. All subjects further completed the Derriford Appearance Questionnaire and the Orbital Appearance and Function Questionnaire.Normative reference values for periorbital asymmetry were determined in a reference population. The mean asymmetry was less than 1.6 mm for each measured morphologic feature. In the trauma population, primary orbital reconstruction effectively restored normal periorbital symmetry in 16 of 20 measured parameters. The fracture population showed no significant differences in the degree of asymmetry in globe projection, lower eyelid position, or ciliary margin length.The overall DAS59 scores were significantly higher in the fracture population (P = 0.04). This was due to significantly higher physical distress and dysfunction scores (P = 0.02), as well as a trend toward higher general and social self-consciousness scores (P = 0.06). No significant difference in facial self-consciousness was noted (P = 0.21). Thus, although primary orbital reconstruction was effective in restoring periorbital morphology, patients still experienced a higher level of physical distress and dysfunction than their nontraumatized counterparts. This was in accordance with patient self-report, which indicated that a greater percentage of patients were significantly bothered by functional outcomes postoperatively as opposed to appearance.

Steroid injection and needle aponeurotomy for Dupuytren contracture: a randomized, controlled study.

PURPOSE: To compare flexion deformity at 6 months in patients with Dupuytren contracture who had percutaneous needle aponeurotomy (PNA) combined with a series of triamcinolone acetonide (TA) injections to that of patients who had PNA alone. METHODS: Forty-seven patients with Dupuytren disease who were candidates for PNA (at least 1 contracture of at least 20°) participated in the study. Patients were randomized either to receive TA injections immediately following and 6 weeks and 3 months after the procedure or to receive no injections. Injections were administered into cords. The number of injections and the amount of TA per injection was determined based on the number of digits involved and the cord size. All subjects returned for 3 follow-up visits after the procedure, and contractures were measured using a goniometer. Change in total active extension deficit (TAED) was analyzed using a repeated measures analysis of variance to assess for differences between groups, time points, and interaction between group and time point. Descriptive statistics were calculated for all variables of interest. Continuous measures were summarized using means and standard deviations. RESULTS: There was no significant difference in TAED between groups before cord aponeurotomy. Correction at 6 months was 87% of preoperative TAED for the TA group versus 64% for the control group. This difference was statistically significant. The amount of TA administered did not correlate with TAED improvement. CONCLUSIONS: The study group who received TA in combination with PNA experienced a significantly greater degree of correction of flexion deformity at 6 months than those who had PNA alone.

Service innovation: a comparison of two approaches for physical screening of psychiatric inpatients.

OBJECTIVE: Psychiatric medications have clear links to obesity, diabetes, dyslipidaemia, hypertension, hyperprolactinaemia and movement disorders. These disorders are a common cause of morbidity and mortality in psychiatric patients but physical screening by health services is often haphazard. METHODS: We report the findings of an audit of physical screening across two hospital wards. Each ward undertook a process of service improvement. One ward modified the admissions proforma and the other developed a discharge screening clinic. The effectiveness of each of these interventions was then compared through a reaudit of practice across both wards. RESULTS: At baseline, screening was performed inconsistently and infrequently. On average, the modified admissions proforma increased screening rates by 4.7% compared to 30.7% for discharge screening clinics. The discharge screening clinic demonstrated statistically significant improvements in screening rates and effectively delivered health promotion advice. CONCLUSIONS: Discharge screening clinics are significantly more likely than improved admissions procedures to detect clinically significant abnormalities. If these abnormalities are detected and treated then the long-term physical health of psychiatric patients may be improved.

Comparison of third toe joint cartilage thickness to that of the finger proximal interphalangeal (PIP) joint to determine suitability for transplantation in PIP joint reconstruction.

PURPOSE: To compare the cartilage thickness of the third toe joints to the finger proximal interphalangeal (PIP) joints to assess the appropriateness of using third toe osteochondral grafts for finger PIP joint reconstruction. METHODS: A laser scanner was used to construct 3-dimensional computer models of 6 matched cadaver right third toe PIP joints, condyles of the third toe middle phalanx, and finger PIP joints with and without cartilage. Cartilage distribution patterns were computed and analyzed for each surface. The cartilage thickness of both sides of the third toe PIP joint and the third toe middle phalanx condyles were compared to the PIP joint of the fingers. A total of 18 third toe and 48 finger joint surfaces were analyzed. RESULTS: For the third toe middle phalanx condyles, the mean thickness was 0.20 ± 0.09 mm with a maximum of 0.52 ± 0.18 mm, and a coefficient of variation (CV%; a measure of uniformity of cartilage distribution) of 62. For the third toe proximal phalanx condyles, the mean cartilage thickness was 0.26 ± 0.10 mm with a maximum thickness of 0.56 ± 0.14 mm and a CV% of 44. The mean thickness, maximum thickness, and CV% of the finger proximal phalanx condyles was 0.43 ± 0.11 mm, 0.79 ± 0.16 mm, and 31, respectively. For the third toe middle phalanx base, the mean thickness was 0.28 ± 0.06 mm with a maximum of 0.47 ± 0.09 mm and a CV% of 34, compared to the finger middle phalanx base mean of 0.40 ± 0.12 mm with a maximum of 0.67 ± 0.14 mm and a CV% of 27. CONCLUSIONS: There were significant differences in cartilage thickness between the third toe and the fingers in this study. However, fewer differences were observed with the third toe middle phalanx base cartilage thickness than with the third toe condyles in comparison to the fingers.

Structural comparison of the finger proximal interphalangeal joint surfaces and those of the third toe: suitability for joint reconstruction.

PURPOSE: This study compared the degree of surface structural similarity between finger proximal interphalangeal joints and third toe articular surfaces to assess the appropriateness of using partial toe articular osteochondral grafts for finger joint reconstruction. METHODS: Computer models were generated from 4 paired cadaver hands and feet and compared the radius of curvature of toe and finger articular surfaces. The angle created by the palmar divergence of adjacent condyles of the same phalanx was also compared and described as the angular difference. The distal articular surfaces of the third toe proximal and middle phalanx were compared to distal articular surfaces of all 4 finger proximal phalanges. The radius of curvature was also compared between the third toe middle phalanx base and those of all 4 fingers. RESULTS: The toe middle phalanx medial and lateral condyles were 66% and 60% the size of the respective finger condyles. The mean angular difference between adjacent condyles of the toe middle phalanx compared to the finger was 20°. The toe proximal phalanx medial and lateral condyles were 75% and 70% the size of the respective finger condyles, with a mean angular difference between adjacent condyles of 6°. The toe middle phalanx medial base was closer in size to that of the finger (95% to 178%) compared to the toe middle phalanx lateral base (205% to 254%). CONCLUSIONS: This study revealed that the third toe proximal phalanx distal articular surface more closely matched the geometric characteristics of the finger proximal phalanx distal articular surface than did the toe middle phalanx distal articular surface. The medial base of the toe middle phalanx more closely approximated the size of the finger middle phalanx base than did the lateral toe middle phalanx base. CLINICAL RELEVANCE: Quantitative data have been provided to help guide third toe osteochondral donor site selection when reconstructing traumatic finger proximal interphalangeal joint defects. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A new system for severity scoring of facial fractures: development and validation.

Facial fractures are often the result of high-velocity trauma, causing skeletal disruption affecting multiple anatomic sites to varying degrees. Although several widely accepted classification systems exist, these are mostly region-specific and differ in the classification criteria used, making it impossible to uniformly and comprehensively document facial fracture patterns. Furthermore, a widely accepted system that is able to provide a final summary measure of fracture severity does not exist, making it difficult to investigate the epidemiologic data surrounding facial fracture severity. In this study, a comprehensive method for panfacial fracture documentation and severity measurement is proposed and validated through a retrospective analysis of 63 patients operated on for acute facial fracture. The severity scale was validated through statistical analysis of correlation with surrogate markers of severity (operating room procedure time and number of implants). Spearman correlation coefficients were calculated, and a statistically significant correlation was found between severity score and both number of implants and operating room procedure time (R = 0.92790 and R = 0.68157, respectively). Intraclass correlation coefficients were calculated to assess intrarater and interrater reliabilities of the severity scale and were found to be high (0.97 and 0.99, respectively). This severity scale provides a valuable, validated research tool for the investigation of facial fracture severity across patient populations, allowing for systematic evaluation of facial fracture outcomes, cost-benefit analysis, and objective analysis of the effect of specific interventions.

Which outcome measure is the best? Evaluating responsiveness of the Disabilities of the Arm, Shoulder, and Hand Questionnaire, the Michigan Hand Questionnaire and the Patient-Specific Functional Scale following hand and wrist surgery.

The purpose of this study was to determine and compare the responsiveness of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Michigan Hand Questionnaire (MHQ), and the Patient-Specific Functional Scale (PSFS) in patients with carpal tunnel syndrome, wrist pain, finger contracture, or tumor. Eighty-one subjects prospectively completed each questionnaire shortly before and 3 and 6 months after surgery. Data were analyzed using one-way analysis of variance and Newman-Keuls multiple comparison tests. Responsiveness to clinical change was calculated using standardized response means. The DASH was responsive for those with carpal tunnel syndrome (0.77), wrist pain (0.61), and tumor (0.55); the MHQ was responsive for those with carpal tunnel syndrome (1.04), wrist pain (0.87), and finger contracture (0.62); and the PSFS was responsive for those with carpal tunnel syndrome (0.65) and finger contracture (0.64). The interval during which the highest responsiveness occurred for the carpal tunnel, wrist pain, and finger contracture groups was the preoperative to 6-month period. The tumor group experienced the highest responsiveness during the preoperative to 3-month period. Our results indicate that one or more of the instruments evaluated are suitable for outcomes research related to surgery to treat carpal tunnel syndrome, wrist pain, finger contracture, and tumor.