Dual pedicle epiphyseal transfer for paediatric bony sarcoma reconstruction: Technique and review of outcomes.

Skeletal reconstruction after tumour resection in paediatric patients is challenging. The resultant reconstruction needs to meet the demands of graft incorporation as well as the potential for growth. The vascularised fibular epiphyseal transfer (VFET) offers the potential for both. We retrospectively reviewed eight paediatric patients treated with VFET after bony tumour resection. All patients underwent a dual pedicle transfer with the peroneal artery for the diaphyseal blood supply and the recurrent branch of the anterior tibial artery for the physis. This is the largest series in literature for dual pedicle transfers for bony reconstruction. We present our surgical technique and outcomes in terms of functional limb salvage and growth.

Developing a Three-Layered Synthetic Microsurgical Simulation Vessel.

BACKGROUND: Microsurgery is increasingly relevant, and is difficult to learn. Simulation is relied upon ever more in microvascular training. While living models provide the ultimate physiological feedback, we are ethically obliged to optimize non-living models to replace, refine, and reduce the use of animals in training. There is currently no three-layered synthetic vessel available for microsurgical training. METHODS: A three-layered synthetic vessel was designed with a simulation company. One anastomosis was performed by 14 microsurgical experts at one center. The realism of the vessel was assessed via user questionnaires and the construct validity using objective, validated task scores to assess the anastomosis performance and the final product. Videos were obtained, which were anonymized and marked remotely by a consultant plastic surgeon. RESULTS: The synthetic vessel intima and media displayed reasonable realism, while the adventitia was less realistic. Areas for improvement were identified. Both the task specific assessment score and the final product assessment appropriately identified experts. CONCLUSION: A three-layered synthetic model for microvascular training is a hygienic and useful intermediate-level alternative to commonly used synthetic and ex vivo alternatives.

The natural history of Becker expandable breast implants: a single-center 10-year experience.

BACKGROUND: Use of Becker expandable breast implants in single-stage breast surgery is a well-established technique; however, replacement with fixed-volume implants is common. The authors sought to analyze the long-term natural history of these implants over a wide range of surgical indications. METHODS: A retrospective review of 330 consecutive patients who underwent 384 Becker expander breast reconstructions over a 10-year period in a dedicated plastic surgery unit was undertaken. Implant indication, Becker type, volume and site, complications, expander lifespan, and explant reasons were assessed. RESULTS: Two hundred twenty-eight patients (267 implants) and 102 patients (117 implants) underwent implantation for congenital deformities and breast cancer reconstruction, respectively. One hundred eighty-seven (48 percent) were explanted at a median period of 13.0 months (range, 9.0 to 26.0 months), 149 (39 percent) for aesthetic reasons and 38 (10 percent) for complications. Complication rates were higher in breast cancer reconstruction compared with congenital patients (19.6 percent versus 7.9 percent; p = 0.002), driven by an increased rate of wound complications (13.7 percent versus 4.4 percent; p = 0.003). Cancer-related surgery and advancing age were the only predictors of complication risk. The overall Becker expander retention rate was 24.9 percent and 46.8 percent at 150 months in the cancer reconstruction and congenital groups, respectively. CONCLUSIONS: Forty-seven percent of Becker implants were retained long term after congenital corrective surgery; only 25 percent were retained after postmastectomy reconstruction. Poor aesthetics was driving the exchange for fixed-volume implants, indicating that after breast cancer reconstruction, Becker expanders were being used as part of a two-stage reconstructive strategy.

The effect of the grade of surgeon on blood loss in fractured neck-of-femur surgery.

Significant blood loss in neck-of-femur (NOF) fracture surgery contributes to the high morbidity and mortality. Since the introduction of the European Working Time Directive, trainee surgeons are more junior and inexperienced. We assessed NOF surgical blood loss in relation to the surgeon grade and experience. We assessed a prospective consecutive cohort of 105 acute NOF fracture patients treated surgically. Blood loss was calculated as the difference between the pre- and post-operative haemoglobin levels. Warfarin was reversed pre-operatively where necessary. There were 32 male and 73 female patients, with mean age 83.8 years (range 48-98). One patient died peri-operatively and was excluded. There were 49 intra-capsular fractures and 55 extra-capsular fractures, with no significant difference in group characteristics. Mean haemoglobin drop was 2.8 g/dL [intra-capsular fractures, 2.5 g/dL; extra-capsular fractures, 3.1 g/dL (p = 0.019)]. The difference in blood loss between different surgeon grades was not significant: consultants 2.4 g/dL (21 cases), senior staff grades 2.7 g/dL (17 cases), junior staff grades 3.1 g/dL (15 cases) and registrars 2.9 g/dL (50 cases). Whilst mean haemoglobin drop was least for consultants, the mean for trainees was only marginally higher than for experienced staff grade surgeons and lower than for their junior counterparts. Mean blood loss for patients taking anti-platelet agents was not significantly different (aspirin 2.7 g/dL, clopidogrel 3.7 g/dL, 4.4 g/dL for those taking both) compared to patients taking neither agent (2.8 g/dL). We conclude that surgeon grade does not significantly impact peri-operative haemoglobin drop, regardless of pre-operative morbidity. It is safe for trainees to operate, with adequate supervision where appropriate, on all NOF fracture patients without compromising blood loss.

Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing.

INTRODUCTION: Rivaroxaban is the first licensed oral direct inhibitor of factor Xa. Recent studies from the RECORD trials suggest rivaroxaban has superior efficacy compared to enoxaparin in preventing venous thromboembolism (VTE) with no significant increase in the major bleeding risk. Concerns remain regarding the incidence of minor bleeding, consequent delayed wound healing and subsequent risk of infection. The aim of this observational study was to assess the incidence of post-operative complications in patients receiving either rivaroxaban or enoxaparin thromboprophylaxis following elective hip and knee arthroplasty. METHODS: A total of 258 patients undergoing elective total hip or knee arthroplasty within one NHS Trust were included. A total of 202 subjects (mean age, 70.7 years ± 10.0, 43 % men) received a daily dose of 10 mg of oral rivaroxaban and 56 (mean age, 70.9 years ± 9.8, 39 % men) had a daily subcutaneous injection of 40 mg of enoxaparin as thromboprophylaxis. Endpoints included VTE (deep vein thrombosis and pulmonary embolism), haemorrhagic wound complications, hospital re-admission, requirement for blood transfusion, minor and major bleeding and death. RESULTS: There were no significant differences in the incidence of VTE, requirement for blood transfusion and readmission rate between rivaroxaban and enoxaparin-treated patients. The incidence of minor bleeding (2.0 vs. 0 %) and haemorrhagic wound complications (5.0 vs. 1.8 %) were non-significantly higher in the rivaroxaban-treated group. There were no cases of pulmonary embolism, major bleeding or death in either group. CONCLUSION: Our experience with rivaroxaban in elective hip and knee arthroplasty showed no significant difference in the incidence of VTE or major bleeding. There was, however, a tendency to greater risk of minor bleeding and wound complications that were largely haemorrhagic in nature, which may have reached significance in a larger study.

Life-threatening coma and full-thickness sunburn in a patient treated with transdermal fentanyl patches: a case report.

INTRODUCTION: Fentanyl transdermal patches have been widely used in the treatment of chronic pain and in palliative care settings since 1991 in cases where prolonged opioid use is often necessary. Transdermal drug delivery is deemed safe and effective with the advantages of delivering a steady dose of the drug and improving patient compliance due to its ease of use. However, intentional and unintentional misuse and overdose using transdermal opioid patches has been widely reported in the literature. CASE PRESENTATION: We describe the case of a 77-year-old Caucasian woman who developed severe opioid toxicity while sun tanning, likely due to altered fentanyl transdermal patch function in a heated environment. As a result of prolonged sun exposure due to an opioid-induced coma she then sustained hyperthermia and severe burns to her abdomen and lower limbs. This inadvertent fentanyl overdose necessitated initial treatment in intensive care and follow on care in a specialist burn unit. CONCLUSION: Patients who are using fentanyl patches and their relatives should be educated about how to use the patch safely. Healthcare practitioners should warn patients about the possibility of overdosing on transdermally delivered drugs if used incorrectly. They should avoid strenuous activities and external heat sources such as warming blankets, hot water bottles, saunas, hot tubs or sunbathing and should seek medical attention if they develop a fever. Additionally, any burns sustained in the context of altered consciousness levels such as in this case with opioid overdose should raise suspicion about a potential deeper burn injury than is usually observed.