A Systematic Review of the Efficacy of Haemostatic Interventions in Primary Cleft Palate Repair.

OBJECTIVE: To evaluate the effectiveness of adrenaline infiltration, topical adrenaline, systemic tranexamic acid, fibrin tissue sealants and alginate-based topical coagulants at reducing blood loss and post-operative bleeding in primary cleft palate repair. DESIGN: Systematic review according to PRISMA-P guidelines, using Covidence systematic review software to facilitate 3-stage screening and data extraction by two reviewers. SETTING: Academic cleft surgery center. INTERVENTIONS: Any peri-operative intervention to reduce intra-operative and post-operative bleeding. MAIN OUTCOME MEASURES: Estimated blood loss, rate of post-operative bleeding, rate of return to theatre for haemostasis. RESULTS: Sixteen relevant studies were identified, with a total of 1469 study participants. Nine studies examined efficacy of infiltrating vasoconstrictors and all concluded that 1:100,000-1:400,000 adrenaline infiltration reduced intra-operative blood loss, to the range of 12-60 ml. Secondary bleeding and re-operation for haemostasis were uncommon. Tranexamic acid was studied in five randomised controlled trials, two of which demonstrated a significant reduction in blood loss compared to a control group. Use of fibrin and gelatin sponge products was examined in 3 studies, all of which reported no or minimal bleeding, but did not have quantifiable outcome measures. CONCLUSIONS: Infiltration with vasoconstricting agents, administration of systemic tranexamic acid and application of fibrin sealants have a well-studied and favorable safety profile in pediatric cases, and likely contribute to the relatively low incidence of post-operative bleeding and intra-operative blood loss in primary cleft palate repair.

Cranial Vault Distraction in Nonsyndromic Sagittal Synostosis.

ABSTRACT: A multitude of operations exists for the treatment of patients with sagittal craniosynostosis presenting after 6 months of age, of which total cranial vault remodeling now provides the most reliable aesthetic outcome. As our national craniofacial center evolved and began to develop a comprehensive multi-disciplinary team to manage complex surgical cases, we offered cranial vault distraction as an alternative to more invasive surgery for late presentation nonsyndromic scaphocephaly. The authors conducted a retrospective review of all patients undergoing this procedure.An average distraction distance of 39.4 mm was achieved in 15 patients aged 1 to 9 years. As a result, the cephalic index changed an average of 4%. The mean transfusion volume in the perioperative period was 32.47% of estimated blood volume. There were 2 complications requiring further operative intervention and distraction was stopped early in 1 patient.The authors propose that internal calvarial distraction is a viable alternative to total cranial vault remodeling for the management of late presentations of sagittal craniosynostosis.

Frailty as a predictor of adverse outcomes in head and neck reconstruction: A systematic review.

BACKGROUND: Frailty has been shown to adversely impact outcomes in a number of surgical disciplines. In head and neck reconstructive surgery, frailty may represent a significant risk factor in predicting post-operative outcomes due to the common characteristics of the patient population undergoing these procedures. OBJECTIVES: To summarize the available evidence about frailty as a predictor of post-operative complications, length of hospital stay and quality of life in patients undergoing head and neck reconstructive surgery. STUDY DESIGN: Systematic Review. METHODS: The study protocol was registered with PROSPERO, registration CRD42022302899. Methodology was in keeping with the PRISMA Guidelines for Systematic Reviews. MEDLINE, SCOPUS, EMBASE, Web of Science and CENTRAL were the databases searched. Qualitative synthesis of the included studies was carried out, and quality assessment was performed. RESULTS: Nine studies that reported data on 10,457 patients undergoing reconstruction of the head and neck were included in the review. A number of different tools were used to assess frailty, with the modified frailty index being the most frequently used. In total, 8 studies reported increased rates of complications in patients with increased levels of frailty, irrespective of the frailty tool used, with varied levels of statistical significance across the studies. CONCLUSION: An association is observed between increased rates of perioperative complications and increased levels of frailty in patients undergoing head and neck reconstruction. Frailty tools may represent a useful method to risk stratify patients undergoing reconstructive head and neck surgery.

Temporoparietal fascial flap for primary reconstruction of complex ring avulsion injury: A case report.

Ring avulsion injuries pose difficult treatment decisions for hand surgeons. Urbaniak class III injuries have poor replantation rates, therefore other reconstructive options have to be explored. We present the case of a 39 year old fireman with a complete ring avulsion injury of the left ring finger that was reconstructed with a free temporoparietal fascial flap, covered with a split skin graft. At 6 months follow-up the patient had an excellent range of motion with acceptable aesthetic result but no sensation.

Case Report: Acquired collagenoma on the dorsum of the foot.

Collagenoma is a rare benign skin lesion classified as a hamartomatous proliferation of normal collagen fibres and varying amounts of elastic fibres. They most frequently occur on the arms or trunk and may present as solitary or multiple lesions, as part of a syndrome (such as Cowden Syndrome, Tuberous Sclerosis, or MEN1) or sporadic and of varying sizes. Herein, we report on a case of large acquired collagenomas found in an unusual location on the dorsum of both feet.

Analysis of Outcomes of Pharyngo-laryngo-esophagectomy and Reconstruction with Longitudinal Comparison in a Single Institution.

Advanced hypopharyngeal tumours present complex clinical challenges, and where resection is attempted, there is a requirement for major reconstruction. Despite advances in surgical technique, outcomes remain poor for this patient group, and optimum treatment has yet to be established. We aimed to assess the treatment and outcomes of patients in our institution in the context of previous studies. All patients from 2008 to 2018 who underwent surgical management for hypopharyngeal tumours with pharyngo-laryngo-esophagectomy and flap-based reconstruction were included in the study. Demographic and outcome data were collected, and patient-reported outcomes were solicited from surviving patients using the EORTC QLQ H&N 43 questionnaire. Thirty patients were assessed, in which 12 had gastric pull-ups, 16 had free jejunum flaps, and 2 had free anterolateral thigh flaps. There was a 38% five-year survival rate. Overall, the rates of stricture (10.7%) and fistula (7.1%) were low. The majority of patients (53.6%) returned to a normal diet within three months with a soft or puree diet in 35.7% of patients. Some form of speech was possible in 92.9% of patients. The average questionnaire score for surviving patients was 87.3, with good outcomes related to eating and swallowing, but poorer outcomes for speech and communication. This study showed that outcomes for patients receiving complex reconstruction following hypopharyngeal tumour resection are improving over time. There is still scope for improvement of patient outcomes and refinement of optimum surgical management strategies.

Pedicled sural flaps versus free anterolateral thigh flaps in reconstruction of dorsal foot and ankle defects in children: a systematic review.

BACKGROUND: This systematic review compared free anterolateral thigh (ALT) flaps versus pedicled distally based sural artery (DBSA) flaps for reconstruction of soft tissue defects of dorsal foot and ankle in children. METHODS: A systematic literature search was performed to identify cases where an ALT or DBSA was used to reconstruct the dorsal foot in children. A total of 19 articles were included in the systematic review. RESULTS: Eighty-three patients underwent an ALT reconstruction and 138 patients underwent a DBSA reconstruction. Patients who had a DBSA were more likely to require grafting of the donor site (P<0.001). The size of ALT flaps was significantly larger than DBSA flaps (P=0.002). Subsequent flap thinning was required in 30% of patients after ALT and 12% of patients after DBSA reconstruction (P<0.001). Complications occurred in 11.6% of DBSA and 8.4% of ALT flaps (8.4%). CONCLUSIONS: Both flaps are valid options in reconstructing pediatric foot and ankle defects. Each flap has advantages and disadvantages as discussed in this review article. In general for larger defects, an ALT flap was used. Flap choice should be based on the size of the defect.

Aggressive Digital Papillary Adenocarcinoma Mimicking a Giant Cell Tumour - A Case Report and Review of the Literature.

Aggressive digital papillary adenocarcinoma (ADPAca) is a rare, underreported, and often misdiagnosed malignant tumour of the eccrine sweat gland, with high recurrence and metastatic potential. We present a case of a painless mass over the middle phalanx of the dominant index finger in a 51-year-old man. The mass was present for over 20 years, which had slowly increased in size. The patient only presented when it began to interfere with his profession as an electrician. The clinical presentation was consistent with a giant cell tumour. Histological diagnosis was of an ADPAca. Staging investigations were negative and he subsequently went on to have a ray amputation. The importance of high clinical suspicion of digit lesions is highlighted. No specific histologic features have been identified to predict recurrence or metastasis. We review the merits of performing sentinel node biopsy and alternative treatment options such as Moh's micrographic surgery. We review the international literature to assess metastatic potential and follow-up requirements.

Cell suspensions of autologous keratinocytes or autologous fibroblasts accelerate the healing of full thickness skin wounds in a diabetic porcine wound healing model.

Autologous dermal fibroblasts may be useful in the treatment of diabetic skin wounds. We hypothesized that cultured fibroblasts or cultured keratinocytes would not only survive in a hyperglycemic wound environment but also enhance the rate of re-epithelialization. We previously developed a new porcine model of delayed cutaneous wound healing in the diabetic pig. Full thickness wounds were created on the dorsum and dressed with polyurethane chambers to keep the wounds wet and to allow for wound fluid monitoring. Suspensions of either autologous fibroblasts or autologous keratinocytes were injected into full thickness wounds and compared with wounds treated in a wet environment in normal saline. Serum glucose and wound fluid glucose concentrations were monitored daily. Wound contraction was monitored and biopsies taken on day 12. Transplantation of suspensions of autologous fibroblasts or autologous keratinocytes enhanced re-epithelialization of cutaneous full thickness wounds. Wounds treated with autologous fibroblasts showed a re-epithelialization rate of 86.75% and wounds treated with autologous keratinocytes showed a re-epithelialization rate of 91.3%. This is compared with a re-epithelialization rate of 56.8% seen in the normal saline treated wounds. While previous studies have shown fibroblasts suspension to have little effect in the treatment of full thickness wounds in nondiabetic wounds, this study shows a clear beneficial effect in the use of fibroblast or keratinocyte suspensions for the cutaneous healing of diabetic wounds in pigs.

Impaired wound healing in an acute diabetic pig model and the effects of local hyperglycemia.

Diabetic wounds result in significant morbidity, prolonged hospitalization, and enormous health-care expenses. Pigs have been shown to have wound healing resembling that in humans. The aim of this study was to develop a large-animal model for diabetic wound healing. Diabetes was induced by streptozotocin injection in Yorkshire pigs. Full-thickness wounds were created and dressed with a sealed chamber. Nondiabetic pigs with or without high glucose wound fluid concentration served as controls. Glucose concentration in serum and wound fluid was measured and collected. Wound contraction was monitored, and biopsies were obtained for measurement of reepithelialization. Wound fluid was analyzed for insulin-like growth factor-1 (IGF-1), platelet-derived growth factor, and transforming growth factor. Glucose concentration in wound fluid initially followed serum levels and then decreased to undetectable on day 9. Reepithelialization was significantly delayed in diabetic pigs. In nondiabetic pigs, wounds treated in a local hyperglycemic environment, and thus excluding the effects of systemic hyperglycemia, showed no difference in wound closure compared with controls. This suggests that delayed wound healing in diabetes is not induced by local high-glucose concentration itself. Analysis of growth factor expression showed a marked reduction in IGF-1 in the diabetic wounds. Diabetic pigs have impaired healing that is accompanied by a reduction of IGF-1 in the healing wound and is not due to the local hyperglycemia condition itself.

Optimal plaster conformation derived using a custom-made jig to obtain maximum strength of protective plaster of Paris for hand surgery.

BACKGROUND: Surgical repair of soft tissue trauma in the upper limb frequently requires postoperative immobilization to prevent tension across repaired tendons, vessels, or nerves. A plaster of Paris backslab, placed on either the volar or the dorsal surface, is frequently used, as it is inexpensive and easy to apply. METHODS: In an effort to improve upon the strength of plaster of Paris backslabs, we designed a custom-made jig to subject angled backslabs (n = 5 per group) of various designs to a torsional force. We tested 10-layered backslabs with 0, 1, or 2 ridges and 15-layered backslabs without ridges. RESULTS: We demonstrate that the addition of longitudinal reinforcing ridges on the convex surface of backslabs can improve simple backslabs in terms of breaking strength, plaster stiffness, and failure load. The optimal design employs a single, centrally placed ridge, which provides the maximum support in the axis of the net force acting across the angle, the fulcrum of angle backslabs. The formation of two parallel longitudinal ridges does not offer any additional support. CONCLUSIONS: Backslabs can be strengthened significantly by placement of a single reinforcing ridge. This allows plaster weight and thickness to be kept to a minimum, reducing the setting time of the plaster and contributing to patient comfort. These findings demonstrate the ideal construction of angled plaster of Paris backslabs for the protection of soft tissue repairs.

Experiences with pins and rubber band traction in the treatment of proximal interphalangeal joint contracture.

BACKGROUND: Proximal interphalangeal joint (PIPJ) contracture is a difficult problem to treat regardless of etiology. Although numerous interventions have been recommended, published results are mediocre at best. OBJECTIVE: The authors describe their experience and results of using a modification of pins and rubber band traction (PRBT) - applying a dynamic extension apparatus to a contracted PIPJ using the constant traction force in a stretched rubber (elastic) band. METHOD: A retrospective review of patients treated with this method was performed, and the results are presented. The technique itself is described, and clinical photographs illustrate the method. RESULTS: Mean PIPJ flexion contracture before PRBT was 82° (range 60° to 110°). The full correction of eight contracted PIPJs in seven patients was achieved, in a mean of 17.8 days (range 14 to 31 days). At one month postremoval of PRBT, the mean PIPJ flexion contracture was 22.8° (range 0° to 46°). DISCUSSION: The method is compared with previously described methods of PIPJ contracture correction, whether surgical or splinting; the latter may be static, dynamic or a combination of the two. The results of previously published studies are discussed and compared with the method described. CONCLUSION: The present method is a powerful and effective simplification of a previously described method of correcting PIPJ contractures. This technique is simple, 'low-tech' and can be applied under local anesthetic; the authors believe it offers a useful adjunct to surgical release.

HISTORIQUE: Quelle qu'en soit l'étiologie, la contracture de l'articulation interphalangienne proximale (AIPP) est difficile à traiter. Même si de nombreuses interventions sont recommandées, les résultats publiés sont pour le moins médiocres. OBJECTIF: Les auteurs décrivent leur expérience et les résultats de l'utilisation d'une traction par des tiges et des ancres (TTA), soit l'application d'un appareil d'extension dynamique sur une AIPP contractée à l'aide d'une force de traction constante par une bande élastique étirée. MÉTHODOLOGIE: Les auteurs présentent une analyse rétrospective des patients traités par cette méthode et les résultats du traitement. Ils décrivent la technique et l'illustrent pas des photos cliniques. RÉSULTATS: La flexion moyenne de la contracture de l'AIPP avant la TTA était de 82 ° (plage de 60 ° à 110 °). Huit AIPP contractées ont été complètement corrigées chez sept patients, sur une période moyenne de 17,8 jours (plage de 14 à 31 jours). Un mois après le retrait de la TTA, la flexion moyenne de la contracture de l'AIPP était de 22,8 ° (plage de 0 ° à 46 °). EXPOSÉ: La méthode est comparée à des méthodes par chirurgie ou attelle déjà décrites pour corriger la contracture de l'AIPP. L'attelle peut être statique, dynamique ou combinée. Les résultats d'études déjà publiées sont exposés et comparés à la méthode décrite. CONCLUSION: La présente méthode simplifie avec puissance et efficacité un moyen décrit antérieurement pour corriger les contractures de l'AIPP. Elle est simple, peu complexe et peut être effectuée sous anesthésie locale. Les auteurs sont d'avis qu'elle constitue un ajout utile à la libération chirurgicale.

Gene therapy in the treatment of lower extremity wounds.

This article presents a brief overview of the etiology of chronic wounds of the lower extremities and their current medical and surgical treatment. Gene therapy as a potential tool for treating therapeutically challenging wounds is described in terms of the vectors employed in gene transfer, as well as the strategies used to promote wound healing. Results from animal model studies, as well as clinical trials, are presented.

Cell suspension cultures of allogenic keratinocytes are efficient carriers for ex vivo gene transfer and accelerate the healing of full-thickness skin wounds by overexpression of human epidermal growth factor.

The concept of using growth factor therapy to induce wound repair has been endorsed in studies that show reduced growth factors in wound fluid from chronic and aged wounds. In this study, we used cell suspensions of allogenic keratinocytes as gene-delivery vehicles for human epidermal growth factor (hEGF) and analyzed their impact on wound repair in a porcine wound-healing model. Full-thickness wounds were created on the backs of six Yorkshire pigs and covered with a wound chamber to create a wet wound-healing environment. First, 5 x 10(5) allogenic, autogenic, or mixed keratinocytes were transplanted into wounds and healing parameters were analyzed. Second, we measured long-term reepithelialization and contraction rates from day 8 until day 35. In the third experiment, allogenic keratinocytes were transfected with an hEGF-expressing plasmid pCEP-hEGF and transplanted in full-thickness wounds to improve repair. Wounds treated with autogenic, allogenic, or mixed keratinocytes showed a significantly higher rate of reepithelialization relative to saline-treated control wounds. Repetitive biopsies indicated that the use of allogenic keratinocytes did not lead to long-term wound breakdown. Wounds treated with hEGF-expressing allogenic keratinocytes reepithelialized faster than wounds treated with allogenic keratinocytes or control wounds. With a peak hEGF expression of 920.8 pg/mL, hEGF was detectable until day 5 after transplantation compared with minimal hEGF expression in control wounds. This study shows that allogenic keratinocytes can serve as efficient gene transfer vehicles for ex vivo growth factor delivery to full-thickness wounds and overexpression of hEGF further improves reepithelialization rates.

Highly efficient regulation of gene expression by tetracycline in a replication-defective herpes simplex viral vector.

Employing the tetracycline repressor tetR and the wild-type hCMV major immediate-early promoter, we have developed a highly sensitive tetracycline-inducible transcription switch in mammalian cells (T-REx; Invitrogen, Carlsbad, CA, USA). In view of the previous difficulty in achieving regulatable gene expression in recombinant HSV vector systems, we constructed a T-REx-encoding replication-defective HSV-1 recombinant, QR9TO-lacZ, that encodes two copies of the tetR gene controlled by the HSV-1 immediate-early ICP0 promoter and a reporter, the LacZ gene, under the control of the tetO-bearing hCMV major immediate-early promoter. Infection of cells, such as Vero, PC12, and NGF-differentiated PC12 cells, with QR9TO-lacZ led to 300- to 1000-fold tetracycline-regulated gene expression. Moreover, the expression of the LacZ gene by QR9TO-lacZ can be finely controlled by tetracycline in a dose-dependent fashion. Efficiently regulated gene expression can also be achieved in vivo following intracerebral and footpad inoculations in mice. The demonstrated capability of T-REx for achieving high levels of sensitively regulated gene expression in the context of the HSV-1 genome will significantly expand the utility of HSV-based vector systems for studying gene function in the nervous system and delivering regulated gene expression in therapeutic applications, particularly in the treatment of CNS diseases.