The internal pudendal artery turnover (IPAT) flap: A new, simple and reliable technique for perineal reconstruction.

Perineal defects can be a reconstructive challenge following abdomino-perineal excision of the rectum, pelvic exenteration or the excision of severe pilonidal disease. These defects often involve large perineal cavities and pelvic dead space with often poorly mobile soft tissues due to neoadjuvant chemoradiation. Because of the inherent challenges of wound healing in the perineal region, well vascularised and robust reconstruction is mandated. In this paper, we describe a novel perforator-based turnover flap for perineal reconstruction - the internal pudendal artery turnover flap (IPAT flap). The flap requires no visualisation or dissection of perforating vessels, has a reliable vasculature, is quick and straightforward to perform and allows for the effective reconstruction of deep three-dimensional defects following perineal excisions. This is a retrospective study. A cohort of 38 consecutive patients who underwent various reconstructions with the IPAT flap under a single surgeon were included between 2012 and 2019. At three months, 37 flaps were fully healed. There were no flap failures or partial flap losses. Complications were seen in 10 of 38 patients with nine of these being minor and one that requires a return to the theatre for washout secondary to a urinary leak. The Internal Pudendal Artery Turn Over Flap allows us to reconstruct three-dimensional defects following perineal surgery, achieving more significant mobilisation of the flap to fill deep dead space without the added complexity and additional operative time associated with perforator dissection. The IPAT flap can be used in several common perineal reconstructive challenges expeditiously - often at the end of lengthy oncological resections - with minimal donor site morbidity, and in our experience, yields reliable outcomes.

Thigh burns from exploding e-cigarette lithium ion batteries: First case series.

E-cigarette (EC) use has risen meteorically over the last decade. The majority of these devices are powered by re-chargeable lithium ion batteries, which can represent a fire hazard if damaged, over-heated, over-charged or stored inappropriately. There are currently no reports in the medical literature of lithium ion battery burns related to EC use and no guidance on the appropriate management of lithium ion battery associated injuries. We report two individual cases of burn resulting from explosion of EC re-chargeable lithium ion batteries. Both patients required in-patient surgical management. We provide evidence that lithium ion battery explosions can be associated with mixed thermal and alkali chemical burns, resulting from the significant discharge of thermal energy and the dispersal of corrosive lithium ion compounds. We would recommend, as with other elemental metal exposures, caution in exposing lithium ion battery burns to water irrigation. Early and thorough cleaning and debridement of such burns, to remove residual lithium contamination, may limit the risk of burn wound extension and potentially improve outcomes.

A users guide for reducing the pain of local anaesthetic administration.

Local anaesthetics (LAs) are used by medical practitioners in a number of clinical settings. The choice of agent and mode of administration is influenced by their experience, speciality and knowledge of the evidence base. Patients often express concern about the discomfort experienced during injection. Although short lived, the pain of LA administration in some patients is severe enough for them to decline future surgery. Methods to minimise the pain of LA administration relate to (1) the patient, (2) the LA, and (3) the injection technique (table 1). This article aims to provide a practical guide to doctors of all specialities who use LAs.

Diagnosing PIP breast implant failure: a prospective analysis of clinical and ultrasound accuracy.

INTRODUCTION: The risk of Poly Implant Prosthesis (PIP) breast implant failure has been quantified by the Department of Health as 2-6 times greater than other brands. In the UK, removal of PIP breast implants is recommended when failure is suspected from patient history or clinical findings. Owing to conflicting reports of accuracy in current literature, ultrasound is not recommended as a routine investigation. We aimed to evaluate the accuracy of patient history, clinical impression, and ultrasound at diagnosing implant failure in a large consecutive series of women against the reference standard. We aimed to provide evidence in response to current guidelines and help guide best practice. METHODS: All patients from January 2012-January 2013 who underwent PIP breast implant explantation at the Spire Murrayfield Hospital were prospectively evaluated. Operative findings were correlated to pre-operative results of patient history, clinical impression and ultrasound imaging. Sensitivity, specificity and accuracy were calculated with 95% confidence intervals. RESULTS: A total of 192 women who underwent 384 PIP implant explantations from January 2012 to January 2013 were included. Twenty-three patients (12.0%) reported a positive patient history pre-operatively. In 35 patients (18%), failure was pre-operatively diagnosed clinically. Intra-operatively, 80 implants (21%) in 63 women (33%) had failed. The sensitivity of patient history, clinical impression and ultrasound was 12%, 34%, and 91%, respectively. The specificity was 88%, 89%, and 97%, respectively. Ultrasound was 96% accurate at diagnosing PIP implant failure, whilst patient history and clinical impression were 63% and 71% accurate, respectively. CONCLUSION: Ultrasound provides a far more reliable test of implant failure than patient history or clinical impression. Considering the availability, cost and number of women in the UK with PIP implants, we would recommend high-resolution ultrasound be implemented as a routine investigation.

The epidemiology of multifocal upper limb fractures.

AIM: The aim of this study is to identify the epidemiology of multifocal upper limb fractures and define any commonly occurring patterns. PATIENTS: Patients included were those over the age of 13 years who presented to one orthopaedic trauma unit, in an eight-year period, and who sustained a multifocal upper limb fracture. RESULTS: There were 83 patients with 171 multifocal upper limb fractures. Mean age 60 years; range 13 to 92 years. 78 patients had bifocal fractures and 5 had trifocal. The most common pairing of fourteen different combinations was distal radius and proximal humerus. All but nine patients had involvement of the proximal humerus or distal radius. The most common injuries were the two-part proximal humerus fracture, the simple intra-articular olecranon fracture and the extra-articular fracture of the distal radius with metaphyseal comminution. CONCLUSION: This study has shown that multifocal fractures of the upper limb are most likely to occur in the middle aged to elderly women who have had a fall from standing height. As previously demonstrated osteopenic fractures are increasing in incidence in developed countries, where the population is ageing, which implies that the incidence of multifocal fractures of the upper limb is likely to increase.

Thrombolysis and its implications in the management of stroke in the accident and emergency department.

OBJECTIVES: Examination of initial management of stroke patients in the emergency setting to assess feasibility of thrombolysis for acute ischaemic stroke. METHODS: Retrospective analysis of all patients presenting with a clinical diagnosis of stroke over a two month period. Exclusion criteria for thrombolysis were applied to assess the number of patients that would potentially have been eligible for thrombolysis. RESULTS: Of 94 patients identified with clinical stroke, only 57 (60.6%) had a CT scan; 23 (24.4%) were confirmed as having had an acute ischaemic stroke. Mean delay in scanning was 2.2 days (range 0-15 days). Even if all patients had presented and been scanned within three hours (as required for thrombolysis), only six (6.4%) patients would have been eligible for thrombolysis. CONCLUSIONS: The great majority of patients presenting with clinical stroke do not fulfill the criteria for thrombolysis. Current practice involves significant delays in CT scanning, which has implications for resource structuring should thrombolysis become widely available.

The ad hoc perforator flap for contracture release.

Release and autografting remains a mainstay of treatment of cutaneous and joint-associated contractures. However, owing to secondary contraction of grafts and the increase of children undergoing burn reconstructive surgery, recurrence of contractures is not uncommon. Locally available, well-vascularised tissue that will contract minimally and grow with the patient is the ideal for contracture release. Many 'predesigned' cutaneous flaps have been described, but use of these may involve tailoring a defect to fit a known flap. We introduce the concept of the 'ad hoc' perforator flap, an improvised island flap based on a perforator, innominate or otherwise, that happens to be adjacent to a particular soft-tissue defect and can be reliably raised on scarred skin. We carried out a retrospective analysis of all patients undergoing contracture release within our unit. Twenty-three ad-hoc perforator flaps in 20 patients were carried out between 2000 and 2005. Eleven of the 20 patients were children, and all but one case was subsequent to a burn injury. Fifteen of the 23 flaps were upper limb. In one case, a significant complication involving total flap loss occurred. Only one patient required a skin graft to close the flap donor site, and no patients required revisional surgery for contracture recurrence. The ad hoc perforator flap is a safe and simple technique for the management of contractures, and fulfils the ideal of well-vascularised tissue that can grow with the patient. The flap can be designed as required and, with experience, the concept is applicable not only to contracture release, but many other reconstructive scenarios.

Superficial acral fibromyxoma.

Superficial acral fibromyxoma is a rare soft tissue tumour affecting the digits, particularly the nail bed region. The condition was first described in 2001. We report the case of a 71-year-old man who presented with a long standing history of a lump affecting the pulp of the his right ring finger. This was surgically excised and subsequent pathological analysis confirmed the lesion to have been a superficial acral fibromyxoma. We use this case to highlight the features of this rare clinical entity, which has never previously been described in the surgical literature.

Changing trends in a decade of circumcision in Scotland.

PURPOSE: There has been a move toward conservative management of foreskin problems. The aim of this study was to examine overall trends for circumcision in Scotland to see if there has been a decrease in the number of operations performed. METHODS: Retrospective analysis looking at the number of circumcisions performed each year over a 10-year period (1990 to 2000), in the 0 to 13-year age group. The principal indication for circumcision in each case was ascertained as were the number of preputioplasties performed over the corresponding period. RESULTS: A total of 15,605 circumcisions were performed during the 10-year period; 10,888 (69.8%) for phimosis, 2,724 (17.5%) for nonmedical/religious reasons, and 1993 (12.8%) for all other indications. There was a 33.7% decrease in total number of circumcisions performed between the first and second halves of the study period. The fall in operations performed is almost solely attributable (94.5%) to a reduction in number of procedures carried out for phimosis. There was a corresponding increase in preputioplasties performed over the study period. CONCLUSIONS: There has been a steady decrease in circumcision rates in Scotland. This is in keeping with greater appreciation of pathologic phimosis as distinguished from a healthy nonretractile foreskin, which does not require circumcision.