Joseph Hardwicke

Fistula incidence after primary cleft palate repair: a systematic review of the literature.

Background: The development of an oronasal fistula after primary cleft palate repair has a wide variation reported in the literature. The aim of this review is to identify the reported oronasal fistula incidence to provide a benchmark for surgical practice. Methods: A systematic review was undertaken to investigate the incidence of fistula. Multiple meta-analyses were performed to pool proportions of reported fistulae, in each data set corresponding to the continent of origin of the study, type of cleft, and techniques of cleft palate repair used. Results: A total of 9294 patients were included from 44 studies. The overall incidence of reported fistula was 8.6 percent (95 percent CI, 6.4 to 11.1 percent). There was no significant difference in the fistula incidence corresponding to the continent of origin of each study or the repair technique used. The incidence of fistula in cleft lip–cleft palate was 17.9 percent, which was significantly higher (p = 0.03) than in cases of cleft palate alone (5.4 percent). Conclusions: Palatal fistulae were more likely to occur in cases of combined cleft lip–cleft palate, compared with cleft palate alone. The authors would recommend the prospective examination and recording of all fistulae to a standardized classification scheme. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A pilot evaluation study of high resolution digital thermal imaging in the assessment of burn depth

Thermal imaging is a tool that can be used to determine burn depth. We have revisited the use of this technology in the assessment of burns and aim to establish if high resolution, real-time technology can be practically used in conjunction with clinical examination to determine burn depth. 11 patients with burns affecting upper and lower limbs and the anterior and posterior trunk were included in this study. Digital and thermal images were recorded at between 42 h and 5 days post burn. When compared to skin temperature, full thickness burns were significantly cooler (p<0.001), as were deep partial thickness burns (p<0.05). Superficial partial thickness burns were not significantly different in temperature than non-burnt skin (p>0.05). Typically, full thickness burns were 2.3°C cooler than non-burnt skin; deep partial thickness burns were 1.2°C cooler than non-burnt skin; whilst superficial burns were only 0.1°C cooler. Thermal imaging can correctly determine difference in burn depth. The thermal camera produces images of high resolution and is quick and easy to use.

Chemical burns – An historical comparison and review of the literature

Chemical burns represent a small proportion of cutaneous burn with an incidence of up to 10.7%, but have been reported to account for up to 30% of all burn deaths. A review of the literature shows incidences ranging from 2.4% to 10.7%, with a substantial predominance in males. Adult patients with a burn referred to our Regional Burns Centre, over an eight-year period, were identified. 185 chemical burns were recorded (7.9%). The mean age of patient was 40 years (range 16-81 years) and male to female ratio was 6.4:1. Over three-quarters of chemical injuries occurred in the domestic or industrial setting. Acids caused 26% of all chemical burns and alkalis caused 55%. A previous study from the same centre highlights a change in the demographics of chemical burn over the last 25 years. The proportion of chemical burns has risen from 2.7% to 7.9%. Chemical burns occurring in an industrial setting, have dropped, whilst the number of domestic chemical burns has increased by over three times. This change reflects the improved industrial health and safety policy in recent years. The move from the industrial setting to the domestic has implications for future regulations.

A Systematic Review of 2-Strand Versus Multistrand Core Suture Techniques and Functional Outcome After Digital Flexor Tendon Repair

PURPOSE To determine published evidence to evaluate the hypothesis that multistrand techniques result in a poorer outcome than 2-strand techniques for digital flexor tendon repairs. METHODS A systematic review was undertaken to compare outcomes and rupture rates between 2-strand and multistrand core sutures in digital flexor zones 2 to 5. Outcome was measured by the American Society for Surgery of the Hand criteria, original or modified Strickland criteria, or Buck-Gramcko criteria. RESULTS A total of 1,878 patients (2,585 digits; 3,749 tendons) were included from the selected studies. Thirty-three studies reported 2-strand repairs and 15 reported multistrand repairs. Of the total tendon injuries, 59% were flexor digitorum profundus, 38% were flexor digitorum superficialis, and 2% were flexor pollicis longus. The pooled rupture rate was 3.9 per 100 digits. No significant difference was detected between 2-strand and multistrand repairs for outcomes by all measures or rupture rate. CONCLUSIONS Because of the wide variation in reporting of outcomes and study design on which this analysis was based, we cannot definitively confirm our hypothesis. We present the standards for outcomes as well as rupture rate for digital flexor tendon repair. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Outcomes of burns in the elderly: revised estimates from the Birmingham Burn Centre.

Outcomes after burn have continued to improve over the last 70 years in all age groups including the elderly. However, concerns have been raised that survival gains have not been to the same magnitude in elderly patients compared to younger age groups. The aims of this study were to analyze the recent outcomes of elderly burn injured patients admitted to the Birmingham Burn Centre, compare data with a historical cohort and published data from other burn centres worldwide. A retrospective review was conducted of all patients ≥65 years of age, admitted to our centre with cutaneous burns, between 2004 and 2012. Data was compared to a previously published historical cohort (1999-2003). 228 patients were included. The observed mortality for the study group was 14.9%. The median age of the study group was 79 years, the male to female ratio was 1:1 and median Total Body Surface Area (TBSA) burned was 5%. The incidence of inhalation injury was 13%. Median length of stay per TBSA burned for survivors was 2.4 days/% TBSA. Mortality has improved in all burn size groups, but differences were highly statistically significant in the medium burn size group (10-20% TBSA, p≤0.001). Burn outcomes in the elderly have improved over the last decade. This reduction has been impacted by a reduction in overall injury severity but is also likely due to general improvements in burn care, improved infrastructure, implementation of clinical guidelines and increased multi-disciplinary support, including Geriatric physicians.

An analysis of 277 consecutive latissimus dorsi breast reconstructions: a focus on capsular contracture.

Background: Breast reconstruction by means of a latissimus dorsi myocutaneous flap in combination with a prosthesis is a well-established technique. Previous published series have highlighted significant rates of local complications, including capsular contracture. Methods: A retrospective analysis of latissimus dorsi myocutaneous flap reconstructions performed between 2000 and 2010 was undertaken. A standardized preoperative, perioperative, and postoperative clinical protocol was applied to all cases, which included the use of textured, cohesive-gel silicone implants. Results: Two hundred seventy-seven procedures were performed in 243 patients, with one-third being immediate reconstructions. The mean age at reconstruction was 50.4 years. Mean follow-up was 47 months, and 3.6 percent of patients developed Baker grade III capsular contracture requiring capsulotomy. Chemotherapy provided a protective effect (p = 0.0197) against capsular contracture formation. Previous radiotherapy had no significant influence on symptomatic capsule formation. The rate of infection requiring implant removal was 1.1 percent, and 0.7 percent of mastectomy scars showed evidence of recurrent disease. Conclusion: The use of textured, cohesive-gel silicone implants, combined with a standardized surgical approach, can reduce complications in the short- and long-term postoperative period, independent of radiotherapy.

Infiltration of epinephrine in reduction mammaplasty: a systematic review of the literature.

Background: Evidence of the benefit of dilute epinephrine infiltration before reduction mammaplasty is provided by several controlled trials. Despite variation in operative technique and data collection, a reduction in intraoperative blood loss has been shown. The aim of this review of the literature is to weigh the available evidence with respect to reducing blood loss during surgery and other outcome measures such as postoperative drainage. Methods: Two researchers independently selected articles for review, and data were extracted from each primary article and used for statistical and descriptive comparisons. Results: A meta-analysis of operative blood loss showed a highly significant drop in operative blood loss in breasts infiltrated with epinephrine and a reduction in the need for blood transfusion. Operative time, postoperative drainage, and complications were not significantly affected by epinephrine infiltration. Conclusion: The authors’ recommendation would be for the use of dilute epinephrine infiltration before reduction mammaplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The acute effects of electronic cigarette smoking on the cutaneous circulation.

For large volume pelvic-perineal defects, the combined TUG-PAP flap is an excellent option where the VRAM is unavailable. The inclusion of two pedicles increases the vascular reliability of the flap while their common origin from the same parent vessel helps in achieving an adequate pedicle length. Skeletonization of the pedicles may further improve flap reach as well as helping to prevent kinking. The flap can also be tunnelled instead of incising the skin bridge, but care needs to be taken to avoid pedicle compression. Our technique allows flexibility in cases where a large dead space component exists alongside a smaller skin defect. In such cases, most of the cutaneous component can simply be excised and the remaining tissue used to obliterate the dead space. The disadvantages of the combined flap include longer operating time and increased complexity of flap harvest as compared to the VRAM flap. However, these are largely offset due to distinct advantages such as reliable perfusion of the skin paddle and well hidden scar as well as the eliminination of any possible abdominal wall hernia. In summary, we report two cases of large volume pelvicperineal reconstruction using a combined TUG-PAP flap with good outcomes. We consider this to be a reliable and safe reconstructive option and it may well replace the VRAM flap in selected cases.

Facial Aesthetic Outcomes of Cleft Surgery: Assessment of Discrete Lip and Nose Images Compared with Digital Symmetry Analysis

Background: High-quality aesthetic outcomes are of paramount importance to children growing up after cleft lip and palate surgery. Establishing a validated and reliable assessment tool for cleft professionals and families will facilitate cleft units, surgeons, techniques, and protocols to be audited and compared with greater confidence. This study used exemplar images across a five-point aesthetic scale, identified in a pilot project, to score lips and noses as separate units and compared these human scores with computer-based SymNose symmetry scores. Methods: Forty-five assessors (17 cleft surgeons nationally and 28 other cleft professionals from the UK South West Tri-centre units), scored 25 standardized photographs, uploaded randomly onto a Web-based platform, twice. Each photograph was shown in three forms: lip and nose together, and separately cropped images of nose only and lip only. The same images were analyzed using the SymNose software program. Results: Scoring lips gave the best intrarater and interrater reliabilities. Nose scores were more variable. Lip scoring associated most closely with the whole-image score. SymNose ranking of the lip images related highly to the same ranking by humans (p = 0.001). The exemplar images maintained their established previous ranking. Conclusions: Images illustrating the aesthetic outcome grades are confirmed. The lip score is reliable and seems to dominate in the whole-image score. Noses are much harder to score reliably. It appears that SymNose can score lip images very effectively by symmetry. Further use of SymNose will be investigated, and families of children with cleft will trial the scoring system. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Birmingham Burn Centre archive: A photographic history of post-war burn care in the United Kingdom

The Medical Research Council Burns and Industrial Injuries Unit at the Birmingham Accident Hospital pioneered civilian burn care and research in the United Kingdom during the post-war years. A photographic archive has been discovered that documents this period from 1945 to 1975. The aim of this project was to sort, digitize and archive the images in a secure format for future reference. The photographs detail the management of burns patients, from injury causation and surgical intervention, to nursing care, rehabilitation and long-term follow-up. A total of 2650 images files were collected from over 600 patients. Many novel surgical, nursing, dressing and rehabilitation strategies are documented and discussed. We have chosen to report part of the archive under the sections of (1) aseptic and antimicrobial burn care; (2) burn excision and wound closure; (3) rehabilitation, reconstruction and long-term outcomes; (4) accident prevention; and (5) response to a major burns incident. The Birmingham collection gives us a valuable insight into the approach to civilian burn care in the post-war years, and we present a case from the archive to the modern day, the longest clinical photographic follow-up to date.