R. H. Milner

The vascular anatomy of the lower anterior abdominal wall: a microdissection study on the deep inferior epigastric vessels and the perforator branches.

&NA; The deep inferior epigastric artery provides the main blood supply to the lower abdominal wall. Microdissection of the artery, its main branches, and the perforator vessels was undertaken in 20 cadavers. The artery was found to be associated with two veins in most of the cases (90 percent). The lateral division of the deep inferior epigastric artery and the perforator vessels it gives are more dominant (80 percent of cases) than the medial perforators (20 percent of cases). The lateral perforators were greater in number (80) and more consistent than those that arose from the medial division (28). The musculocutaneous perforators are the most important perforators supplying the anterior abdominal wall. An average of 5.4 large perforators (>0.5 mm in diameter) were dissected in each case. These perforators are mostly contained in the area lying laterally and below the umbilicus, with an average distance of 4 cm from the umbilicus. The musculocutaneous perforators may have a direct or indirect course. Larger perforators (>0.5 mm in diameter) were found to have a direct course through the subcutaneous fat to the skin. Smaller perforators do not reach the skin but terminate at the level of the deep fat layer by branching after piercing the rectus sheath. The direct perforator vessels with their associated veins (microdissection) keep a consistent diameter before dividing at the subdermal level and end by contributing to the subdermal plexus. (Plast. Reconstr. Surg. 109: 539, 2002.)

CARPAL TUNNEL SYNDROME: THE CORRELATION BETWEEN OUTCOME, SYMPTOMS AND NERVE CONDUCTION STUDY FINDINGS

A retrospective study was performed on 62 patients who had undergone carpal tunnel decompression surgery. Each patient was assessed in clinic, their case notes were reviewed and their electrophysiological results were analysed and graded according to severity. The median preoperative duration of symptoms was 2 years. No relationship was found between the nature or duration of pre-operative symptoms and the severity of the electrophysiological impairment. Furthermore, no relationship could be identified between pre-operative nerve conduction impairment and either successful outcome of surgery (defined as complete symptom relief) or time to resolution of symptoms after surgery.

A Prospective Randomized Comparison of Sutter and Swanson Silastic Spacers

This study compares two currently available prostheses for the reconstruction of rheumatoid joints. A single operator performed 72 resection arthroplasties with Swanson or Sutter prostheses being randomly allocated. Assessment of each patient was carried out preoperatively, and at 6 months and 12 months postoperatively by a single investigator. In the Swanson group an improvement of the flexion arc was seen, from 29° to 44° at 6 months but this reduced to 36° at 12 months. In the Sutter group there was no significant difference between flexion arcs pre- and postoperatively. Grip strength improved in the Swanson group, but not in the Sutter group. Extensor lag was improved in both groups. Patient satisfaction measured by linear analogue scales for pain, function and deformity was high in both groups

Intraneural lipofibroma of the median nerve

Intraneural lipofibroma of the median nerve is rare. We present three cases of this condition and discuss the surgical management. Open biopsy and carpal tunnel release are usually required.

Early active mobilization following UCL repair With Mitek bone anchor.

Ulnar collateral ligament (UCL) injuries of the thumb are common. Surgical repair is accepted as the treatment of choice for complete rupture of the ligament. Biomechanical studies have suggested that Mitek bone anchor repairs are potentially safe and strong enough to allow early controlled active mobilization. To date, there have been no studies to compare early active mobilization following Mitek bone anchor repair to standard postoperative rehabilitation involving thumb spica immobilization for the first 4 to 6 weeks. We performed a small pilot randomized control trial to assess the outcome of this new rehabilitation technique to that of standard immobilization following UCL repair with Mitek bone anchor. Our results show that on average early active mobilization leads to an earlier return to full hand function (6 vs. 8 wk) and an earlier return to work (7 vs. 11 wk). There is no difference in the final range of motion achieved. We suggest that Mitek bone anchor repairs for UCL ruptures are robust enough to allow early active mobilization and that a larger trial is warranted to assess whether early active mobilization is superior to standard rehabilitation.

EXPERIENCE OF ANGIOSARCOMA IN THE NORTH OF ENGLAND BONE AND SOFT TISSUE TUMOUR SERVICE

INTRODUCTION Angiosarcomas are rare aggressive sarcomas of vascular endothelial origin. These tumours have the potential to be multicentric and are associated with high rates of local recurrence, which makes treatment challenging. The gold-standard is that these patients are managed in specialist centres by a multidisciplinary team. We present our experience of managing patients with angiosarcoma in the North of England Bone and Soft Tissue Tumour Service and a review of the literature. METHODS A prospectively collated electronic database was used to identify patients with angiosarcoma treated between 2000 and 2008, and an analysis performed of demographics, anatomical site, surgical excision and reconstruction, local disease recurrence and metastatic disease. RESULTS Fifteen patients (ten female, five male, mean age 71 years) were identified. Eight patients developed tumours in a previously irradiated area, after a mean of 11 years. Six patients had metastatic disease at presentation. Fourteen patients underwent wide surgical excision of the tumour, of which nine required defect reconstruction (five free latissimus dorsi flaps, two free anterolateral thigh flaps, two pedicled latissimus dorsi flaps). One patient was treated with chemotherapy only. Five of 14 patients received adjuvant radiotherapy, and one received adjuvant chemotherapy. Two out of 14 patients developed local recurrence. Eight patients developed metastases, the majority of which were pulmonary. Estimated five-year survival was calculated as 33% in our patient cohort. CONCLUSIONS Angiosarcomas are aggressive, difficult to treat tumours, which can occur secondary to a multitude of causes. Clinical suspicion, biopsy and early diagnosis are essential to allow optimum treatment, which currently consists of radical surgery, together with adjuvant radiotherapy and chemotherapy.

Thumb reconstruction using a free osseocutaneous fibular flap following excision of an epithelioid haemangioendothelioma

Epithelioid haemangioendothelioma are a rare type of aggressive vascular tumour, which can occur in multiple areas of the body. Current treatment is surgical with wide excision of the tumour and surrounding tissue often resultant in large defects requiring reconstruction. We present the case of a patient with an epithelioid haemangioendothelioma affecting the proximal and distal phalanx of their dominant thumb. Local reconstructive options were poor given the wide excision margin including both skin and bone. After careful consideration, the decision was made to reconstruct the area using a free osseocutaneous fibula flap to provide both vascularised bone and an overlying skin paddle. We report the first documented case of a thumb reconstruction with an osseocutaneous free fibula flap following excision of an epithelioid haemangioendothelioma.Level of Evidence: Level V, therapeutic study.

Spontaneous auricular seroma

We present a case of spontaneous seroma of the ear, which can be encountered in the plastic surgery clinic. We describe our management and briefly review the literature regarding this interesting condition.