Vikram S. Devaraj

Reducing non-attendance at outpatient clinics.

Outpatient non-attendance is a common source of inefficiency in a health service, wasting time and resources and potentially lengthening waiting lists. A prospective audit of plastic surgery outpatient clinics was conducted during the six months from January to June 1997, to determine the clinical and demographic profile of non-attenders. Of 6095 appointments 16% were not kept. Using the demographic information, we changed our follow-up guidelines to reflect risk factors for multiple non-attendances, and a self-referral clinic was introduced to replace routine follow-up for high risk non-attenders. After these changes, a second audit in the same six months of 1998 revealed a non-attendance rate of 11%—i.e. 30% lower than before. Many follow-up appointments are sent inappropriately to patients who do not want further attention. This study, indicating how risk factor analysis can identify a group of patients who are unlikely to attend again after one missed appointment, may be a useful model for the reduction of outpatient non-attendance in other specialties.

Microdrilling of digital calcinosis

Abstract Soft tissue calcification may be an unspecific local response or cause pain and present as part of a complex underlying disease. It can be exquisitely painful when located in the pulp of the digits. In this paper we describe a new minimally invasive technique for the treatment of finger calcinosis in patients with CREST syndrome (calcinosis, Raynaud’s phenomenon, esophageal hypomotility, sclerodactyly, telengectasia). A rose head or micropoint burr on a minidriver or microaire system is used to disrupt the calcific deposit. Healing is usually rapid.

Ultrasound-guided steroid injection for osteoarthritis of the trapeziometacarpal joint of the thumb

This contribution introduces an unreported technique of ultrasound-guided steroid injection, for osteoarthritis of the trapeziometacarpal joint.

Surgical tip: Simple technique for harvesting split thickness skin grafts from degloved skin

In cases of degloving, skin grafts can be harvested from the avulsed tissue. This can, however, be technically challenging due to the loss of contour to the flap and the uneven under-surface. Several methods for harvesting the skin have been described. We have found that the most simple and effective approach is to use either a bag of saline or an up-turned kidney dish, to create a contour over which the flap can be tented by an assistant (Figure 1).

Finding the lateral cutaneous nerve of the thigh

Meralgia Paraesthetica is defined as a painful mononeuropathy of the lateral femoral cutaneous nerve, which is commonly due to nerve entrapment focally as it passes through the inguinal ligament. Other causes have been reported such as direct trauma, ischaemia, diabetes, pregnancy and stretch injuries. Typically, this disorder occurs in isolation, and the features are so characteristic, history and examination are sufficient to make the diagnosis. However, nerve conduction studies can further corroborate and confirm the diagnosis. To date, the literature states that the treatment is largely supportive. The lateral cutaneous nerve of the thigh is a nerve of the lumbar plexus. It arises from the dorsal divisions of the second and third lumbar nerves. It emerges from the lateral border of the psoas major at about its mid-point and crosses the iliacus muscle obliquely, towards the anterior superior iliac spine, which is the most common site of entrapment. It then passes under the inguinal ligament and over the sartorius muscle into the thigh, where it divides into an anterior and a posterior branch, (Figure 1). Patients commonly report pain and numbness. Some may report aching in the groin or pain across the buttocks. The pain is commonly aggravated by light touch rather than firm pressure; a common neuropathic symptom. Taking a thorough history is key to making the diagnosis. Details about recent surgery, pregnancy, injuries to the hip and pelvis and sporting activities should be sought as all of these could irritate the nerve. A clinical examination particularly concentrating on neurological aspects should be conducted delineating any sensory alteration in both the affected and unaffected leg. There is no motor loss, as it a purely sensory nerve. Once the diagnosis has been made clinically, nerve conduction studies through electromyography can be conducted to confirm the diagnosis and

Use of the A3 pulley as an interposition flap to cover periosteal defects

Dear Sir, Loss of periosteal continuity after periosteal fracture or removal of bony exostoses can result in an exposed bone surface, with potential involvement of adjacent structures via adhesions, including flexor and extensor tendons (Yamazaki et al., 2008). This can lead to reduced function and therefore needs to be minimised as far as possible. We propose a simple technique for attempting such a reduction, while incurring minimal donor morbidity. A 14-year-old female with hereditary multiple exostoses developed one on the volar aspect of the index finger. This was restricting tendon excursion and was electively excised back to reproduce a more normal bone contour. However, the periosteal covering was intricately involved in the exostosis and therefore was also excised. To facilitate adequate exposure, the A3 pulley (Fig 1a) was incised laterally and reflected. The exposed raw bone surface (Fig 1b), a potential source of tendon adhesions,

The mermaid procedure for a complex hand anomaly.

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Osteoarthritis after cold injuries

Frostbite is a thermal injury resulting in localised tissue damage due to inadequate circulation when the ambient temperature is below freezing. Osteoarthritis (OA) can develop after cold injuries. A 30-year old rock-climber presented with clinical and radiological signs of OA in his right middle and ring finger distal interphalangeal joints (DIPJ). He denied any hand trauma but had suffered frostbite to his fingers at the age of 19 during a trip in the Himalayas. Arthrodesis was performed in a functional position for his activities. The exact pathophysiology is unknown, but it is believed that both freezing and rapid rewarming are contributing factors. We postulate that osteoarthritis after frostbite in young adults is more likely to occur as the growth plate is nearing maturity. Initially, the ischaemic insult is partially remedied during reperfusion, but further cartilage damage may continue during the remodelling phase as the young adult continues to be active and the joints are subjected to constant load transmission. This may explain the variability in the timing of clinical presentation with osteoarthritis. Arthrodesis is indicated for symptomatic cases and facilitates continued interest in active sports. Hobbies should be considered in the history, including exposure to extreme weather conditions when young active patients present with OA.Level of Evidence: Level V, diagnostic study.

Synovial sarcoma within the carpal tunnel of a child: sentinel lymph node biopsy and microvascular reconstruction:

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Suture repair of nail bed lacerations - macro or micro: does it really matter?

D.W. Oliver ́ A.S. Halim ́ V.S. Devaraj ()) Department of Plastic and Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, U.K. Fingertip injuries account for a considerable workload in any Accident and Emergency and Plastic Surgery department. Studies have confirmed that meticulous primary nail bed repair is associated with good results [1] particularly in children [2]. However we were disappointed to find little data as to what constitutes a meticulous repair and whether this is always necessary. A small prospective (non-randomised) appraisal was organized to study the outcome following nail bed repair either performed in the Accident and Emergency department without magnification using 5/0 Polyglactin (Vicryl ) or using loupe magnification and 8/0 Polyglycolic acid (Dexon aSo ) sutures. All repairs were performed using interrupted sutures by a member of the department of Plastic Surgery. Twenty patients were assessed between December 1995 and August 1996. The mechanism of injury, operative findings and type of suture used was recorded. The zone of injury was also recorded and graded viz (I) Matrix, (II) Proximal, (III) Mid, (IV) Distal. All patients were seen in the outpatient department at 6 weeks and 3 months following injury. Fifteen (75%) patients were seen between 9±20 months (mean 12 months) after injury. At this time results were graded: