The use of tendon grafts has diminished as regimes of primary repairs and rehabilitation have improved, but they remain important in secondary reconstruction. Relatively little is known about the cellular biology of grafts, and the general perception is that they have little biological activity. The reality is that there is a wealth of cellular and molecular changes occurring with the process of engraftment that affect the quality of the repair. This review highlights the historical perspectives and modern concepts of graft take, reviews the different attachment techniques and revisits the biology of pseudosheath formation. In addition, we discuss some of the future directions in tendon reconstruction by grafting, which include surface modification, vascularized tendon transfer, allografts, biomaterials and cell-based therapies.

We assessed the use of guided plasticity training to improve the outcome in the first 6 months after nerve repair. In a multicentre randomized controlled trial, 37 adults with median or ulnar nerve repair at the distal forearm were randomized to intervention, starting the first week after surgery with sensory and motor re-learning using mirror visual feedback and observation of touch, or to a control group with re-learning starting when reinnervation could be detected. The primary outcome at 3 and 6 months post-operatively was discriminative touch (shape texture identification test, part of the Rosen score). At 6 months, discriminative touch was significantly better in the early intervention group. Improvement of discriminative touch between 3 and 6 months was also significantly greater in that group. There were no significant differences in motor function, pain or in the total score. We conclude that early re-learning using guided plasticity may have a potential to improve the outcomes after nerve repair. Level of evidence: II

Objective: To present a small case series of a novel solution, using pedicled adipofascial anterolateral thigh (ALT) flaps for skin grafting, for the reconstruction of perineo-scrotal defects following Fournier’s gangrene (a complex surgical problem). Many options are described. We believe that this procedure overcomes the contracture complications of skin grafting alone and that it is a more supple reconstruction in the Western population. Patients: We performed pedicled adipofascial ALT flaps on three patients, for the reconstruction of complex perineo-scrotal wounds with exposed testes, following Fournier’s gangrene. Patients were of male gender, aged 38 – 56 years old and otherwise healthy. The adipofascial ALT flap was raised based on the lateral circumflex femoral artery and was inset with split-thickness skin graft coverage. Results: Study outcomes were time-to-healing and complications. Follow-up was between 6 months to 4 years. At routine outpatient follow-up, all three patients had healed wounds; and at long-term follow-up, all three patients were satisfied with their wound reconstruction. There were no surgical complications. Conclusion: This study demonstrated that the pedicled adipofascial ALT flap is a reliable flap that is straightforward to raise, of an appropriate bulk, and has pliability for the neo-scrotum. The authors recommend this procedure as a good treatment option for reconstructing complex perineo-scrotal wounds following Fournier’s gangrene.

Background Glucocorticoids (GCs) are first-line treatment for keloid disease (KD) but are limited by high incidence of resistance, recurrence and undesirable side-effects. Identifying patient responsiveness early could guide therapy.Methods Nineteen patients with KD were recruited at week 0 (before treatment) and received intralesional steroids. At weeks 0, 2 and 4, noninvasive imaging and biopsies were performed. Responsiveness was determined by clinical response and a significant reduction in vascular perfusion following steroid treatment, using full-field laser perfusion imaging (FLPI). Responsiveness was also evaluated using (i) spectrophotometric intracutaneous analysis to quantify changes in collagen and melanin and (ii) histology to identify changes in epidermal thickness and glycosaminoglycan (GAG) expression. Biopsies were used to quantify changes in glucocorticoid receptor (GR) expression using quantitative reverse transcriptase polymerase chain reaction, immunoblotting and immunohistochemistry.Results At week 2, the FLPI was used to separate patients into steroid responsive (n = 12) and nonresponsive groups (n = 7). All patients demonstrated a significant decrease in GAG at week 2 (P < 0.05). At week 4, responsive patients exhibited significant reduction in melanin, GAG, epidermal thickness (all P < 0.05) and a continued reduction in perfusion (P < 0.001) compared with nonresponders. Steroid-responsive patients had increased GR expression at baseline and showed autoregulation of GR compared with nonresponders, who showed no change in GR transcription or protein.Conclusions This is the first demonstration that keloid response to steroids can be measured objectively using noninvasive imaging. FLPI is a potentially reliable tool to stratify KD responsiveness. Altered GR expression may be the mechanism gating therapeutic response.

Introduction The results of patients with primary zone II flexor tendon repairs rehabilitated using a traditional forearm-based splint were audited and compared with those who were managed in the Manchester short splint. Method The short splint was fabricated to permit maximal wrist flexion and up to 45° of wrist extension with a block to 30° of metacarpophalangeal joint extension. A rehabilitation regimen consisting of early combined passive flexion exercises and active motion was employed. In 2011, 62 patients (76 digits) with a mean age of 34 years (range 14–58) were rehabilitated using the forearm-based splint (group A). In 2012, 40 patients (45 digits) with a mean age of 31 years (range 15–71) were rehabilitated using the Manchester short splint (group B). Results Group B had significantly less flexion contracture at their proximal interphalangeal joints than group A at 6 weeks (median 15° versus 28°; p = 0.003) and 12 weeks (median 6° versus 18°; p = 0.024) postoperatively. At the final review, group B had a significantly greater arc of flexion at their distal interphalangeal joints (median 59° versus 30°; p < 0.001) and a greater proportion of patients with excellent/good Strickland’s grades. There were three (3.9%) ruptures in group A and two (4.4%) ruptures in group B (p > 0.999). Conclusion The use of a shorter splint would appear to enhance the outcomes whilst preserving repair integrity.

We investigated the cellular biology of tendon grafting in a mouse model using green fluorescent protein mismatch grafting and quantitative immunohistochemistry of molecular markers for inflammation, proliferation, collagen synthesis, cell death, and myofibroblast/pericyte expression. We provide a detailed analysis of the healing characteristics during the phases of inflammation, synthesis, and remodelling. Our findings indicated that survival of the cells in the grafted tendon was finite. Syngenic and autologous grafts provoked a similar cellular reaction and all grafts healed. Cells in the graft contributed significantly to collagen synthesis and do have a role in healing.

The second toe was harvested from the ipsilateral foot with simultaneous recipient site preparation (Coskunfirat et al., 2005). Hand therapy began on the fifth day after surgery and essentially followed the scheme of Wallace and Wei (2007). Pulp plasty for tip toe remodelling was performed after 6 months. No other secondary procedures were required. Hand function was evaluated at 18 months. Sensibility was measured from the pulp of the toe transfer. The static 2-point discrimination (Dellon Discriminator, Fisicomedica) was 7 mm. Grip and pinch strength (Jamar dynamometer) were 75% and 87% of the normal contralateral side, respectively. Total range of active motion of the reconstructed finger was 193o (active movement was 44o, proximal interphalangeal; 43.5o, distal interphalangeal; and 105o, metacarpophalangeal joint). He had no donor site problems. He reports being able to the play guitar as well as he did prior to the injury (Figure 1). Reconstruction of single-finger amputations (distal to the proximal interphalangeal joint) with toe transplantation may be indicated in a limited number of patients with functional special requirements: manual workers, musicians, children, or women for cosmesis. The second toe is an ideal option for singlefinger reconstruction. Restoration of length, grip, stability, sensibility, and appearance can be successfully achieved with this flap with a limited donor foot deformity. Preservation of the anatomical structures as much as possible at the initial surgical intervention is one of the main prerequisites of the successful toe transfer (Lee and Buncke, 2007). In the present case we could not have preserved the mid-phalanx stump because there was inadequate bone length (<5 mm). The entire distal condyles of the proximal phalanx were exposed and the articular cartilage was reamed with a small burr. The toe was disarticulated at the metatarsophalangeal joint and cut to the desired length. Finally, it was attached on top the proximal phalanx of the fifth finger with two oblique K-wires. Toe transplants have inherent limitations (del Piñal, 2004) disregarding functional issues such as the fact that the toe is bulbous. Pulp plasty for tip toe remodelling was necessary for adequate guitar neck strings and frets management. Furthermore, interphalangeal joints of the toe move poorly once transferred, and flexion deformity is difficult to avoid. In order to do so, the extensor tendon repair was performed in maximal tension immediately after bony fixation and before proceeding to the flexor tendon. Tension from the flexor tendon repair should reinstate the normal neutral digital cascade.

The cutaneous ligaments of the digits have been recognized by anatomists for several centuries, but the best known description is that of John Cleland. Subsequent varying descriptions of their morphology have resulted in the surgical community having an imprecise view of their structure and dynamic function. We micro-dissected 24 fresh frozen fingers to analyze the individual components of Cleland's ligamentous system. Arising from the proximal interphalangeal (PIP) joint, proximal, and sometimes middle phalanx, we found strong ligaments that ran proximally (PIP-P) and distally (PIP-D). On each side of each finger there was a PIP-P ligament present, which passed obliquely from the lateral side of the proximal and sometimes middle phalanx towards its insertion into the skin at the level of the proximal phalanx. The distal (PIP-D) ligaments were found to pass obliquely distally on the radial and ulnar aspects of the digit towards cutaneous insertions around the middle phalanx. A similar arrangement exists more distally with fibres originating from the DIP joint and middle phalanx (the DIP-P pass obliquely proximally, and the DIP-D, distally). Each individual PIP ligament consisted of three different layers originating from fibres overlying the flexor tendon sheath, periosteum or joint capsule, and extensor expansion. Ligaments arising at the DIP joint had two layers equivalent to the anterior two layers of the proximal ligaments. Cleland's ligaments act as skin anchors maintaining the skin in a fixed relationship to the underlying skeleton during motion and functional tasks. They also prevent the skin from 'bagging', protect the neurovascular bundle, and create a gliding path for the lateral slips of the extensor tendon.

The effect of core suture geometry on the mechanical interaction with the epitenon suture in terms of gap prevention, failure strength and mode of failure was investigated in a flexor tendon repair model. A total of 48 porcine flexor tendons were repaired using three techniques with distinct core suture geometry: single Kessler; double Kessler; and cruciate repair. Cyclic linear testing was carried out with and without a simple running epitenon suture. At failure load the epitenon suture reduced gapping by 87% in the double Kessler, 42% in the single Kessler and 15% in cruciate repairs. It increased the strengths of the repairs by 58%, 33% and 24%, respectively. Kessler repairs failed mainly by suture rupture, with and without epitenon suture, but cruciate repairs failed mainly by suture pull-out. The epitenon suture did not have a significant mechanical effect on the three repairs. Rather, its effect varied with the core suture geometry. The greatest effect occurred with double Kessler repairs.

INTRODUCTION:Revascularisation following axial arterial system injury is effective in upper limb salvage but necrosis of muscle, the tissue most sensitive to ischaemia, may still occur. We examined the frequency of necrosis, its related factors and its functional significance.METHODS:The clinical findings and operative management of 13 patients with injuries at the elbow referred to 2 plastic surgical hand surgery units over a 30-month period were reviewed. Good outcome was defined as minimal impairment with return to previous occupation, intermediate outcome as moderate impairment with change in occupation and poor outcome as major functional loss preventing work.RESULTS:Seven patients injured the brachial and six injured both the radial and ulnar arteries. Concomitant injuries were severe with nerve injuries in 11 and muscle damage in 12 patients. Functional outcome was good in four cases, intermediate in four and poor in five. Muscle necrosis developed in four brachial artery injuries. In all four cases, initial successful revascularisation failed post-operatively. Case review revealed delayed recognition in three cases where pain heralded ischaemia but distal skin circulation and pulses were adequate. Of patients with necrosis, three had a poor outcome and one had an intermediate outcome.CONCLUSIONS:The risk of muscle necrosis must be considered when managing these injuries, particularly if initial revascularisation is unsuccessful. Every effort should be made to optimise repair technique and post-operative monitoring. Limb salvage is no longer enough. Fully viable muscle is necessary to restore function and livelihoods.

Thirty-eight fingers in 27 patients with Dupuytren’s contracture of the proximal interphalangeal joint (PIPJ) in excess of 70° were treated using a staged technique. The first stage involved applying a mini external fixator across the PIPJ for continuous extension over 6 weeks with intensive hand therapy to maintain mobility of the joint and help correct the deformity. Twice weekly during hand therapy sessions the tension of the elastic band across the mini ex-fix was increased, allowing that full active flexion of the PIPJ against the elastic band could still be achieved. The second stage, 4 weeks after the external fixator was applied, involved an open palm technique of fasciectomy for the contracted cords restricting metacarpophalangeal joint movement and dermofasciectomy with full-thickness skin grafting over the proximal phalanx for bands restricting PIPJ movement. The external fixator was used to maintain active extension force until the graft healed. It was generally removed in the outpatient clinic under ring block 2 weeks after the second stage procedure. The patients were followed for a mean of 20.6 (6–48) months. The mean preoperative PIPJ deformity improved from 75° to 37° postoperatively. Overall, 69% of results were rated as good to excellent. Only one patient reported any on-going functional problems. There were eight cases of pin site infections and one case each of loose pins, osteoarthritics at the PIPJ, reflex sympathetic dystrophy, and disease recurrence needing PIPJ fusion. We conclude that our simple staged procedure is a valid alternative in the management of severe Dupuytren’s PIPJ contracture.

Tom Gibson made enormous contributions to the modern development of Plastic and Reconstructive Surgery. His key 1943 paper ‘The fate of skin homografts in man’ described the ‘second set’ phenomenon attributing graft rejection to an immunological phenomenon. Later in his career he visualised the concept of microvascular tissue transplantation and inspired many young surgeons through his various roles of Director of the unit at Canniesburn Hospital, Professor of Bioengineering and President of the Royal College of Physicians and Surgeons of Glasgow.

BACKGROUND:Overproduction of collagen and its abnormal assembly are hallmarks of keloid scars. Type I/III collagen ratios are altered in keloids compared with normal skin. Fibroblasts from different sites in keloid tissue, perilesional compared with intralesional and extralesional sites, show differential apoptosis and contraction. Additionally, early vs. later cell culture passages display differential collagen expression. We therefore hypothesize that keloid fibroblasts from the growing margin of the keloid express higher levels of collagen type I and III, and that collagen production is altered by extended cell culture passage.OBJECTIVES:(i) To measure collagen I and III at mRNA and protein levels quantitatively in keloid fibroblasts, growth media and tissue sections; and (ii) to perform tissue staining for collagen I and III expression in different lesional sites.METHODS:Keloid fibroblast cultures from intralesional, perilesional and extralesional sites (n = 8 separate keloid cases, yielding 64 biopsy samples) were established from passage 0 to passage 3. Collagen I and III mRNA was quantified using quantitative reverse transcription-polymerase chain reaction. We also measured the protein levels quantitatively by developing a highly specific and sensitive capture sandwich enzyme-linked immunosorbent assay. A novel in-cell Western blotting was carried out in addition to haematoxylin and eosin and Herovici staining on keloid tissue sections for collagen I and III.RESULTS:Collagen types I and III were significantly higher (P < 0·03) in fibroblasts from the growing margin (perilesional site) compared with extralesional and intralesional keloid biopsy sites. As the passage number increased, the amount of collagen I significantly (P < 0·05) decreased and the collagen I/III ratio also decreased.CONCLUSIONS:Our data show that cells from the growing margin of keloid scars have a higher production of collagen I and III compared with other lesional sites. Additionally, temporal extension of cell passage affects collagen production. Clinically these findings may influence selection and interpretation of extended cell passage and provide future direction for lesional site-specific therapy in keloid scars.

Background Hyaluronan (HA) is a major component of the extracellular matrix (ECM) with increased synthesis during tissue repair. Tumour necrosis factor-stimulated gene-6 (TSG-6) is known to catalyze the covalent transfer of heavy chains (HC1 and HC2) from inter-alpha-inhibitor (I alpha I) onto HA, and resultant HC.HA complexes have been implicated in physiological and pathological processes related to remodelling and inflammation.Objective The aims of this study were to determine the expression of HA, TSG-6 and the IaI polypeptides in unscarred skin, normal scars and keloid scars.Methods Formalin-fixed paraffin-embedded sections of unscarred skin, normal scars and keloid scars were prepared from patient samples collected during scar revision surgery. Haematoxylin and eosin, as well as immunofluorescent staining for HA, TSG-6 and the three polypeptide chains of I alpha I (i.e. HC1, HC2 and bikunin) were performed.Results All skin types stained positive for TSG-6, HC1, HC2 and bikunin, associated with keratinocytes, fibroblasts and skin appendages all in close proximity to HA. Keloid lesions showed altered HA organization patterns compared with unscarred skin and normal scars. TSG-6 staining was significantly more intense in the epidermis compared with the dermis of all sample types. There was a significant reduction in TSG-6 levels within keloid lesions compared with the dermis of unscarred skin (P = 0.017).Conclusion TSG-6 is expressed in unscarred skin, where its close association with HA and I alpha I could give rise to TSG-6-mediated HC.HA formation within this tissue. A reduction in the beneficial effects of TSG-6, caused by diminished protein levels in keloid lesions, could contribute to this abnormal scarring process.