Zone 1 flexor tendon avulsion and laceration injuries are commonly managed by plastic surgeons. These injuries are traditionally repaired using the button pullout technique originally described by Bunnell in 1940. The morbidity related to this method is well documented and this has lead to the development of alternative repair methods. These include modifications of the pullout button technique, internal suture techniques and more recently techniques using bone anchors. However, at present no one technique has been shown to be superior to the others either in terms of outcome or low complication rates. This review examines the published techniques for dealing with these injuries with a view to providing the reader with the available outcome data for each repair type.

This article evaluates the outcome of 42 consecutive zone 1 flexor tendon injuries treated by using micro bone anchors during the period 2003-2008. Patients were rehabilitated using the modified Belfast Regime. The range of motion at the distal interphalangeal joint was assessed using Moiemen's classification. A total of 56% of patients achieved excellent or good results for range of motion at the distal interphalangeal joint and 23% had a poor outcome. The mean distal interphalangeal joint and proximal interphalangeal joint range of motion were 48° and 96°, respectively. A total of 94% of patients returned back to work by 12 weeks. One patient sustained a tendon rupture and one developed osteomyelitis. The mean QuickDASH score was 13.5 and 81% of patients were satisfied with their outcomes. This is the largest clinical study on the use of bone anchors for zone 1 tendon injuries. Our study demonstrated a low rate of complications and outcomes that compare favourably with other published techniques.

INTRODUCTION: Significant controversy surrounds the effectiveness of negative pressure wound therapy although it has been in use for decades. Whilst many clinicians favour this modality in relation to its practicality, ease of use especially in complex wounds, it has faced the same challenges as other dressings in relation to evidence base of efficacy in relation to a number of outcome measures. In view of current financial pressures on healthcare systems worldwide this structured review systematically challenges the evidence for perioperative application of Topical Negative Pressure (TNP) to Split Thickness Skin Grafts through evidence-based critical appraisal, and extrapolate the mechanisms of action on the mechanisms through which TNP may aid wound healing. Weighted evidence-based recommendations regarding the impact of TNP on split skin graft quality and quantity of take as outcomes. METHODS: Phase 1: Structured literature search. Phase 2: retrieved articles were critically appraised (CA) for rigour and methodological validity by three independent authors, then stratified according to a validated “levels of evidence” framework. Graded ‘current best evidence’ recommendations could therefore be proposed. Weighted evidence-based recommendations regarding the impact of TNP on split skin graft quality and quantity of take as outcomes. RESULTS: (Table 1) Of 220 studies retrieved in the initial search, 38 studies satisfied our quality of evidence criteria. Current best evidence supports two complementary trends explaining the mechanisms whereby STSG benefits from TNP. Active stimulation of epithelial mitosis: TNP creates mechanical stretch which stimulates multiple signaling pathways up-regulating growth- and mitosis-associated epithelial transcription factors. TNP also promotes microcirculatory flow (graft and wound edge), stimulates angiogenesis and basement membrane integrity (Grade C). Prevention of complications: significant reduction of graft lift-off by edema, exudates, sub-graft hematoma, and reduction of shear when compared to traditional dressings (Grade B). TNP promotes significant qualitative improvement in the final STSG result studies (Level 1B). The role of TNP in prevention of infection is however equivocal and further research is required. No evidence of harm from TNP application was reported.Table 1: Perioperative Application of Topical Negative Pressure to Split Thickness Graft: Hierarchy of Evidence and Graded Recommendations.DISCUSSION: Literature published in the last ten years suggests TNP expedites active graft take and reduces the rate of complications. Evidence of an effect of TNP on quality of the graft take rests within level 2 to 5 evidence which suggested a positive effect. No study reported any deleterious effect arising from TNP application to graft take. Moreover a synthesis of 101 cases reported in the literature reports 95% graft take in complicated cases. Naturally, case-series data is open to the possibility of reporting bias, however this pooled data matches the general outcome trends from other studies. Only one study suggested no significant difference between TNP and traditional bolster dressings, and the validity of this study’s qualitative findings may have been affected by non-independent experimental conditions. TNP is therefore proposed as the dressing of choice for STSG applied to complex, large, exuding, irregularly contoured wounds. CONCLUSION: TNP increases quantity and quality of split skin graft take compared to traditional bolster dressings. The advantages are increased in irregularly contoured, technically difficult wounds and suboptimal recipient wound beds where it appears to be the best modality currently available. Large scale randomized clinical controlled trials remain scanty in all areas of wound dressing research including negative pressure therapy.

Despite being one of the rarest congenital upper limb abnormalities, a wide spectrum of the typical mirror hand has been described in the literature. We report a very interesting case of a new variant of mirror hand presenting in a 78-year-old man. The unique features of the case include the age at diagnosis, the anatomical features present and the acquired function despite no form of reconstructive surgery.

INTRODUCTION:Pre-operative limb preparation (PLP) usually involves lifting the limb and holding it in a fixed 'static' posture for several minutes. This is hazardous to theatre staff. Furthermore, 'painting' the limb can be time consuming and difficult areas such as between toes and fingers may remain unsterile. We demonstrate the time efficiency and asepsis achieved using the 'sterile bag' preparation technique. An additional advantage is the ability to prepare and anaesthetise a limb prior to theatre, increasing efficiency substantially for units with a large throughput of cases, such as day-case hand surgery lists.METHODS:We monitored the duration of PLP in 20 patients using the 'sterile bag' technique compared to 20 patients using a conventional 'painting' method. Additionally, microbiology samples acquired from prepared upper limbs of 27 sequential patients operated on by a single surgeon over a two-month period were sent for culture immediately prior to commencement of surgery.RESULTS:The mean duration of the 'sterile bag' PLP was significantly lower than that of the conventional method (24 seconds vs 85 seconds, p=0.045). The technique can take as little as ten seconds (n=1). Final microbiology reports showed no growth for any of the 27 patients from whom a culture sample was taken.CONCLUSIONS:The sterile bag technique is effective in achieving asepsis, has the potential to increase theatre efficiency and reduces manual handling hazards compared to the conventional method. It is now taught to all theatre staff in our hospital during manual handling training. It can be undertaken in approximately ten seconds with practice for the upper limb.

Orthopaedic literature regarding lower limb joints reports a decline in operative management of rheumatoid arthritis since the 1980s. We investigated whether the demand for hand surgery for rheumatoid disease had changed over the last 13 years in our unit. Data for all patients undergoing operative treatment for rheumatoid arthritis of the hand and wrist over a 13-year period were analysed. Between 1996 and 2009, 1,069 patients with rheumatoid disease (182 men, 887 women) underwent a total of 1,109 hand surgery procedures. The operations were synovectomy (430, 39%), arthroplasty (252, 23%), arthrodesis (194, 18%) and tendon surgery (233, 21.0%). Linear regression analysis showed a statistically significant decrease in the number of synovectomies, arthroplasties and arthrodeses between 1996 and 2009, but no decrease in tendon surgery. We explore possible factors responsible for this change in operative workload.

Iatrogenic femoral nerve injury is an uncommon but recognised complication of abdominal and gynaecological surgery. There have been several reported cases following colorectal surgery which specifically report transient femoral nerve neuropathies with variable but often full recovery. To our knowledge, this is the first documented case of femoral nerve reconstruction after iatrogenic resection during right hemicolectomy. We present a case report of complete femoral nerve transection following abdominal surgery and discuss our management.

Cigali BS, Kutoglu T, Cikmaz S. Musculus extensor digiti medii proprius and musculus extensor digitorum brevis manus – a case report of a rare variation. Anat Histol Embryol. 2002, 31: 126–7. Ogura T, Inoue H, Tanabe G. Anatomic and clinical studies of the extensor digitorum brevis manus. J Hand Surg Am. 1987, 12: 100–7. Ouellette H, Thomas BJ, Torriani M. Using dynamic sonography to diagnose extensor digitorum brevis manus. Am J Roentgenol. 2003, 181: 1224–6. Rodriguez-Niedenfuhr M, Vazquez T, Golano P et al. Extensor digitorum brevis manus: anatomical, radiological and clinical relevance. A review. Clin Anat. 2002, 15: 286–92.

Sting-ray injuries have recently had high profile media coverage following a rare fatality. However, minor injuries to the hands and feet are common. We present a case of a sting-ray injury to the hand. This was washed out under local anaesthetic at the local emergency department and was a delayed presentation to a specialist hand surgeon, 1 month post injury with severe pain. Ultrasound scan showed synovitis of the palm, confirmed at synovectomy the following day, along with frankly necrotic lumbrical muscles. Histology showed extensive low grade chronic inflammation. At 1 month follow up the patient was pain free and making good progress with a full and functional range of movement. We review the available literature and discuss the circumstances and pathophysiology of the sting-ray sting, the most appropriate first aid management, need for prompt surgical exploration and wound debridement and the possible complications. We would also like to suggest an algorithm for the management of sting-ray injuries to the hand.

One of the challenges facing our profession is the adequate training of plastic surgeons in the subspeciality of aesthetic surgery, in addition to covering the rest of the large curriculum. The UK's Chief Medical Officer, Professor Sir Liam Donaldson, has recently called for better training for doctors, better information for patients, and a touger regulatory structure for private cosmetic surgery. In this study, we show that the training of cosmetic procedures in our unit has risen steadily over the 6 year period studied. As part of our committment to improving training, our unit has recently organised a 3 month block soely dedicated to aesthetic surgery, allowing increasing exposure to cosmetic clinics and theatre sessions. It is clear that as a group, we must continue to develop robust training schemes to produce plastic surgeons able to cope with the demands of 21st Century healthcare, and ensure that the public does not fall prey to practitioners in unregulated clinics.