Supportive care needs of patients following treatment for colorectal cancer: risk factors for unmet needs and the association between unmet needs and health-related quality of life-results from the ColoREctal Wellbeing (CREW) study

Purpose

To investigate unmet needs of patients with colorectal cancer (CRC) at the end of treatment and whether unmet needs improve over time. Identify predictors of need following treatment and whether unmet need is associated with worse health-related quality of life (HRQoL).

Methods

As part of the UK ColoREctal Wellbeing (CREW) cohort study, patients treated for CRC completed the Supportive Care Needs Survey Short Form-34 (SCNS SF-34) 15 and 24 months following surgery, along with questionnaires measuring HRQoL, wellbeing, life events, social support, and confidence to manage their cancer before surgery, 3, 9, 15, and 24 months post-surgery.

Results

The SCNS SF-34 was completed by 526 patients at 15 months and 510 patients at 24 months. About one-quarter of patients had at least one moderate or severe unmet need at both time points. Psychological and physical unmet needs were the most common and did not improve over time. Over 60% of patients who reported 5 or more moderate or severe unmet needs at 15 months experienced the same level of unmet need at 24 months. HRQoL at the beginning of treatment predicted unmet needs at the end of treatment. Unmet needs, specifically physical, psychological, and health system and information needs, were associated with poorer health and HRQoL at the end of treatment.

Conclusions

Unmet needs persist over time and are associated with HRQoL. Evaluation of HRQoL at the start of treatment would help inform the identification of vulnerable patients. Assessment and care planning in response to unmet needs should be integrated into person-centred care.

Implications for Cancer Survivors

Early identification of CRC patients at risk of unmet needs will help infrom personalised survivorship care plans. The implementation of personalised and tailored services are likely to confer HRQoL gains.

Electronic supplementary material

The online version of this article (10.1007/s11764-019-00805-6) contains supplementary material, which is available to authorized users.

Cryopreserved cadaveric allografts for treatment of unexcised partial thickness flame burns: clinical experience with 12 patients

Partial thickness burns (PTB) usually heal within 3 weeks. Prevention of infection and desiccation of the wounds are crucial for optimal healing. Early tangential excision of the burn eschar and allografting prevent deepening of the burns, and are therefore advocated for treatment with the best functional and aesthetic results. For superficial partial thickness burns (SPTB) conservative use of topical antimicrobial agents with frequent dressing changes are implemented. We compared the conservative treatment for PTBs and SPTBs to grafting cryopreserved cadaveric allografts with no prior excision. Twelve patients with flame PTB areas were allografted after mechanical debridement without excision of the burn wounds. The allografts were cadaveric skin cryopreserved by programmed freezing and stored at -180 degrees C for 30-48 months. Matching burns for depth and area were treated with silver sulfadiazine (SSD) one to two times daily until healing or debridement and grafting were required. It was found that 80 per cent of the cryopreserved allografts adhered well and 76 per cent of the treated areas healed within 21 days, whereas only 40 per cent of the SSD-treated burns healed within 21 days. Partial thickness burns can be treated successfully with viable human allografts (cryopreserved cadaveric skin) with no prior surgical excision. The burn wounds heal well within 3 weeks. For deep partial thickness burns (DPTB) treatment with allografts has no advantage if they have not been previously excised.

Periorbital burns – a 6 year review of management and outcome

INTRODUCTION

Periorbital burns are an infrequent but potentially devastating injury. This study aimed to elucidate the spectrum of such injuries presenting to a UK burns centre and the outcome achieved in the cases requiring periorbital reconstruction for the restoration of function and form.

METHODS

Patients admitted to a UK regional burns centre between January 2005 and January 2011 with periorbital burns were identified from the Patient Administration System (PAS), theatre logs and the International Burns Injury database (IBID). Multiple parameters were assessed using patient notes, ITU and hospital image databases.

RESULTS

Over 6 years, 167 patients with facial burns requiring surgery were treated, including 103 patients with eyelid burns. The mean burn size was 33% total body surface area. The eyelid burn depth varied; 67% superficial partial thickness, 17% deep dermal and 16% full thickness. Two patients lost complete vision in one eye, one patient underwent amniotic membrane grafting. In total 16 patients required periorbital reconstruction to maintain eye closure, with 1.8 operations on average per patient. Acute surgery was required in 11 patients, whilst late intervention (>3 months) was needed in 5, 2 patients had both acute and delayed surgery. Of the 5 late intervention patients 4 were treated with full thickness skin grafts and 1 with a Z plasty. Average time for final reconstruction with delayed surgery was 4.5 months.

CONCLUSION

The goal in management of periorbital burns is preservation of vision, prevention of future complications and restoration of an acceptable aesthetic outcome. Total visual loss is thankfully rare, but early ophthalmology intervention is vital given the evidence of corneal damage as a brief therapeutic window exists.

The medial sural artery perforator (MSAP) flap: A versatile flap for lower extremity reconstruction

BACKGROUND

The medial sural artery perforator (MSAP) flap provides a thin, pliable and durable soft tissue reconstruction with adequate pedicle length and low donor morbidity. It is an ideal choice for small-to-moderate defects of the lower extremity, although it does have limitations. We report our experience of the flap in a three-pronged anatomical, clinical and patient reported outcome-based study.

METHODS

Cadaveric fresh frozen lower limbs (n = 10) were used for anatomical dissections to assess pertinent and clinically relevant findings. Data relating to MSAP flaps was collected from a prospectively maintained database over a 2-year period. Both clinical data and modified Enneking scores were analysed.

RESULTS

Anatomical study: A mean of 2.1 ± 0.99 perforators arose from the medial sural artery, located 11.9 cm ± 2.07 along the line between the popliteal fossa and medial malleolus. The largest perforator was located 13.58 cm ± 2.01 from the popliteal artery. The distance from the dominant perforator to the first branching point within the gastrocnemius was 7.39 ± 1.50 (range 5-9.2 cm). The short saphenous vein was located on average 3.08 cm ± 0.77 from the dominant perforator. Clinical study: Twenty free and nine pedicled MSAPs were included (n = 29). Open lower limb fractures (n = 18, 62%) and infection (n = 10, 35%) were the most common aetiologies. Defects sites included: foot-and-ankle (n = 12, 55%), knee (n = 9, 31%) and anterior leg (n = 4, 14%). Four patients (14%) required SSG to for donor site coverage. Venous congestion was responsible for partial flap necrosis in 6.9%(n = 2) of patients. All wounds were healed at discharge. At 14 months, the mean Enneking score was 72.5%. All patients were ambulant, 96% returned to work and 87% were using pre-operative footwear.

CONCLUSIONS

The MSAP provides robust foot-and-ankle reconstruction, whilst permitting glide when over the knee. Patient satisfaction and functional outcomes are excellent with careful patient selection. Care should be taken to avoid compression or kinking of the large, thin walled veins as the most commonly observed complication was venous congestion. We advocate MSAP as a first choice flap for small-to-moderate foot, ankle or knee defects.

Burns ITU admissions: length of stay in specific levels of care for adult and paediatric patients

Prediction of total length of stay (LOS) for burns patients based on the total burn surface area (TBSA) is well accepted. Total LOS is a poor measure of resource consumption. Our aim was to determine the LOS in specific levels of care to better inform resource allocation. We performed a retrospective review of LOS in intensive treatment unit (ITU), burns high dependency unit (HDU) and burns low dependency unit (LDU) for all patients requiring ITU admission in a regional burns service from 2003 to 2011. During this period, our unit has admitted 1312 paediatric and 1445 adult patients to our Burns ITU. In both groups, ITU comprised 20% of the total LOS (mean 0.23±0.02 [adult] and 0.22±0.02 [paediatric] days per %burn). In adults, 33% of LOS was in HDU (0.52±0.06 days per %burn) and 48% (0.68±0.06 days per %burn) in LDU, while in children, 15% of LOS was in HDU (0.19±0.03 days per %burn) and 65% in LDU (0.70±0.06 days per %burn). When considering Burns ITU admissions, resource allocation ought to be planned according to expected LOS in specific levels of care rather than total LOS. The largest proportion of stay is in low dependency, likely due to social issues.

The e-scooter pandemic at a UK Major Trauma Centre: A cost-based cohort analysis of injury presentation and treatment

OBJECTIVES

The aim of the study was to describe injuries related to electric scooter at a Major-Trauma-Centre in the UK, We reviewed data from January 2020-December 2020.

METHODS

All patient-records mentioning electric-scooter at a major-MTC. Records were reviewed, and data were stratified according to two groups: electric scooter riders and other road users. A predefined survey was completed in all cases where 'e-scooter or electric scooter' was present. This contained variables such as patient demographics, mechanism of injury (including head and body protection), acuity, intoxication, treatment facility and clinical utilisation. Among incidents involving electric scooters, summary statistics on continuous and categorical variables of interest were reported. Healthcare modelling utilising time driven activity-based costing and Patient-Level-Activity-Costing used to conduct a post hoc analysis of health provider costs.

RESULTS

202 e-scooter injuries were identified. Riders were more likely to be young males aged 18-35, a minority of reported cases being associated with the influence of alcohol or drugs (7.4%). They fall independently involving no other party (87%); sustaining both minor and major injuries; with a significant proportion requiring urgent and emergent surgery 23.7% (n = 40) with 60.1% (n = 121) requiring further secondary care follow-up; whilst 16% require immediate admission with a mean LOS of 5.9 days, including 8-ITU admissions. The overall mortality rate was 0.5% (n = 1), and cost per patient was £1482.46/patient, reducing to £927.25/patient if immediate surgery (<12 h s) was not required.

CONCLUSION

Due to an emphasis on social distancing, changes in UK law, e-scooters injuries have increased. Most injuries are reported in riders, and are minor, however the mean health episode cost was over £1000.00/patient due to the minority of serious injuries. Research on interventions to prevent e-scooter injuries including protective clothing like helmet wearing is needed to address this growing area of concern, and unnecessary costly healthcare utilisation.

Perioperative care of a patient with stroke

Strokes and TIAs, with their high cumulative mortality and morbidity rates, are occurring with increasing frequency in western population 14. As such, it is vital for clinicians to provide optimal medical management in the perioperative period for those patients with this common neurological problem. This review aims to highlight the importance of the perioperative period and the stages of pre-optimization that can be taken by the multi-disciplinary team to aid this 171819. The evidence suggests that there are significant physiological advantages to early invasive monitoring and high dependency care in these complex patients. These cohort of patients are at increased risk of development of respiratory, gastrointestinal, nutritional and electrolyte disturbances so a constant vigil should be exercised in early recognition and treatment.

Single-stage buried autologous breast reconstruction (BABR)

BACKGROUND

Breast reconstructive standards are increasingly high oncologically, aesthetically, and practically. Autologous breast reconstruction remains the gold standard which, buried, after nipple-sparing mastectomy (where oncologically safe) or wise pattern reduction for large or ptotic patients, with contralateral symmetrisation where required, enables single-stage reconstruction. However, previous series report prohibitively high revision rates. This series prospectively compares a series of buried and non-buried free flaps for breast reconstruction.

METHODS

All breast reconstructions with free autologous tissue transfer, buried or with a cutaneous paddle, conducted over 8 years by a single surgeon were included. Demographic, oncologic and reconstructive details, immediate complications and revision surgeries were recorded and compared between the two groups.

RESULTS

A total of 182 free flaps were performed on 156 patients, 69 buried and 113 with cutaneous paddles. There were no significant demographic or complication differences between the two groups. Of the buried group, 51% did not require further surgery compared to 29% of the paddle group.

CONCLUSIONS

Buried autologous breast reconstruction is a safe and aesthetic option for breast reconstruction, and potentially single stage. This is particularly true where it is combined with nipple-sparing mastectomy (where oncologically safe) or breast reduction mastectomy, and contralateral symmetrisation, where required. Further research could include patient reported outcome measures and cost analysis.

Expression analysis of transcription factors in sugarcane during cold stress

Transcription factors (TF) are a wide class of genes in plants, and these can regulate the expression of other genes in response to various environmental stresses (biotic and abiotic). In the current study, transcription factor activity in sugarcane was examined during cold stress. Initially, RNA transcript reads of two sugarcane cultivars (ROC22 and GT08-1108) under cold stress were downloaded from SRA NCBI database. The reads were aligned into a reference genome and the differential expression analyses were performed with the R/Bioconductor edgeR package. Based on our analyses in the ROC22 cultivar, 963 TF genes were significantly upregulated under cold stress among a total of 5649 upregulated genes, while 293 TF genes were downregulated among a total of 3,289 downregulated genes. In the GT08-1108 cultivar, 974 TF genes were identified among 5,649 upregulated genes and 283 TF genes were found among 3,289 downregulated genes. Most transcription factors were annotated with GO categories related to protein binding, transcription factor binding, DNA-sequence-specific binding, transcription factor complex, transcription factor activity in RNA polymerase II, the activity of nucleic acid binding transcription factor, transcription corepressor activity, sequence-specific regulatory region, the activity of transcription factor of RNA polymerase II, transcription factor cofactor activity, transcription factor activity from plastid promoter, transcription factor activity from RNA polymerase I promoter, polymerase II and RNA polymerase III. The findings of above results will help to identify differentially expressed transcription factors during cold stress. It also provides a comprehensive analysis of the regulation of the transcription activity of many genes. Therefore, this study provides the molecular basis for improving cold tolerance in sugarcane and other economically important grasses.

The impact of discussing preoperative fasting with patients

Patients awaiting surgery are often fasted preoperatively well in excess of the recommended fasting times. Educated perioperative practitioners were asked to discuss preoperative starvation with patients. Preoperative starvation period for clear fluids was significantly reduced from a mean of 8 hours 30 minutes in the original audit, to 6 hours 10 minutes in this study of 113 patients (p < 0.001). Improving patient understanding of preoperative fasting can increase compliance with fasting recommendations.

Should all acromioclavicular joint injections be performed under image guidance?

INTRODUCTION

Steroid and local anaesthetic injection to the acromioclavicular joint (ACJ) is a very common diagnostic and therapeutic procedure, which is often performed in the outpatient department. However, it can be difficult to localize this joint because of its small size, presence of osteophytes and variable morphology in the population. We performed a study to determine whether the use of an image intensifier (X-ray guidance), in theatre, improves the accuracy of this injection.

METHODS

This was a prospective study carried out between March 2014 and March 2015. The injections were performed by two senior orthopaedic surgeons. First, we clinically palpated the ACJ and marked the area over this point as A. Then, with the use of a needle and an image intensifier in a single plane, we identified the actual location of the ACJ and marked this point as B. We measured the distance between A and B in millimetres (mm) and determined the accuracy of the injections. Further analysis taking into account the ACJ capsular attachments was also performed.

RESULTS

In total, 45 patients and 50 injections were included in the study; five patients had repeated injections at different times. We found that only 12 injections (24%) were palpated to be correct with no discrepancies between A and B (95% confidence interval: 14-37%). For the remaining 38 injections (76%), the use of an image intensifier had significantly improved the accuracy of ACJ location ( p < 0.05). Taking the capsular attachments of the ACJ into consideration reduced the number of inaccurate injections to 27 (54%).

CONCLUSION

We recommend the use of an image intensifier (or ultrasound guidance) to accurately determine the location of the ACJ for steroid and local anaesthetic injections. This prevents an injection into the wrong place, which can lead to wrong diagnosis and/or suboptimal treatment.

Determination of virginiamycin in combination with chlortetracycline in feeds by anion-exchange chromatography

Standard additions experiments for chlortetracycline hydrochloride and virginiamycin at a ratio of 16:1 showed a positive bias for both the plate and turbidimetric methods. The bias was eliminated by anion-exchange chromatography in both the presence and absence of feed components. When chlortetracycline and virginiamycin pre-mixes were used for fortification of laboratory-prepared feeds at chlortetracycline to virginiamycin ratios of 8 or 16:1, the recovery of virginiamycin, without treatment, was 93-100% using the plate assay and 181-236% with the turbidimetric method. The corresponding values obtained using anion-exchange chromatography were 89-99 and 85-91%, respectively. The anion-exchange technique is necessary if the turbidimetric method is used for the assay.

Beyond Teenage and Young Adult Cancer Care: Care Experiences of Patients Aged 25-39 Years Old in the UK National Health Service

AIMS

Adolescents and young adults aged 15-39 years with cancer face unique medical, practical and psychosocial issues. In the UK, principal treatment centres and programmes have been designed to care for teenage and young adult patients aged 13-24 years in an age-appropriate manner. However, for young adults (YAs) aged 25-39 years with cancer, little access to age-specific support is available. The aim of this study was to examine this possible gap by qualitatively exploring YA care experiences, involving patients as research partners in the analysis to ensure robust results.

MATERIALS AND METHODS

We conducted a phenomenological qualitative study with YAs diagnosed with any cancer type between ages 25 and 39 years old in the last 5 years. Participants took part in interviews or focus groups and data were analysed using inductive thematic analysis. Results were shaped in an iterative process with the initial coders and four YA patients who did not participate in the study to improve the rigor of the results.

RESULTS

Sixty-five YAs with a range of tumour types participated. We identified seven themes and 13 subthemes. YAs found navigating the healthcare system difficult and commonly experienced prolonged diagnostic pathways. Participants felt under-informed about clinical details and the long-term implications of side-effects on daily life. YAs found online resources overwhelming but also a source of information and treatment support. Some patients regretted not discussing fertility before cancer treatment or felt uninformed or rushed when making fertility preservation decisions. A lack of age-tailored content or age-specific groups deterred YAs from accessing psychological support and rehabilitation services.

CONCLUSIONS

YAs with cancer may miss some benefits provided to teenagers and young adults in age-tailored cancer services. Improving services for YAs in adult settings should focus on provision of age-specific information and access to existing relevant support.

Does laminar flow reduce the risk of early surgical site infection in hip fracture patients?

Objective

To determine if there is a difference in the rate of early infection in hip fracture surgery performed under laminar flow and conventional turbulent ventilation.

Method

The impact on the rates of early surgical site infection (SSI) in patients who sustained a hip fracture after our trauma theatre was moved from a laminar to a non-laminar flow theatre was assessed. Data was retrospectively collected for six months prior to the merging of the trauma service and six months after. For each operation: age, gender, American Society of Anesthesiologists (ASA) grade, dementia, diabetes, immunosuppressants, anticoagulation, smoking status, duration of surgery, administration of peri-operative antibiotics, surgeon grade, skin closure method, and SSI were extracted from the hospital electronic notes with input from the trust's SSI surveillance team.

Results

259 hip fracture operations were performed during this period. Seven patients were excluded due to incomplete information. There were 95 patients in the laminar flow group and 157 in the non-laminar flow group. There were no SSIs in the laminar flow group and a 3.2% SSI rate (Fishers exact p = 0.16) in the non-laminar flow group. Three were superficial infections and two deep. This difference was not statistically significant. Patient characteristics were included in a Firth logistic regression model which did not show a significant change in the odds ratio.

Conclusion

A higher incidence of early SSI was found when hip fracture surgery was performed under non-laminar flow conditions but this difference was not statistically significant. Larger studies may change this outcome.

The utility of microalbuminuria measurements in pediatric burn injuries in critical care

PURPOSE

Microalbuminuria, as measured by urinary albumin-creatinine ratios (ACRs), has been shown to be a marker of systemic inflammation and an indicator of the potential severity of trauma and critical illness. Severe pediatric burns represent the best model in which to investigate the clinical utility of microalbuminuria. This study aims to ascertain whether ACR measurements have any role in predicting the severity or the intensive care requirements in the critically unwell pediatric burn population.

MATERIALS AND METHODS

A retrospective observational study was undertaken within a regional burn center with a dedicated 8-bed burn intensive care unit (ICU). This looked at 8 years of consecutive pediatric burns requiring intensive care support-a total of 63 patients after exclusions. Daily urinary ACR measurements were acquired from all patients.

RESULTS

All patients had greater than or equal to 1 ACR measurement out with the reference range, and only 8% (5/63) presented to the ICU with a normal ACR. The median day for the peak ACR measurement was day 4. The relative lack of mortalities (3/63) precluded adequate correlations between ACR and outcomes. Peak and mean ACR values correlate well with length of ICU stay, and the peak ACR also correlates with total length of hospital stay and severity of burn injury as measured by total body surface area burnt and number of organ systems requiring support. No significant differences were found when the patients were stratified by age. The peak ACR measurement was found to be independently predictive of the length of the ICU stay. As such, we have created a predictive model to prove that an ACR that remains less than 12 mg/mmol is predicative of an ICU stay of less than or equal to 7 days.

CONCLUSIONS

The clinical utilities of ACR measurements are demonstrated by their correlation with the severity of injury, length of ICU stay, and requirements for multiple organ support. Albumin-creatinine ratios raised over certain thresholds highlight to the clinician the need for closer observation and the potential deterioration of patients.

Stack, PAP and Bury: Technical refinements from a case series of 56 profunda artery perforator flaps for breast reconstruction

AIMS

To share experiences and learning curve of the introduction of profunda artery perforator (PAP) flaps in breast reconstruction. The secondary aim was to share techniques to improve outcomes.

METHODS

Case series reviewing outcomes of 56 consecutive PAP flaps performed by a single surgeon across five institutions between March 2021 and May 2023 were reported. The senior author's preference is to routinely stack and bury the flaps to optimise cosmetic outcomes.

RESULTS

Fifty-six PAP flaps were performed in 30 patients. The majority of the PAPs were stacked (n = 43, 77%). The mean age at surgery was 46 years (SD 8.44 years) and mean body mass index was 23.86 (SD 3.59). The mean flap weight was 198.83 g (SD 82.86 g) and the mean combined weight for stacked flaps was 369.57 g (SD 98.65 g). Mean ischaemia time was 56.59 min (SD 17.83 min). There was one flap loss (2%). Of the immediate flaps, 90% were buried and monitored using flow couplers.

CONCLUSION

The routine use of PAPs, in particular stacked PAPs, allows for adequate volume and height for breast reconstruction in patients who may have otherwise been deemed unsuitable for autologous breast reconstruction. The PAP flap has replaced the transverse upper gracilis and superior gluteal artery perforator flaps as the second line flap choice in our practice.

Trainee and trainer experiences and recommendations for plastic surgery training: A qualitative pilot study

BACKGROUND

The COVID-19 pandemic has compounded existing training issues for plastic surgeons. The issues that exist result from a complex interplay of system, generational and individual factors, and can be hard to tease out by quantitative means. This pilot study aimed to investigate the perceptions of trainees and trainers of plastic surgical training in the UK.

METHODS

Ten semi-structured interviews were performed using purposive sampling in a central London plastic surgical unit. These were coded into and discussed in four themes: Medical directives and service demands; Sociocultural norms within plastic surgical training; Equity and access; and Plastic surgery training methods.

RESULTS

This study showed that current plastic surgery training is not optimised for learning or well-being, and that inequities are fostered, to the detriment of the specialty. Investment and planning are required to support our trainers and protect the diversity of our trainee group, with efficient and monitored learning essential to maintain our breadth and competence of practice.

CONCLUSION

Expanding this work through a broader study could provide valuable information to contribute to the development of future training schemes and curricula within British plastic surgery.

Detection of circulating schistosome antigens in serum and urine of schistosomiasis patients and assessment of cure by a monoclonal antibody

From a panel of monoclonal antibodies (MAb), an IgM monoclonal antibody (7F1/6B) reactive with repetitive epitopes on S. mansoni soluble egg antigen was selected. This MAb was employed both as antigen capture and detection antibody in a sandwich ELISA and had a detection limit < 1 ng S. mansoni SEA/mi. Serum and urine samples were collected from rural students who had S. mansoni (169 subjects) or mixed S. mansoni and S. haematobium (64 subjects) infections. Samples were collected before and at 4, 8 and 12 weeks after praziquantel therapy. Circulating schistosome antigens (CSA) were demonstrated in 90% of sera and 97% of urine samples of S. mansoni group and in 91% of sera and 100% of urine samples of mixed infection group. All sera from 29 uninfected individuals, 30 patients with other parasites and 70% of 55 S. haematobium-infected subjects were negative in this assay. CSA level in serum and urine samples correlated positively with the number of S. mansoni eggs/g stool in both groups. A significant reduction in CSA level was observed in serum and urine samples after praziquantel therapy. By 12 weeks post-treatment, negativity was 98% in sera and 97% in urine of S. mansoni-infected group and 98% in sera and 91% in urine of mixed infection group. The data demonstrate that the use of MAb 7F1/6B for the detection of CSA provides a sensitive method for immunodiagnosis of schistosomiasis and monitoring of cure.

Buried Autologous Breast Reconstruction: Outcomes and Technical Considerations

The purpose of this study is to compare outcomes in patients undergoing buried and non-buried free flaps for breast reconstruction, in addition to evaluating the safety and reliability of venous flow couplers. A retrospective review was performed of all patients undergoing free flap breast reconstruction between 2013 and 2023. The primary outcomes were free flap failure, complications and the number of procedures required to complete the reconstructive journey. A total of 322 flaps were performed in 254 consecutive patients, with 47.5% (n = 153) being buried and 52.0% (n = 169) being non-buried reconstructions. The most common flap of choice being deep inferior epigastric artery perforator flaps (81.9%) followed by profunda artery perforator flaps (14.3%). There was no significant difference between the two groups in complications, including flap failure (buried 2.0% vs. non-buried 1.8% p = 0.902). There was a significant reduction in the number of procedures required to complete the reconstructive journey, with 52.2% (n = 59) of patients undergoing single-stage breast reconstruction in the buried group compared with only 25.5% (n = 36) in the non-buried group (p < 0.001). Two (0.6%) patients experienced a false negative in which the signal of the flow coupler was lost but the flap was perfused during re-exploration. No flap losses occurred without being identified in advance by a loss of audible venous flow signal. Buried free flap breast reconstruction is safe and requires fewer operations to complete patients' reconstructive journey. Flow couplers are a safe and effective method of monitoring buried free flaps in breast reconstruction.

Clinical outcomes of closed versus open simple ankle fractures patterns requiring soft tissue reconstruction: A prospective comparative observational study

BACKGROUND

Contemporary guidelines advocate for initial debridement and single-stage definitive fixation with immediate soft tissue reconstruction for open fractures. This study aims to evaluate the effectiveness of single-stage stabilization and immediate definitive soft tissue coverage in open ankle fractures compared to closed fractures.

METHODS

We compared all isolated open ankle fractures (OF) treated between January 2017 and June 2019 to a control group of operatively managed closed ankle fractures (CF). The OF group included patients with extensive soft tissue injury loss with periosteal stripping and bone exposure (Gustilo and Anderson IIIB) requiring split skin graft, rotational flap or free flap. Clinical outcomes assessed included infection rates, amputation, revision hardware surgery, surgical reduction, non-union rates, and functional outcomes (assessed using the MOXFQ and EQ-5D-5L questionnaires). Health provider matrices were utilized to evaluate cost-benefit parameters, such as length of stay (LOS). Statistical analysis was performed with a significance level set at P < 0.05.

RESULTS

A total of 27 OF and 35 CF cases with AO classification 44 A-C fractures were analyzed following standard treatment protocols. No amputations were reported, but deep/superficial infections occurred in 3 patients in the OF group compared to 2 in the CF group. There was a three-folds increase in mal-union (P = .11), rates of additional surgeries and discharge times in the OF group. (P < 0.05). However, return to functional weight bearing between OF (mean 10.6 weeks) and CF (mean 7.2 weeks) was similar (P = 0.06), and there were no significant differences in EQ-5D-5L and MOXFQ scores at the end of orthopaedic treatment p = 0.5 and 0.16 respectively. The mean hospital LOS was significantly longer for OF (15.6 days) compared to CF (5.4 days) (P < 0.05).

CONCLUSION

Definitive stabilization and immediate soft tissue reconstruction in the management of open ankle fractures result in high rates of limb salvage and achieve functional outcomes similar to those seen in matched closed ankle fractures upon completion of orthopedic treatment. Although the patient journey is extended, soft tissue and infective complications do not significantly differ. This calls for further investigation to establish the long-term cost-benefit implications of this approach.

500 Tetraminos Flap

30 year old male, who had been hit at 90mph whilst on a motorbike sustaining femoral, tibial and right foot open fractures. He underwent an open reduction and internal fixation (ORIF) of his right lateral femoral condyle, a right retrograde femoral nail, and ORIF of the tibia. He had 2 separate free flaps (a chimera scapular/parascapular and antero-lateral thigh-ALT) to his right lower leg, and split skin grafting to the remainder of the right lower limb. Upon regular post-operative review it was found that whilst healed the limb was showing a poor return of function and a major contributor was the lack of motion of the right knee joint. Patient had an excision of the split skin graft, with a quadriceps plasty, where the myofascial planes were released, and the contractures incised, with a chimeric scapular and parascapular free flap onto the defect. This resulted in coverage of large soft tissue defect with no need to skin graft donor sites and no functional implication of muscle harvest. Tetraminos in appearance, like the popular computer game, which has never before been described, compared with normal coverage, which would be latissimus dorsi free flap and graft.