Dorsal chevron flap for exposure of the proximal interphalangeal joint

We have used a dorsal V-flap, or chevron flap, to expose the proximal interphalangeal joint. A retrospective clinical study of its use in 16 patients over 5 years is presented, including indications, functional return of movement, and complications. Long-term follow-up showed an average range of active movement of 70 degrees (range, 13-84 degrees). Surgical exposure of the joint was better than other dorsal approaches and overall recovery of movement was not significantly compromised. Alternative surgical techniques such as the dorsal longitudinal split, dorsolateral split and palmar approach are compared in a group of 36 cases.

A five year review of islanded distally based fasciocutaneous flaps on the lower limb

The use of the distally based islanded fasciocutaneous flap is described in 61 patients with lower limb defects and its application in coverage of compound fractures of the tibia is highlighted. A total of 66 flaps were raised from the posteromedial border of the leg, based on a single perforator off the posterior tibial artery. Flap coverage extended to include defects of the lower one third of the leg (n = 47) as well as the ankle, heel and foot (n = 4). Bony stabilisation was performed with a tibial intramedullary locking nail in 30 out of 53 fractures; mean time to bony union was 5.9 months. Mean operating time was 1.7 hours and mean hospital stay was 25 days (range 8-98 days). Mean follow-up time was 13 months (maximum 5 years). Twenty-five flaps were used to cover Gustilo IIIb fractures primarily, with a 20% complication rate in this group. The flaps were used preferentially in males and in older females. The overall flap failure rate was 7.6%, with a further 10.6% of flaps suffering from tip necrosis and haematoma formation. Contributory factors to suboptimal healing included the presence of peripheral vascular disease and heavy smoking.

The transpelvic rectus abdominis flap: its use in the reconstruction of extensive perineal defects

We present our experience of rectus abdominis flaps tunnelled transpelvically in 12 patients (mean age 48.4 years, range 19-72 years) with a diverse range of surgical pathologies, the largest reported series to date. Satisfactory obturation of the pelvic cavity and control of radionecrotic tissue sepsis was achieved. Average duration of hospital stay was 17.6 days with a mean follow-up of 18.7 months. The rectus abdominis flap provides a significant volume of well-vascularised tissue, ideally suited for reconstruction of extensive perineal defects after tumour ablative surgery. When tunnelled transpelvically, the flap is unique in its ability to obturate the pelvic inlet, eliminating the distressing complication of perineal bowel herniation and allowing for perineal radiotherapy.

Digital flexor sheath injury: a new diagnostic test

The diagnostic value of the transthecal digital nerve block is proposed for identifying flexor sheath injuries associated with seemingly trivial finger lacerations. Its use is described in five cases which were referred to our hand service for further exploration, with subsequent confirmation of flexor sheath and tendon injury.

Multidisciplinary approach to the management of head and neck arteriovenous malformations

Arteriovenous malformations (AVM) of the head and neck are quite rare in contrast to low-flow vascular anomalies, but often present with significant haemorrhage or cosmetic defects. Treatment of these high-flow vascular anomalies is hazardous and has a predictably high incidence of recurrence if not managed correctly. Intervention is indicated for complications such as pain, haemorrhage, pressure symptoms, ischaemic ulceration and even congestive cardiac failure. A multidisciplinary team approach is required in the assessment and treatment of these lesions, and involves preoperative angiography with superselective embolisation, followed by resection of the lesion, ideally within 72 h. Recent advances in microsurgery and in therapeutic radiology have greatly improved the prognosis for patients with these malformations. We present a series of four patients who have undergone preoperative embolisation and subsequent surgical excision, with a mean follow-up of 28 months. The complication rate has remained low and there has been no re-expansion of the lesions to date.

Epithelioid sarcoma masquerading as Dupuytren's disease

Epithelioid sarcoma is a rare and deceptive lesion, often confused both clinically and on histopathological examination with other malignant processes. The surgical course of two patients with initial diagnoses of Dupuytren's disease is described. Early biopsy of all unusual fibrotic lesions on the palm is recommended. An aggressive surgical approach to confirmed malignancy is mandatory.

Endoscopic carpal tunnel decompression

A study of endoscopic carpal tunnel release was carried out in three parts, consisting of initial cadaveric dissections, a prospective pilot study of 20 patients and a prospective, randomized trial of 71 patients comparing endoscopic with open decompression. In the main trial, 25 patients with bilateral symptoms underwent simultaneous endoscopic and open release, with the remainder randomized to one or other technique. Both techniques effectively decompressed the median nerve. A significant improvement in group and pinch strength over 3 months was achieved in those undergoing endoscopic surgery. Average return to work was 14 days in the endoscopic series and 39 days in the open series. A complication rate of 35% was achieved with the transbursal endoscopic technique, 3.7% with the extrabursal endoscopic technique and 13.5% in the open series.

Malignant schwannoma mistakenly diagnosed as carpal tunnel syndrome

A rare nerve sheath tumour masquerading as carpal tunnel syndrome is described. It arose in a digit, with perineural spread proximally along the median nerve.

Transcutaneous extravasation of silicone following breast augmentation

Transcutaneous leakage of silicone in the absence of sinus formation has not previously been described. We present a case in which silicone extravasation occurred following the rupture of a breast implant inserted 14 years previously.

Os calcis fractures: a randomized trial comparing conservative treatment with impulse compression of the foot

Published data suggest that soft tissue involvement plays a role in the aetiology of residual symptoms following fractures of the os calcis. This randomized study involved 23 patients with 24 intra-articular fractures of the calcaneum. It was designed to evaluate the efficacy of a pneumatic plantar impulse device in reducing pain, associated morbidity and convalescent time. The results show a significant improvement in subtalar range of movement in the pumped group at 3 months, with pain significantly reduced at 6 months and at 1 year. There was no difference in weight bearing or walking distance between the pumped and control groups. The time from date of injury to return to work was significantly reduced in the pumped group by an average of 3 months.