Reconstruction of a soft tissue defect in the finger using the heterodigital neurocutaneous island flap

Background

This article describes reconstruction of a soft tissue defect in the finger using the heterodigital neurocutaneous island flap and reports the results of the use of the flap.

Methods

From February of 2008 to March of 2011, the neurocutaneous island flap was used in 12 patients with soft tissue defects in the middle phalanx or the proximal interphalangeal joint, or both. The injured fingers included 4 index, 3 middle, 3 ring and 2 little fingers. The donor fingers included 7 middle fingers and 5 ring fingers. The mean size of soft tissue defects and the flaps was 2.4 cm × 1.8 cm and 2.7 cm × 2.0 cm, respectively. The mean pedicle length was 2.8 cm.

Results

Full flap survival was achieved in 11 cases. Partial distal flap necrosis was noted in one case, which healed without surgical intervention. At a mean follow-up of 22 months, the mean static 2-point discrimination and Semmes-Weinstein monofilament scores on the flap were 8.3 mm and 3.94, respectively. Based on the modified American Society for Surgery of the Hand guidelines for stratification of 2-point discrimination, 10 (83%) of 12 flaps achieved good results. According to the Michigan Hand Outcomes Questionnaire, 5 patients were strongly satisfied and 7 were satisfied with functional recovery of the reconstructed finger.

Conclusions

The neurocutaneous island flap of the dorsal branch of the digital nerve is useful, reliable, and technically easy for reconstructing a defect in the adjacent fingers, especially when sensory reconstruction is needed.     

Repair of multiple finger defects using the dorsal homodigital island flaps

Background

Providing soft-tissue coverage for multiple finger defects remains a challenge for the hand surgeons. This article reports reconstruction of multiple digital defects using the dorsal homodigital island flaps based on the dorsal branch of the digital artery.

Methods

Over 3 years, a retrospective study was conducted with 12 patients who had multiple finger defects treated with the dorsal homodigital island flaps. Our series included nine male and three female patients. There were 30 soft-tissue defects in 30 fingers. The injured fingers included seven index, nine long, nine ring and five little fingers. The average size of soft-tissue defects and flaps was 2.4 ± 0.4 cm × 1.7 ± 0.2 cm and 2.6 ± 0.4 cm × 1.9 ± 0.2 cm, and the mean pedicle length was 1.1 ± 0.2 cm.

Results

Full flap survival was achieved in 26 fingers. Partial distal flap necrosis was noted in four fingers, which healed without surgical intervention. At a median of 20 (range, 19–23) months’ follow-up, the static two-point discrimination on the flap averaged 9.1 ± 1.6 mm, and the median (range) Semmes–Weinstein monofilament score was 3.84 (3.84–4.17). The donor-site morbidity was accepted. According to the Michigan Hand Outcomes Questionnaire, seven patients were strongly satisfied and five were satisfied with functional recovery of the reconstructed fingers.

Conclusions

The dorsal homodigital island flap, based on the dorsal branch of the digital artery, is less invasive, versatile and technically easy for simultaneous coverage of small-to-moderate defects in multiple fingers.     

Free medial thigh perforator flap for reconstruction of the dynamic and static complex burn scar contracture

Introduction

Dynamic and static complex scar contractures after burn commonly cause tendon adhesion, deep adipose tissue stiffness and further limitation of major joints motion. Skin autografting or locoregional flaps are not adequate reconstructive options, because of the easy recurrence and limitation of donor sites. Therefore, free perforator flaps are playing increasing role in reconstruction of complex scar contractures.

Patients and methods

The free medial thigh perforator (MTP) flap is an addition to the reconstructive armamentarium and is particularly useful since the medial thigh is commonly spared in burn injury. Between December 2001 and October 2005, eight patients with severe post-burn scar contractures received free MTP flaps treatment in the Linkou Burn Center. The free MTP flap harvest was modified to enhance its reliability and versatility. Flap sizes ranged from 5 × 15 cm to 8 × 24 cm. The follow-up period was from 12 to 26 months. Flap harvest is rapid, averaging 37.8 min.

Results

The significantly improved range of motion of the contracture joints approximated to normal activity at 6–22-month follow-up (p < 0.05). No free major MTP flap complication was noted, except for mild marginal necrosis in one case.

Conclusion

The free MTP flap with new modified harvest is a good choice for dynamic an static complex scar contractures of major joints, due to short harvesting time and few variations of the pedicle. However, thick skin paddle was considered in secondary hand reconstruction.     

“Is the length of time in acute burn surgery associated with poorer outcomes?”

Background

Acute wound closure surgery improves outcomes, after burn particularly mortality, but also imposes physiological stress on the patient. The duration of surgery is associated with adverse outcomes in other populations. This study aimed to examine if extended acute burn surgery duration was associated with poorer in-hospital outcomes.

Methods

This retrospective cohort study included adult burn patients who required a single wound closure surgery at Royal Perth Hospital between 2004 and 2011. Multivariable regression analyses were used to assess the influence of patient and injury factors on surgery duration and length of stay (LOS).

Results

Surgery duration independently increased LOS (incidence rate ratio [IRR] = 1.004, p < 0.001). This translates to a predicted 13% increase in LOS for a 30 min increase in surgery ‘knife to skin’ time. Total body surface area (TBSA) was identified as a significant predictor of surgery duration (IRR = 1.047, p < 0.001), estimating that a 10% TBSA increase results in a 59% increase in surgery duration.

Conclusion

The results show that surgery duration is associated with LOS after adjusting for size of burn and other factors. The study justifies the need to explore strategies to reduce acute burn surgery duration.     

Distally based perforator flaps for reconstruction of post-traumatic defects of the lower leg and foot. A review of the anatomy and clinical outcomes

Study aims

To report the surgical anatomy of the perforator arteries at the lower leg, analyse clinical outcomes in previous studies, and forward methodological recommendations for future studies of post-traumatic perforator flap reconstructions.

Methods

A study sample of 640 human patients drawn from 24 clinical reports was included for review. The sample comprised of four subsets: sural flap reconstructions (n = 257), saphenous flaps (n = 122), supramalleolar flaps (n = 92), and propeller flaps (n = 169).

Results

Statistical analysis of samples from anatomical studies documents significant differences in the perforator distribution from the tibial and peroneal artery; peroneal perforator arteries are randomly organised whereas tibial artery perforators are clustered at three definite levels. The failure rates in clinical studies ranged from 0% to 6%, being lowest for supramalleolar flap reconstructions and highest for saphenous flaps; however, differences between the four subsets were not statistically significant at the 95% confidence level. Due to methodological flaws, outcome comparisons in the actual study sample should be interpreted cautiously; in most clinical studies both risk variables and outcome indicators are poorly defined. The outcome of Dynamic Infrared Thermography imaging of post-transposition changes of flap perfusion is reported.

Summary

Fasciocutaneous perforator flaps seem to have high survival rates and represent a feasible approach to post-traumatic reconstructions, especially in low-resource settings. A template for data gathering is recommended for higher accuracy in future comparative studies, and for scientific analysis of success and risk factors. New imaging techniques indicate a promising potential of micro-circular angiogenesis during the first two weeks after flap transpose.     

Wound healing at adaptation zones of skin flaps harvested from acute burned skin

Background

Early reconstruction of burn defects culminates in more successful results. The wound healing process of the burned skin affects not only the curative phase of the burned area but also result of any reconstructive procedure including the regional flaps. Thus, in this study, we have evaluated the wound healing process at the distal incisions of random-pattern skin flaps prepared from burned dorsal skin of rats.

Materials and methods

Thermal burn damage was performed with dimensions of 3 cm × 3 cm on Wistar albino rats. In group 1 (n = 12), no burn was produced and 3 cm × 3 cm caudally based, random-pattern skin flaps were elevated. In group 2 (n = 12), a 5 cm × 5 cm area of partial-thickness thermal damage was produced and after three days a 3 cm × 3 cm random-pattern skin flap was elevated as in group 1 inside the burned skin site. In group 3 (n = 12), 3 cm × 3 cm area of partial-thickness thermal damage was produced and after three days 3 cm × 3 cm random-pattern skin flap was elevated. In group 4 (n = 12), 3 cm × 3 cm area of partial-thickness thermal damage was produced and after three days a 3 cm × 3 cm random-pattern skin flap was elevated at the distal margin of the burned area. The flaps were adapted to the donor sites in all groups. The histopathological evaluation was done and hydroxyproline levels were measured.

Results

There were no significant differences between groups regarding presence of epithelialization, myofibroblast numbers, and collagen texture (p > 0.05). Neovascularization level was significantly higher in group 2 than the other groups (p < 0.05). There were no statistically significant difference among the hydroxyproline levels in all four groups (p > 0.05).

Conclusion

The preference of the incision site in a burn zone while designing a flap during the acute burn period was proposed to possess no difference in terms of wound healing in an animal model.     

Flow-through anterolateral thigh flap for reconstruction in electrical burns of the severely damaged upper extremity

Background

Many surgeons have to face the challenge of the sophisticated management of catastrophic high-voltage injuries to upper extremities. These patients present with both vast soft tissue defects and varied segmental main artery defects with compromised circulation of the distal limb. This study is a first attempt to analyze the outcome of the flow-through anterolateral thigh flap for reconstruction in acute electrical burns of the severely traumatized upper extremity.

Method and patient

From March 2001 to February 2012, five men were enrolled in the study. All in this series suffered from high voltage current (higher than 1000 V) electrical burn and had the presence of wide segmental soft tissue defects, exposure of underlying vital structures and segmental artery injury with compromised circulation. Flow-through anterolateral thigh flaps were used for limb salvage.

Result

Follow up for all patients was present from 6 months to 7 years. The mean age was 37.8 years old. The mean timing of free flap transfer was 5.8 days after injury. The mean flap sizes were 31.6 cm × 16.5 cm. The mean artery defect was 14.2 cm in length. Venous thrombosis occurred 1 day post-operatively in one patient. No donor site morbidity was noted. In the postoperative period, no infection, no hematoma, nor deaths were noted. Successful limb salvage rate was 80% in this series.

Conclusion

In electrical injuries of the severely damaged upper extremity, flow through anterolateral thigh flaps provide for reconstruction of both the vessels and soft tissue simultaneously. Although the risk of flap failure is higher than with other etiologies of burn, the data shows that the above reconstruction technique is useful for upper extremity salvage.     

Biological markers of stress in pediatric acute burn injury

Background

Burns and their associated wound care procedures evoke significant stress and anxiety, particularly for children. Little is known about the body's physiological stress reactions throughout the stages of re-epithelialization following an acute burn injury. Previously, serum and urinary cortisol have been used to measure stress in burn patients, however these measures are not suitable for a pediatric burn outpatient setting.

Aim

To assess the sensitivity of salivary cortisol and sAA in detecting stress during acute burn wound care procedures and to investigate the body's physiological stress reactions throughout burn re-epithelialization.

Methods

Seventy-seven participants aged four to thirteen years who presented with an acute burn injury to the burn center at the Royal Children's Hospital, Brisbane, Australia, were recruited between August 2011 and August 2012.

Results

Both biomarkers were responsive to the stress of burn wound care procedures. sAA levels were on average 50.2 U/ml higher (p < 0.001) at 10 min post-dressing removal compared to baseline levels. Salivary cortisol levels showed a blunted effect with average levels at ten minutes post dressing removal decreasing by 0.54 nmol/L (p < 0.001) compared to baseline levels. sAA levels were associated with pain (p = 0.021), no medication (p = 0.047) and Child Trauma Screening Questionnaire scores at three months post re-epithelialization (p = 0.008). Similarly, salivary cortisol was associated with no medication (p < 0.001), pain scores (p = 0.045) and total body surface area of the burn (p = 0.010).

Conclusion

Factors which support the use of sAA over salivary cortisol to assess stress during morning acute burn wound care procedures include; sensitivity, morning clinic times relative to cortisol's diurnal peaks, and relative cost.     

Hydroxyethylstarch supplementation in burn resuscitation—A prospective randomised controlled trial

Introduction

Hydroxyethylstarches (HES) are thought to be beneficial in trauma and major surgery management, due to their volume expansion and anti-inflammatory properties. This study examined the use of 6% (HES) in burn resuscitation.

Methods

26 adult patients with burns exceeding 15% total body surface area (TBSA) were randomised to either crystalloid (Hartmann's solution) or a colloid-supplemented resuscitation regime, where 1/3 of the crystalloid-predicted requirement was replaced by 6% HES.

Results

There was no difference in age, gender or TBSA between the two groups. The median (95% CI) fluid volume/%TBSA received in the first 24 h was 307 ml and 263 ml for the crystalloid only and HES-supplemented group respectively (p = 0.0234, Mann–Whitney). Body weight gain within the first 24 h after injury was significantly lower in the HES-supplemented group 2.5 kg versus 1.4 kg respectively (p = 0.0039). The median (95% CI) serum C-reactive protein at 48 h after injury was 210(167–257) and 128(74–145) mg/L for the crystalloid only and HES-supplemented group respectively (p = 0.0001). Albumin–creatinine ratio per % burn (ACR, a marker of capillary leak) was lower in the HES-supplemented group at 12 h after burn (p = 0.0310).

Conclusions

Patients treated with HES-supplemented resuscitation required less fluid, showed less interstitial oedema and a dampened inflammatory response compared to patients receiving isotonic crystalloid alone.     

Enhancing the clinical utility of the Burn Specific Health Scale-Brief: Not just for major burns

Introduction

Like many other Western burn services, the proportion of major to minor burns managed at Royal Perth Hospital (RPH) is in the order of 1:10. The Burn Specific Health Scale-Brief (BSHS-B) is an established measure of recovery after major burn, however its performance and validity in a population with a high volume of minor burns is uncertain. Utilizing the tool across burns of all sizes would be useful in service wide clinical practice.

Aim

This study was designed to examine the reliability and validity of the BSHS-B across a sample of mostly minor burn patients.

Method

BSHS-B scores of patients, obtained between January 2006 and February 2013 and stored on a secure hospital database were collated and analyzedCronbach's alpha, factor analysis, logistic regression and longitudinal regression were used to examine reliability and validity of the BSHS-B.

Results

Data from 927 burn patients (2031 surveys) with a mean % total burn surface area (TBSA) of 6.7 (SD 10.0) were available for analysis. The BSHS-B demonstrated excellent reliability with a Cronbach's alpha of 0.95. First and second order factor analyses reduced the 40 item scale to four domains: Work; Affect and Relations; Physical Function; Skin Involvement, as per the established construct. TBSA, length of stay and burn surgery all predicted burn specific health in the first three months of injury (p < 0.001, p < 0.001, p = 0.03). BSHS-B whole scale and domain scores showed significant improvement over 24 months from burn (p < 0.001).

Discussion

The results from this study show that the structure and performance of the BSHS-B in a burn population consisting of 90% minor burns is consistent with that demonstrated in major burns.

Conclusion

The BSHS-B can be employed to track and predict recovery after burns of all sizes to assist the provision of targeted burn care.     

Photographic assessment of burn wounds: A simple strategy in a resource-poor setting

Objective

To validate the use of photographic burn wound assessment in evaluation of burn size and wound characteristics.

Methods

Feasibility study of agreement between methods of measurement of burn size and characteristics, in patients admitted to the burn unit at Kamuzu Central Hospital (KCH), Malawi, over two months in 2011. Burn wounds were photographed and assessed clinically, concurrently, by an experienced clinician. Photographs reviewed by two blinded burn clinicians after 4–6 weeks. Correlation between clinical assessment and photographic evaluation was calculated using kappa score and Pearson's correlation coefficient.

Results

Thirty-nine patients were included in evaluation of TBSA, and fifty wounds assessed for their characteristics. Pearson's correlation coefficient for agreement of TBSA between clinical exam and photograph review by expert#1, and #2, was 0.96, 0.93 (p < 0.001), respectively. Pearson's correlation coefficients comparing expert#1 and #2 to the gold standard were: proportion of full-thickness burn (0.88 and 0.81, p < 0.001), and epithelialized superficial burn (0.89 and 0.55, p < 0.001). Kappa scores were significant for wound evolution (expert#1 0.57, expert#2 0.64, p < 0.001), and prognosis (expert#1 0.80, expert#2 0.80, p < 0.001).

Conclusions

Burn assessment with digital photography is a valid and affordable alternative to direct clinical exam, alleviating access issues to burn care in developing countries.     

nNOS expression in the brain of rats after burn and the effect of the ACE inhibitor captopril

Objective

To investigate the role of endogenous neuronal nitric oxide synthase (nNOS) on brain injury after burn and the effects of the captopril.

Methods

Wistar albino rats (200–250 g) were exposed on the dorsal surface to 90 °C (burn) or 25 °C (sham) water for 10 s. The ACE group was treated with intraperitoneal 10 mg/kg captopril immediately after burn and this treatment was repeated twice daily. At the end of the 24 h brain samples were taken. nNOS was studied in brain areas by immunohistochemistry.

Results

There was no difference between the cerebellar and hypothalamic areas the nNOS expression of all groups. nNOS expression increased in the frontal cortex, striatum and midbrain in the burn group compared to the control group. In the frontal cortex, nNOS expression significantly decreased after ACE inhibitor treatment (p < 0.05). The striatal nNOS of the ACE group significantly increased when compared to the control group (p = 0.001). In the midbrain of the animals, nNOS decreased in the ACE group. Hippocampal nNOS expression did not change after burn and significantly increased after ACE inhibitor therapy (p < 0.05).

Conclusions

Our data showed that the pathophysiological events following burn appear to be related to an acute inflammatory reaction which is associated with nNOS in the frontal cortex, striatum and midbrain, and captopril treatment abrogates the nNOS response in the frontal cortex and midbrain.     

The Long Term (5-Years) Objective TVT Success Rate Does Not Depend on Predictive Factors at Multivariate Analysis: A Multicentre Retrospective Study

Objectives

We evaluated the predictive risk factors that could affect the long-term efficacy of the tension-free vaginal tape (TVT) procedure for the treatment of female stress urinary incontinence (SUI).

Methods

One hundred thirty-eight (mean age, 52.4 ± 9.3 yr) women who underwent the TVT procedure for SUI were selected and followed up for at least 5 yr (mean, 67.2 mo; range, 60–76) after the surgery. We analyzed the preoperative and intraoperative parameters using univariate and multivariate regression for cure rates and patients’ satisfaction.

Results

The overall 5-yr cure rate was 76.8%, with a satisfaction rate of 86.9%. The cure rates were lower in patients with high body mass index (BMI ≥ 25 kg/m²/BMI < 25 kg/m² = 68.3%:83.3%, p = 0.044), low abdominal leak point pressure (ALPP < 60 cm H₂O/ALPP ≥ 60 cm H₂O = 51.6%:82.8%, p = 0.003), and high grade of SUI (40.0% in grade III; 69.7% in grade II; 86.6% in grade I, p = 0.012). On multivariate analysis, there were no independent risk factors related to cure rate, and urgency was the only factor independently associated with patients’ satisfaction (p = 0.017; odds ratio = 4.114).

Conclusions

This study demonstrates that the TVT procedure is effective for female SUI without any independent predictive factors affecting long-term cure rate. Urgency was the only predictive factor affecting patient satisfaction. However, high BMI, low ALPP, and high grade of incontinence may impair the cure rate of the TVT.     

A novel means to classify response to resuscitation in the severely burned: Derivation of the KMAC value

Background

Resuscitation fluid rates following burn are currently guided by a weight and burn size formulae, then titrated to urine output. Traditionally, 24 h resuscitation is reported as volume of resuscitation received without direct consideration for the physiologic response. We propose an input-to-output ratio to describe the course of burn resuscitation and predict eventual outcomes.

Methods

We reviewed admissions to a burn center from January 2003 through August 2006. Inclusion criteria were ≥20%TBSA, admission ≤8 h after burn, and survived ≥24 h. Demographics, input volume and urine output, and clinical outcomes were recorded. A ratio of input volume (cc/kg/%TBSA/h) to urine output (cc/kg/h) was calculated at 24 h. The ratio of fluid intake to urine output reflecting an ‘expected’ response was developed: 4 cc/kg/%TBSA/24 h (0.166 cc/kg/%TBSA/h) divided by 0.5–1.0 cc urine/kg/h for an expected range 0.166–0.334. Subjects were classified based upon the ratio: over-responders (<0.166), expected (0.166–0.334), or under-responders (>0.334). Clinical outcomes were compared and concordance of classification to values was calculated at 12 h.

Results

102 subjects met inclusion criteria; 29 in the over-responders, 37 in the expected, and 36 in the under-responders. Resuscitation volume was directly proportional to the calculated ratio while urine output was inversely proportional. Group mortality was 21%, 11%, and 44%, respectively, with a significant difference between the expected and under-responders (p < 0.002). We found decreased ventilator-free days in the under-responders, and when deaths were excluded, decreased ICU-free days as well (p < 0.05). Concordance of paired data gathered at 12 h and 24 h was 67% for the under-responder group.

Conclusions

We describe a novel ratio to classify acute resuscitation after severe burn including the patient's response. Such a classification is associated with eventual outcomes.     

Outpatient burn data: An untapped resource

Introduction

The National Burn Repository (NBR) currently only contains inpatient data from participating United States burn centres. However, the majority of the patients treated in burn centres are managed as outpatients. Unfortunately, this significant demographic is not represented in the NBR annual report. The purpose of this study is to compare the difference in aetiology and demographics between inpatient and outpatient burn patients. In addition, the workload demands for data entry of inpatient and outpatient records in the burn registry will be compared.

Methods

Outpatient and inpatient burn data at an American Burn Association-Verified Burn Center were prospectively collected during fiscal year 2008. Data collected included age, burn size and aetiology of burn. Aetiology was also stratified by age group. Inpatient data were compared with outpatient data with Fisher's exact test. The amount of time taken to enter inpatients’ and outpatients’ data parameters in the TRACS v5.0 database was also recorded.

Results

Data were collected for 241 inpatients and for 543 outpatients during fiscal year 2008. No significant differences in gender or race were found between the two groups. When comparing demographics, outpatients tended to be younger (26 ± 19 years vs. 32 ± 22 years, p = 0.01) with a smaller burn size (2.5 ± 7% vs. 6.8 ± 12%, p < 0.001) and a lower frequency of full-thickness burns (17% vs. 41%, p < 0.001).Of the patients managed as an outpatient, a total 29.7% were eventually admitted to the hospital. Just over half of those (16.7%) initially managed in the outpatient setting were admitted for a planned surgical procedure. The other 13% were admitted for pain control and wound-care issues.Injury was more likely to be caused by flame in inpatients (p < 0.001). Scald injuries were more common in the outpatient setting (34% vs. 27%), but this difference did not reach statistical significance (p = 0.079). Outpatients were more likely to be injured with a contact burn (p < 0.0001). Outpatient injury was more likely to be work-related than inpatient injury (p = 0.0497), but less likely to be related to recreational activity (p = 0.006) or arson/abuse/assault (p = 0.0158). An experienced TRACSv5.0 user required 11 ± 0.6 min to enter an inpatient record and 6 ± 0.6 min to enter an outpatient record in the system (p = 0.002).

Conclusions

Inpatient injury is more likely to be caused by flame, whereas outpatient injury is more likely to be caused by scald and contact burns. Work-related burn is more likely to be treated in the outpatient setting. Outpatient burn data also take less time to enter. Since significant differences in aetiology exist, outpatient data should be reported separately from inpatient data in order to understand the full spectrum of burn aetiology. The NBR and other registries should be modified to track outpatient burn data and outcomes.     

The effect of epidural anaesthesia on the reverse-flow fasciocutaneous flap: An experimental study in rabbits

Background: The reverse-flow fasciocutaneous flap has been popularised as a feasible alternative to reconstruction of the post-burn contractures around lower-extremity joints. The effect of epidural anaesthesia (EA) on the haemodynamics of reverse-flow fasciocutaneous flap (RFFF) has not yet been investigated. Therefore, it was our primary objective to determine how EA impacts on vascular haemodynamics and tissue perfusion. Materials and methods: This study included 30 New Zealand white rabbits. The reverse-flow saphenous fasciocutaneous island flap in rabbit model was used. In group I (n = 10), epidural catheterisation of the rabbits were performed and they received an epidural infusion of 0.1 ml kg⁻¹ 0.125% bupivacaine 12-h periods until the 10th day. In group II (n = 10), epidural catheterisation of the rabbits was performed and they received an epidural infusion of 0.1 ml kg⁻¹ isotonic sodium chloride solution. In group III (n = 10), epidural catheterisation of the rabbits was not performed. Intra-arterial blood pressure (IABP) and intravenous blood pressure (IVBP) was recorded at time intervals of 5, 15, 30 and 60 min, respectively, after tourniquet release on the first and 10th day. Microcirculatory flow was measured by laser Doppler flowmetry at 2, 4, 6, 8 and 10 days in all the groups. Results: Throughout the experiment, the flaps showed complete survival. A significant difference was noted in the microcirculatory flow measurements in the flap surfaces between group I and groups II–III throughout the experiment (p < 0.05). A significant difference was noted in IVBP and IABP between group I and groups II–III (p < 0.05). On the first and the 10th day, however, there were no significant differences between groups II and III (p > 0.05). Conclusion: EA improves blood flow to RFFF and prevents the progression of venous congestion.     

Three-dimensional digitalized virtual planning for retrograde sural neurovascular island flaps: a comparative study

Background

The purpose of this study was to explore the effectiveness and safety of three-dimensional (3D) digitalized planning for the sural neurovascular island flap in repair of soft tissue defects in the ankle and foot.

Methods

This study included 40 patients with soft tissue defects of the ankle and foot who underwent soft tissue reconstruction between October 2008 and June 2012. The patients were randomly assigned into two groups: 3D-reconstruction group (Group A, n = 20) and control group (Group B, n = 20). Three-dimensional, digitalized virtual planning was performed in the patients in Group A, who underwent computed topographic angiography. The survival rate, operation time, and surgical accuracy were compared between the two groups.

Results

All flaps in Group A survived and the recipient site primarily healed, but 4 flaps in Group B had marginal necrosis after the operation. During the 6–12 month follow-up period, all flaps in Group A had good skin quality. In Group B, hard scarring and mild contracture occurred in 4 cases, and the patients experienced pain when walking. The survival rate of the flap in Group A (100%) was significantly higher than in Group B (70%). The operation time in Group A was significantly less than in Group B. The surgical accuracy in Group A was significantly better than in Group B.

Conclusion

The preoperative use of 3D digitalized virtual planning for the sural neurovascular island flap improves the surgical accuracy, decreases the operation time, and increases the survival rate of the flap.

Clinical question/level of evidence

Therapeutic III.     

Assessing the impact of missing data in evaluating the recovery of minor burn patients

Introduction

Little published evidence is available regarding the recovery of patients with minor burns. Poor attendance at review clinics results in incomplete data which hampers accurate analysis of patient recovery. It is often assumed that non-attendance for review is due to full recovery and the inconvenience associated with clinic attendance. This study aimed to obtain final outcomes for a group of minor burn patients and identify factors contributing to missing data.

Method

A group of patients with minor burn + upper limb involvement, noted to have 81% non-attendance at 6-month review, were contacted to evaluate their recovery and service satisfaction. The stability of responses from 6 months after burn was compared in a subset of participants who did attend review. Demographics of non-responders were compared to responders.

Results

Final outcomes were obtained from 67% of participants. Mean BSHS-B and QuickDASH scores for this group were 150.2 and 1.55% disability, respectively, indicating a good recovery. Subsequent non-responders were significantly younger (p = 0.016), suggestive of a better recovery than responders. Dissatisfaction with the service was not a contributing factor in non-attendance.

Conclusion

Minor burn patients with upper limb involvement recover well and intensive review of these patients is unnecessary.     

The impact of laser Doppler imaging on the early decision-making process for surgical intervention in adults with indeterminate burns

Objective

We aimed to analyze whether laser Doppler imaging (LDI) can lead to earlier decision-making regarding the need for surgery in adults with indeterminate burns.

Methods

In a retrospective cohort study, we developed a prediction model for surgery in adults with indeterminate burns. Patient data (n = 101) from January 2007 to December 2009 were used for model development, and those (n = 40) from January 2010 to October 2010 for external validation.

Results

Between non-surgical and surgical groups, there were significant differences for mean age (p = 0.009), % total body surface area burn (p = 0.016), site of burn wound (p = 0.033), and mean perfusion units (PU) (p < 0.001). Multiple logistic regression showed that only the mean PU differed significantly between the groups. The area under the curve (AUC) of the equation derived from multiple logistic regression was 0.938, which did not differ from that of the mean PU alone (0.931; p = 0.453). Using a cut-off point of 154.7PU, the sensitivity of LDI was 78.3% and the specificity was 92.7%. This cut-off point also yielded a sensitivity of 77.8% and specificity of 95.5% in the external validation dataset.

Conclusion

LDI can help make a decision for surgery in the early stages of care for adults with indeterminate burns.