Tips and Tricks in Microvascular Anastomoses

Microvascular anastomosis is a highly skilled surgical technique that requires the assistance of optical magnification via an operating microscope or loupes to be fully visualised and thus accomplished reasonably well. It demands the full attention of the surgeon throughout the procedure. Even the smallest of inadvertencies may result in disastrous results. Practice has no shortcut and the more experienced a skilled surgeon is, the better his results. The chapter begins with a detailed account of preparedness in the operating room, for preparation is the path to success. There are however tips to reduce the incline of the learning curve and points to remember when things are not quite going right. This chapter attempts to deal with those moments

Crush Injuries of the Hand Part I: History, Mechanism and Pathomechanics

This chapter, the first of two; deals with the basics of crush injuries of the hand as opposed to crush syndrome. The definition is explained and the differences are outlined. A journey through the historical review of the causative mechanisms gives the reader an insight into the machines inflicting a spectrum of injuries and their sequelae. We see how the tools either remain the same or change with time, exacting similar types of injuries but in a different manner and timescale due to mechanisation. Thus it is vital to grasp the mechanics to get a basic understanding of the pathomechanics, enabling one to address the injury by reversing the inflictive force while maintaining respect for the machine. These are humbling injuries that require experience, expertise and enterprise by a dedicated and cohesive team always open to learning

Crush Injuries of the Hand Part II: Clinical Assessment, Management and Outcomes

This chapter details crush injuries of the hand as opposed to crush syndrome. The definition along with the spectrum of injury is described including a historical review of the causative mechanisms to help in the understanding of basic pathomechanics. The main menu comprises Clinical Assessment, Management and Outcomes, where the reader is taken through the steps one by one on how to approach such an injury, from the history, examination and investigations pointing out important aspects. Basic facts and figures to know and memorize have been placed in an easy-to-absorb format of tables and highlighted boxes. Key points are emphasized, and important aspects of management as well as those simple tips to improve outcome are given to ease the novice as well as the tempered surgeon’s encounter. A special section on management of specialized tissue is given toward the end after the basic management is dealt with so that a deeper understanding is gained and applied. Possible outcomes would alert the surgeon on both adverse events to avoid and excellent results to aim for. As always, good functional outcome is sought after but a good cosmetic appearance should be constantly filed away in mind’s eye to enhance the final result

Wound healing assessment using digital photography: a review

Digital photography as a non-invasive, simple, objective, reproducible, and practical imaging modality has been investigated for the wound healing assessment over the last three decades, and now has been widely used in clinical daily routine. Advances in the field of image analysis and computational intelligence techniques along with the improvements in digital camera instrumentation, expand the applications of standardized digital photography in diagnostic dermatology such as evaluation of tumours, erythema, and ulcers. A series of digital images taken at regular intervals carries the most informative wound healing indexes, color and dimension, that may help clinicians to evaluate the effectiveness of a particular treatment regimen, to relieve patient discomfort, to globally assess the healing kinetics, and to quantitatively compare different therapies; however, the extent of underlying tissue damage cannot be fully detected. This paper is an introductory review of the important investigations proposed by researchers in the context of clinical wound assessment. The principles of wound assessment using digital photography were shortly described, followed by review of the related literature in four main domains: wound tissue segmentation, automated wound area measurement, wound three dimensional (3D) analysis and volumetric measurement, and monitoring and evaluation of wound tissue changes during healing

Physical to biological building blocks in hand & microsurgery: the facts, the face, the facility, the field... and the future

The Hand is a truly remarkable instrument - an organ of perception (feel, touch and much more), performance (power grip and fine motor functions), perspiration (sweating assists us in handling items and reducing body temperature), presentation and even communication. Second to the face the most commonly presented part of the body is the hand, thus its appearance of normalcy is crucial. Many a time when we are unable to verbalise our thoughts, we convey our messages, knowingly or otherwise, through non-verbal hand gestures as well as body language. Meanwhile, in dance forms and miming the hands are essential aspects of communication. Similarly sign language is basically that – an entire language communicated via the hands! Anatomically, due to the high density of nerve fibres at the fingertip, digits also aid in stereognosis which enables the blind to “see” and the deaf to “hear” (Alpenfels EJ 1955). The fact that the hand is structurally positioned at the extreme end of the upper limb, to enable it to reach out approximately one metre away from the body, however, makes it extremely susceptible to injury. Injury to the hand and wrist is devastating. All it takes is to imagine a day in one’s life without the right or even left hand. It becomes evident that a major portion of our lives and activities of daily living are dependent on us being able to have complete hand (and upper limb) function. In order for us to get through the day, there are numerous bimanual activities we perform without a thought. Even a minor papercut precludes us from continuing with these normally. Thus, hand injuries from the fingertip to the shoulder are functionally and emotionally distressing and need to be addressed immediately. Most importantly the injury or pathology needs to be treated right the first time. The Hand and Microsurgery field is a sub-specialty dealing with the treatment of conditions pertaining to the entire upper limb from fingertip to shoulder (Wikipedia). This includes both surgical and non-surgical management of congenital and paediatric conditions, trauma, infection, inflammation, haematological aspects, tumours, compression neuropathies, brachial plexus, the spastic hand, degenerative conditions and miscellaneous conditions such as Dupuytren’s and lymphatic anomalies. This relatively new sub-specialty of surgery developed rapidly in the 20th Century. The works of various researchers, clinicians and surgeons in this area brought about a conglomeration of discoveries which in themselves were remarkable but integrated together provided immense opportunities and ginormous developments. The most significant contribution of Sterling Bunnell, the Father of Hand Surgery, I feel, came in the form of a deep understanding of the intricate anatomy of the hand and its connection to function. He pioneered meticulous techniques, characterised by careful, detailed dissection with an eye on precision, leading to outstanding results, which he practically demonstrated by sharing his surgical techniques around the country (Green SA 2013). Developments in the 1960s, both mechanical and technical, allowed small diameter vessels (of 1 mm or less) to be repaired, opening up a plethora of possibilities and enabling various fields to collaborate for the betterment of the inflicted patient. Thus candidates from the fields of Orthopaedics, Plastic and General Surgery all enter this highly specialised field with the same philosophy: to repair, reconstruct and even replace. Great emphasis is placed on regaining function by therapy both prior to and after surgical or even non-surgical treatment. In the 70s and 80ss, as the field took off, anatomical discoveries of new flaps and arterial patterns and microsurgical refinement of the surgical application of these findings kept the momentum going and the excitement building. The birth of Reconstructive (Micro and even Supermicro – 0.3mm to 0.8mm diameter vessels) Surgery brought about new developments with the advances in transplantation medicine allowing amazing technical feats and repair of the human body. Another exciting area is that of biomedicine where the implant sizes are getting smaller, from mini to micro, and moving from surgical steel to Titanium and finally, bioabsorbable materials. Incisions are also reducing in size, assisted by arthroscopic equipment and innovative techniques. All are changing the way surgery is performed and raising the expectation bar higher. Currently however, we are moving slowly but surely to replacement not by physical means but by biological means, mainly rebuilding and regenerating lost tissue by chemical and biological options. Developing countries have both embraced this field as well found difficulties in implementing the finer aspects. Despite the costs being high and the learning curve steep, this has not deterred them. I feel that the excitement of discovering novel ways to tackle previously “impossible” cases has allowed this field of surgery to blossom. I shall discuss the origins of this subject and how it made an entry into our country (The Facts), both clinically as well as academically, the progress at present in terms of manpower development and what it takes to become a Hand Surgeon (The Face). This will be followed by the development of the infrastructure required to support it (The Facilities). The main essence will be examples of cases that have been seen and what needs to be addressed (The Field) as well as what I see for The Future in terms of prospects for upcoming surgeons and of course, the patients

Gait analysis of national athletes after anterior cruciate ligament reconstruction following three stages of rehabilitation program: symmetrical perspective

This study aimed to objectively evaluate changes in gait kinematics, kinetics and symmetry among anterior cruciate ligament (ACL) reconstructed athletes during rehabilitation. Twenty-two national athletes with ACL reconstruction and 15 healthy athletes were recruited for the study. Gait data were collected between the weeks 4–5, 8–9, and 12–13 post-operation using three-dimensional motion analysis system. Five separate components, including knee range of motion (ROM), vertical ground reaction force (VGRF), their symmetries and knee extension moment were evaluated. One way and repeated measure multivariate analysis of variance (MANOVA) were used to analyze the knee ROMs. The VGRF and extension moment were tested using repeated measure ANOVA and independent sample t-test. Findings indicated significant alterations in all measured components between patients’ Test 1 and control group. Repeated measure analysis revealed significant effect for time in components of knee angular and VGRF (P < 0.001), their symmetry index (P = 0.03) and knee extension moment (P = 0.045). Univariate outcomes demonstrated significant improvement in the injured limb's stance and swing (P < 0.001), and single-stance (P = 0.005) ROMs over time. Symmetry indexes of stance and swing ROM, and VGRF reduced significantly by 26.3% (P = 0.001), 17.9% (P < 0.001), and 31.9% (P = 0.03) respectively. After three months, symmetry indexes of single-stance ROM and VGRF along with operated knee extension moment were the only variables which showed significant differences with control group. The rehabilitation program allowed national athletes to restore the operated limb's gait parameters except knee extension moment by 12–13 weeks post-reconstruction; however, more time is required to normalize single-stance ROM and VGRF asymmetries

Knowledge and attitude of occupational health and safety among laboratory worker of Faculty of Medicine and Health Sciences and Faculty of Veterinary Medicine in University Putra Malaysia. .

Introduction:Laboratory workers are exposed to variety of hazards that may affect their health and safety. Awareness of occupational safety and health (OSH) is important in preventing occupational injuries and diseases. The objective of this study was to assess the knowledge of OSH among laboratory workers in Faculty of Medicine and Health Sciences and Faculty of Veterinary Medicine, Universiti Putra Malaysia. Methods:A cross-sectional study was conducted on laboratory workers in the two faculties in Universiti Putra Malaysia.A pretested, self-administered questionnaire comprising of 5 sections including socio-demographic, OSH environment of the laboratory, exposure to the knowledge of OSH, knowledge of OSH and attitude of laboratory workers in the laboratory was distributed to all registered permanent laboratory workers in the faculties. Data entry and analysis was done using Statistical Package for Social Science (SPSS) version 18.Descriptive statistics on socio-demography and job factors were determined. Independent t-test and chi-squared test were used to test associations. Correlation between attitude and knowledge on OSH was computed. Results: The response rate was 64.42% (67 laboratory workers). The overall level of knowledge on OSH was moderate, with a mean score of 62%. A larger proportion of female respondents (51.5%) showed good OSH knowledge compared to male respondents (14.7%) and the difference was statistically significant (10.288, 1; p<0.01). Majority of the respondents (73.7%) who worked in a poor OSH laboratory environment had poor attitude level towards OSH (χ2=7.135, df=1; p=0.008). There was a moderate positive correlation between knowledge and attitude on OSH (r=0.4, p<0.01). Knowledge explains 16% of the variance in level of attitude towards OSH among laboratory workers. Conclusion: Knowledge of OSH among laboratory workers was moderate and is associated with gender and OSH environment in the workplace. A greater effort to promote OSH knowledge among the laboratory workers is needed to ensure their safety and health in workplace

Giant cell tumour of tendon sheath masquerading as trigger finger.

We report a case of a 59-year-old female who presented in the general orthopaedic clinic with triggering of her right middle finger. She did not respond to conventional treatment methods; subsequently she underwent surgical open release under local anaesthesia. Five months postoperatively, the patient presented with signs and symptoms of acute flexor tenosynovitis, and was thought to have a postoperative infection. Re-examination by a hand surgeon raised the possibility of a different aetiology. Based on clinical findings and response to initial treatment, giant cell tumour of the flexor tendon sheath was suspected and later confirmed following surgical biopsy. A high index of suspicion and knowledge of the variegated presentations of giant cell tumour in the hand are beneficial in these types of cases

Bowel dysfunction in spinal cord injury

Bowel Dysfunction is one of the least looked at problems in Spinal Cord Injury (SCI). The goals of this study are to understand bowel dysfunction in SCI and its effects on quality of life (QOL). Cross-sectional study based on interview and assessment of 41 clients. A majority of them were dissatisfied. Bowel opening time was long in about 65% while 76.6% were incontinent. Socially, approximately half refrained from outings even though 90.3% of them carried out bowel evacuation before going out. Attention to bowel education is necessary to improve social continence

Quantitative assessment of wound healing using high-frequency ultrasound image analysis

Purpose: We aimed to develop a method for quantitative assessment of wound healing in ulcerated diabetic feet. Methods: High‐frequency ultrasound (HFU) images of 30 wounds were acquired in a controlled environment on post‐debridement days 7, 14, 21, and 28. Meaningful features portraying changes in structure and intensity of echoes during healing were extracted from the images, their relevance and discriminatory power being verified by analysis of variance. Relative analysis of tissue healing was conducted by developing a features‐based healing function, optimised using the pattern‐search method. Its performance was investigated through leave‐one‐out cross‐validation technique and reconfirmed using principal component analysis. Results: The constructed healing function could depict tissue changes during healing with 87.8% accuracy. The first principal component derived from the extracted features demonstrated similar pattern to the constructed healing function, accounting for 86.3% of the data variance. Conclusion: The developed wound analysis technique could be a viable tool in quantitative assessment of diabetic foot ulcers during healing