Perioperative thromboprophylaxis in digital replantation: a systematic review

Background There is no international consensus on the use of perioperative thromboprophylaxis in digital replantation. Suboptimal perioperative management may lead to replant failure which compromises extremity function, worsens psychosocial outcomes for patients and incurs significant cost. This systematic review evaluates and compares the efficacy and safety of perioperative antithrombotic protocols used in digital replantation. Methods A PRISMA-compliant prospectively registered (PROSPERO CRD42018108695) systematic review was conducted. Cochrane Central Register of Controlled Trials, Medline, EMBASE and Scopus were searched up until December 2019. Articles were assessed for eligibility in duplicate by two independent reviewers. All comparative studies which examined the use of perioperative thromboprophylaxis in digital replantation were eligible for inclusion. Results Collectively, 1,025 studies were identified of which 7 met full inclusion criteria reporting data from 635 patients (908 digital replants, 86% male, average age 37.3 years). Laceration was the most commonly reported mechanism of injury (68%) with 33% of replantation occurring in Tamai zone III. Fourteen distinct perioperative protocols were identified. One study reported significantly higher digital survival with continuous heparin infusion versus bolus heparin. Five studies demonstrated a significantly higher incidence of complications amongst patients treated with systemic heparin. Conclusions The clinical efficacy and safety of peri-operative antithrombotic therapy following digital replantation remains equivocal. The perceived benefits of improved digital survival must be tempered against the adverse systemic side effects of antithrombotic and anticoagulant therapies until further prospectively collected data sets become available

Microbiological and functional outcomes after open extremity fractures sustained overseas: The experience of a UK level I trauma centre

Background Open extremity fractures carry a high risk of limb loss and poor functional outcomes. Transfer of extremity trauma patients from developing countries and areas of conflict adds further layers of complexity due to challenges in the delivery of adequate care. The combination of extensive injuries, transfer delays and complex microbiology presents unique challenges. Methods A retrospective review was conducted to analyse the surgical and microbiological themes of patients with open extremity fractures transferred from overseas to our institution (Imperial College NHS Trust) between January 2011 and January 2016. Results Twenty civilian patients with 21 open extremity fractures were referred to our unit from 11 different countries. All patients had poly-microbial wound contamination on initial surveillance cultures. Five patients (25%) underwent amputation depending on the extent of osseous injury; positive surveillance cultures did not preclude limb reconstruction, with seven patients undergoing complex reconstruction and eight undergoing simple reconstruction to achievewound coverage. Hundred percent of patients demonstrated infection-free fracture union on discharge. Conclusion Patients with open extremity fractures transferred from overseas present the unique challenge of poly-microbial infection in addition to extensive traumatic wounds. Favourable outcomes can be achieved despite positive microbiological findings on tissue culture with adequate antimicrobial therapy. The decision to salvage the limb and the complexity of reconstruction used should be based on the chance of achieving meaningful functional recovery, mainly determined by the extent of bony injury. The complexity of reconstruction was based on the predicted long-term functionality of the salvaged limb

A morphometric analysis of the suitability of the transverse cervical artery as a recipient artery in head and neck free flap microvascular reconstruction

Purpose Gold standard recipient arteries in head and neck free flap microvascular reconstruction are currently branches of the external carotid. However, these arteries can be compromised by neck dissection or radiotherapy, resulting in ‘vessel-depleted neck’ and ‘frozen neck’ respectively. In such cases, the transverse cervical artery (TCA) may be a suitable recipient artery. Methods The origin, course and diameter of the TCA were determined in 46 sides of neck from 23 cadavers. The distances from the origin of the TCA to the angle of the mandible, floor of the mouth and mandibular symphysis were measured to determine the pedicle length required for free flap anastomosis. Results The TCA was present bilaterally in all subjects investigated and its course across the posterior triangle of the neck was constant between individuals. The mean distances from the origin of the TCA to the angle of mandible, floor of mouth and mandibular symphysis were 10.0, 9.2 and 12.6 cm, respectively. There were no significant differences in these distances between the left and right sides of the neck (p > 0.05 for all comparisons). The distances from the TCA origin to the angle of the mandible and floor of the mouth were significantly longer in males than in females (p = 0.004) and correlated directly with the greater height of males compared to females (p = 0.0004). The mean diameter of the TCA measured 2 cm from its origin was 2.2 mm. Conclusion The TCA is a suitable and reliable recipient artery for free flap microvascular reconstruction, when branches of the external carotid artery are unavailable

Autologous fat transfer for thumb carpometacarpal joint osteoarthritis: a prospective study

The publication “Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis: A Prospective Study”1 presents a new surgical treatment for base of thumb osteoarthritis (OA). The associated commentary hails it as a potential breakthrough. We believe there are methodological flaws that warrant attention. First, it was presented as a ‘pilot study’ building on a previous case series of five patients. However, there was no a priori sample size calculation, statistical analysis plan or published protocol. The authors even acknowledge it was not powered for statistical analysis but go on to statistically analyze the data and draw conclusions from the results. It would be better described as an IDEAL Collaboration stage 2A development study.</p

Raising the Alarm: A Cross-Sectional Study Exploring the Factors Affecting Patients' Willingness to Escalate Care on Surgical Wards

Background Delays in escalation of care for patients may contribute to poor outcome. The factors that influence surgical patients’ willingness to call for help on wards are currently unknown. This study explored the factors that affect patients’ willingness to call for help on surgical wards; how patients call for help and to whom; how to encourage patients to call for help, and the barriers to patients calling for help. Methods A cross-sectional study was conducted in three London hospitals using a questionnaire designed through expert opinion and the published literature. A total of 155 surgical patients (83 % response rate) participated. Results Patients were more willing to call for help using the bedside buzzer or by calling a nurse compared to a doctor (p < 0.001). The prompts to calling for help patients were most likely to act on were bleeding and pain. Patients were more willing to call for help if encouraged by a healthcare professional than a relative or fellow patient (p < 0.01). Patients were more likely to worry about taking up too much time when calling for help than being perceived as difficult (p < 0.001). For some prompts, male patients were more willing to call for help (p < 0.05). Conclusions This is the first study to identify factors affecting patients’ willingness to call for help on surgical wards. Interventions that take these factors into account can be developed to encourage patients to call for help and may avoid delays in treatment