Management of a mutilated hand: the current trends

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

Outcomes of Evisceration or Enucleation by Resident Trainees in Patients with Endophthalmitis or Panophthalmitis

Background To evaluate the outcomes of evisceration or enucleation with primary implantation performed by ophthalmology resident trainees in patients with endophthalmitis or panophthalmitis. Methods In this retrospective analysis, the clinical records of all patients diagnosed with endophthalmitis or panophthalmitis who underwent enucleation or evisceration with primary implantation over a 13-year period were reviewed. The predictive factors related to implant exposure or extrusion were identified using multivariate analysis. Results Sixty-six patients, with a median age of 46.8 years, were enrolled. Thirty-six (55%) out of 66 patients were diagnosed with panophthalmitis. The most common causes of endophthalmitis or panophthalmitis were trauma (13 patients) and corneal ulcer perforation (10 patients). Enucleation was performed in 53 patients (80%). Four patients (6%) had implant exposure, and 4 patients (6%) had implant extrusion. Multivariate analysis demonstrated that Pseudomonas aeruginosa infection (P = 0.021, adjusted odd ratio [aOR] 33.75) and not receiving intravitreal antimicrobial drugs before the eye removal procedure (P = 0.02, aOR = 30.11) were associated with implant exposure or extrusion. Patients with panophthalmitis who underwent evisceration had a higher rate of implant exposure or extrusion than those who underwent enucleation (P = 0.031, aOR 38.38). Other complications included socket discharge in 14 patients, lower lid laxity in 5 patients who underwent the lateral tarsal strip procedure, and wound dehiscence in 3 patients. At the last visit, 65 patients had successful prosthesis fitting. Conclusion This study suggests that evisceration or enucleation with primary implant placement in patients with recalcitrant endophthalmitis or panophthalmitis can be performed by resident trainees with acceptable surgical outcomes and a low rate of serious complications.

Case series of shrinking hydroxyapatite orbital implants

BackgroundAn orbital implant is used after enucleation or evisceration surgery to replace the volume lost and to aid in prosthesis fitting and movement. Different materials have been used through the years. The authors noted that with bone-derived hydroxyapatite orbital implants, some patients lose their orbital volume.MethodsThe operating theatre record was searched to find patients who had their hydroxyapatite orbital implant removed at Dunedin Hospital, New Zealand, between 2011 and 2015. The original implant size and size at removal were noted. Histological results were noted. Medical notes were reviewed.ResultsA total of six patients had hydroxyapatite orbital implants removed during this time. Four patients had implants that were smaller than their original sizes. All specimens had fibrovascular infiltration noted, three had chronic inflammatory cells and one had osteoclastic activity.ConclusionsBone-derived hydroxyapatite orbital implants can reduce in size, and this may occur due to osteoclastic activity. The surgeon must consider this scenario when choosing the type of implant to be used after enucleation or evisceration.

Quantification and Pathogenicity of Candida albicans in Denture-Wearing and Nondenture-Wearing Elderly

Objective The primary purpose of this study was to evaluate and compare the microbial loads and pathogenicity traits of oral Candida albicans in denture-wearing (DW; n = 15) and nondenture-wearing (NDW; n = 15) elderly persons. Materials and Methods The fungal counts of the saliva, tongue dorsa, and prosthesis-fitting surfaces of the participants were assessed using real-time polymerase chain reaction to compare the quantity and expression of selected C. albicans biofilm-associated genes (ALS3, HWP1, and YWP1). Statistical Analysis The obtained data were analyzed by one-way analysis of variance, followed by Bartlett’s test. When appropriate, the Student’s t-test was also used; a value of p < 0.05 was considered statistically significant. Results In both groups, the count of C. albicans was found to be significantly higher in saliva than in other oral samples. The expression of the hypha-specific genes (ALS3 and HWP1) in the tongue dorsa was higher in the DW group (p < 0.05), whereas the transcription level of the yeast-specific gene (YWP1) was significantly higher in the NDW group. Conclusion Both tongue dorsa and dentures appear to be sharing factors that are important for C. albicans biofilm growth in abiotic and biotic oral surfaces of the elderly.

Should Chopart Amputation be Performed in Diabetic Foot Ulcer Patients?

Category: Diabetes, Midfoot/Forefoot Introduction/Purpose: Diabetic foot ulcers (DFU) with deep infections and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation is challenging, and is a complex decision based on the patient’s function at baseline, extent of infection, vascular patency and comorbidities. Although Chopart amputation preserves greater limb length than Syme amputation, additional procedures, such as Achilles tenectomy and tendon transfers are necessary to optimize residual foot function. Challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes including patient reported outcomes of Chopart and Syme amputations. Methods: A query utilizing current procedural terminology (CPT) codes was performed to identify patients who had undergone Syme or Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Twenty-two patients with average age of 59.8 (range, 28-79) years, comprising 18 Chopart amputations and 4 Syme amputations were identified. Demographic characteristics, body mass index, hemoglobin A1c, medical comorbidities, major and minor post-operative complications, unplanned admission or return to OR, revision surgeries, and time to receiving a brace or prosthesis information were compiled. After informed consent was obtained, subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments (Pain Interference (PI), Physical Function (PF), and Depression), and the SF-36. Unpaired student t-tests and Fisher’s exact test were utilized to compare patient cohorts. Statistical analysis was performed using Stata®. Results: The majority (17/18) of Chopart and half (2/4) of Syme patients developed complications including wound dehiscence and recurrent/persistent infection. Readmission and unexpected return to the OR for irrigation and debridement or revision occurred in 11/18 (61%) of Chopart and 2/4 (50%) of Syme patients. Revision amputations occurred in 10/18 (56%) Chopart patients (2 Syme, 8 BKA), and 1/4 (25%) Syme patients (BKA). Half of Chopart patients never received a prosthesis due to delayed wound healing and revision amputation. All Syme amputation patients received a prosthesis and resumed ambulation. The average time to prosthesis was 4.5 and 6.5 months for Syme and Chopart patients, respectively. There was no significant difference between Syme and Chopart patients in all PROMIS domains, or the SF-36 (p-values > 0.05) (Table 1). Conclusion: We found a high rate of complications and revision procedures in Chopart amputation patients. In our patient cohort, there was a high likelihood that a patient who underwent a Chopart amputation ultimately received a below knee amputation. Even after wound healing, patients with Chopart amputations may struggle with obtaining a prosthesis suitable for ambulation. Syme amputation patients were less likely to require revision amputation, and received a prosthesis more rapidly relative to Chopart amputation patients. The complication and revision rates of Chopart amputations indicate that surgeons should exercise judicious patient selection prior to performing these procedures.

Long-Term Results of Autologous Auricular Cartilage Graft Applied in Anophthalmic Orbits Unable to Wear Prosthesis

In anophthalmic patients, shallow lower fornices make wearing ocular prostheses impossible and maintaining normal social activities difficult. This study retrospectively investigated the long-term surgical outcomes of autologous auricular cartilage grafting for contracted orbits. From 1995 to 2013, 29 anophthalmic contracture sockets with inadequate lower fornices and poor prosthesis retention presented to Chang Gung Memorial Hospital in Linkou, Taiwan, were treated using this surgical method. The success rate, aesthetic outcome, recurrence, and complications were analyzed. Among the 29 patients, 15 were women, 14 were men, their mean age was 45 years, and the mean follow-up time was 52 months (range = 6–159 months). Satisfactory lid position was achieved in 25 cases (86%), and lower fornix retraction recurred in four cases (14%). Neither donor site morbidity nor auricular deformity was noted during the follow-up period. Therefore, an auricular cartilage graft can be used successfully as a compatible spacer for anophthalmic patients with shallow lower fornices and prosthesis-fitting problems in long-term follow-up.

Successful forearm prosthesis fitting in a patient with epidermolysis bullosa dystrophica: Case report

Background: Epidermolysis bullosa dystrophica is a rare dermatological disease characterized by extreme skin fragility and elevated risk of developing a squamous cell carcinoma. In some cases, amputation of a limb is necessary. Case description and methods: A 37-year-old man with recessive, severe generalized epidermolysis bullosa dystrophica developed a squamous cell carcinoma on the right forearm requiring a below-elbow amputation. Preoperative advice concerning indication and level of amputation was given. Due to potential skin problems, a conventional prosthesis was not feasible. Findings and outcomes: A custom-designed adaptive prosthesis with an upper arm cuff was trialed and was well tolerated. Multiple working tools, attached with a rotation and inclination system, allowed independence and return to work. Conclusion: Despite multiple potential skin problems of the stump, the patient was successfully fitted with a custom-designed adaptive prosthesis. Preparation for this fitting was done by a comprehensive multidisciplinary patient-centered approach. Clinical relevance Despite severe skin fragility, a patient with epidermolysis bullosa dystrophica was successfully fitted with a custom-designed adaptive upper limb prosthesis allowing good functional outcome. This required a multidisciplinary and patient-centered approach.