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This article portrays the authors’ experience with a complex lower limb bone and soft tissue defect, following chronic osteomyelitis and pathological fracture, which was managed by the multidisciplinary orthoplastic team. The decision for functional amputation versus limb salvage was deemed necessary, enhanced by the principles of “spare parts” in reconstructive microsurgery. This case describes the successful use of the osteocutaneous distal tibia turn-up fillet flap that allowed ‘lowering the level of the amputation’ from a through knee to a below-knee amputation to preserve the knee joint function. We comprehensibly review reports of turn-up flaps which effectively lower the level of amputation, also applying ‘spare-parts’ surgery principles and explore how these concepts refine complex orthoplastic approaches when limb salvage is not possible to enhance function. The osteocutaneous distal tibia turn-up fillet flap is a robust technique for modified BKA reconstructions that provides sufficient bone length to achieve a tough, sensate stump and functional knee joint.

Wound coverage by split‐thickness skin graft (SSG) and epidermal graft (EG) shortens healing time, with comparable outcomes. However, the healing mechanism of EG is not as well understood as SSG. The difference in the healing mechanisms of EG and SSG was investigated using gap junctional proteins, proliferative marker, and cytokeratin markers. Paired punch biopsies were taken from the wound edge and wound bed from patients undergoing EG and SSG at weeks 0 and 1 to investigate wound edge keratinocyte migratory activities (connexins 43, 30, and 26), wound bed activation (Ki67), and the presence of graft integration to the wound bed (cytokeratins 14 and 6). Twenty‐four paired biopsies were taken at weeks 0 and 1 (EG, n = 12; SSG, n = 12). Wound edge biopsies demonstrated down‐regulation of connexins 43 (P = .023) and 30 (P = .027) after EG, indicating accelerated healing from the wound edge. At week 1, increased expression of Ki67 (P

Seven models for tendon repair simulation (urinary catheter, liquorice, fishing lure, dental rolls, drinking straw, silicone sealant and the authors’ modification of silicone sealant with Micropore™ tape) were assessed for their performance in a number of domains. The silicone sealant and surgical tape model scored highest overall and for each individual domain. This was significantly higher than all other models with the exception of the silicone sealant alone. The lowest scoring model was the drinking straw model.

Objectives The inability to remove a ring from a finger is a common presentation to Emergency Departments in addition to Orthopaedic and Plastic Surgery Units. This is often complicated by factors including trauma and infection, leading to a superimposed tourniquet effect by the ring, strangulating the subcutaneous tissues. The threat of neurovascular compromise favours early removal of the ring to limit associated morbidity. This article illustrates the common methods within the literature. We offer assessing clinicians an illustrated summary of techniques for removing an incarcerated ring from an extremity and summarise notable considerations to be acknowledged at time of assessment and ring removal. Methods A literature search using PubMed and Medline was performed to identify all articles written in English on ring removal. Results The 12 publications included in this illustrated review describing techniques for removal of an incarcerated ring were published between 1991 and 2018 and include modifications to overcome difficulties due to the composition of the ring or severity of the ring incarceration and penile/scrotal ring removal. Conclusion The ring removal techniques are ring preserving or destructive. The technique used depends on factors including the extent of associated trauma to the digit, evidence of strangulation, ring composition, patient preference and equipment availability. Before an attempt at ring removal, high arm elevation, indirect ice compression of the digit and adequate analgesia maximise chances of success. In cases of strangulation, emergent referral to a specialist is indicated for removal and further management.

Cosmetic tourism is a global commodity, but patients seeking treatment for complications of international cosmetic tourism appear to be on the rise. We calculate the financial burden to a single NHS trust and summarise the literature, reviewing the implications of cosmetic tourism and summarising available guidance to assist surgeons in this ethically challenging, but expanding, field. Hospital episodes for patients with complications from cosmetic tourism between January 2016 and March 2017 were retrieved using the patient management system. The coding department provided the episode costs. A literature search was conducted using Medline, EMBASE and HBE identifying 273 English abstracts. The abstracts were reviewed for relevance followed by assessment of the 48 selected full articles by all authors and 17 papers contained relevant, new information. Eleven patients underwent management for complications of cosmetic surgery, most commonly infection, with a sum of 29 inpatient episodes and total cost of £259,732. Our study illustrates the management of complications of cosmetic surgery carries a high cost. This is not an experience limited to just this trust in the UK. Internationally, healthcare systems are evolving to raise the safety profile for cosmetic tourists, some going the extra mile to accommodate healthcare tourists, reaping the financial reward. Following the examination of the literature, we query whether NHS trusts should heighten their presence as providers of private services on the international market, eliminating numerous medical–ethic concerns associated with substandard cosmetic tourism. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

BACKGROUND Effective skin graft fixation is vital in preventing sheering forces, seroma, and hematoma from compromising graft take. Yet, selecting the ideal technique for securing skin grafts remains a contentious subject, with significant variation in practice existing between surgeons. There is, therefore, benefit to be derived from assessing the literature for evidence-based recommendations to guide the decision-making process. METHODS A search of Medline and Embase was performed using appropriate key terms, yielding 419 articles. Reference lists were analyzed. Inclusion and exclusion criteria were composed. Level I to III studies, as defined by the Centre for Evidence-Based Medicine, that compared skin graft fixation methods were analyzed. Rayyan QCRI was used for abstract and title screening. After full text screening, 41 studies were included for qualitative analysis. All included randomized control trials (RCTs) were assessed for risk of bias using the Cochrane Risk-of-Bias 2 (ROB2) tool. RESULTS We identified 4 groups of fixation technique: "tie-over bolster" (TOB), "no TOB," "adhesive glues," and "negative pressure wound therapy" (NPWT). Twelve studies compared TOB with no TOB, with no difference in graft take demonstrated. Sixteen studies compared adhesive glues with traditional methods, with no difference in graft take demonstrated. Thirteen studies compared NPWT with traditional methods, with enhanced graft take demonstrated. Risk of bias was deemed low in 1 of 13 RCTs. CONCLUSIONS Based on the current evidence, only NPWT is associated with enhanced graft take. However, there is a scarcity of robust level I evidence comparing different fixation techniques, meaning that strong recommendations cannot be made. We propose examples of hypothesis-driven RCTs, in predetermined clinical settings, based on the theoretical benefits of the techniques that would add value to clinical practice.

Autologous skin grafting is an important method for wound coverage; however, it is an invasive procedure and can cause donor site morbidity. Epidermal grafting (EG) enables epidermal transfer to wounds with minimal donor site morbidity. However, data to date have been heterogeneous. This study aims to synthesise the current evidence on EG for wound healing to establish the efficacy of this surgical technique. A comprehensive search in the MEDLINE, EMBASE and CENTRAL databases was conducted. The endpoints assessed were proportion of wounds healed and mean wound-healing time. This systematic review was conducted and reported according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We identified 1568 articles, of which seven articles were included in this review - a total of 209 wounds in 190 patients. The mean wound duration was 17·06 weeks (95% CI 8·57-25·55). Of these, 71·5% (95% CI 56·7-84·2) of the wounds achieved complete healing. Mean time for complete wound healing was 5·53 weeks (95% CI 3·18-7·88). The mean donor site healing time was 7·48 days (95% CI 4·83-10·13), with no reported donor site morbidity. The current data are small and lack level 1 evidence.

Epidermal grafting for wound healing involves the transfer of the epidermis from a healthy location to cover a wound. The structural difference of the epidermal graft in comparison to the split-thickness skin graft and full-thickness skin graft contributes to the mechanism of effect. While skin grafting is an epidermal transfer, little is known about the precise mechanism of wound healing by epidermal graft. This paper aims to explore the evolution of the epidermal graft harvesting system over the last five decades, the structural advantages of epidermal graft for wound healing and the current hypotheses on the mechanism of wound healing by epidermal graft. Three mechanisms are proposed: keratinocyte activation, growth factor secretion and reepithelialisation from the wound edge. We evaluate and explain how these processes work and integrate to promote wound healing based on the current in vivo and in vitro evidence. We also review the ongoing clinical trials evaluating the efficacy of epidermal graft for wound healing. The epidermal graft is a promising alternative to the more invasive conventional surgical techniques as it is simple, less expensive and reduces the surgical burden for patients in need of wound coverage.

Split thickness skin grafting (SSG) is an important modality for wound coverage; however, it leads to donor site morbidity. Epidermal grafting (EG) is a promising option for autologous skin grafting which offers minimal donor site morbidity, though it is not known if EG is an effective clinical alternative for SSG. This study compared the efficacy of EG as an alternative to SSG in terms of wound healing outcomes, donor site morbidity, patient satisfaction and adverse events.EPIGRAAFT is a Phase 2, randomized, open-label trial with two parallel groups: EG and SSG. Patients referred for skin grafting with a healthy granulating wound bed were included. The co-primary endpoints were the proportion of wounds healed and donor site healing time. The secondary endpoints include donor site morbidity measured using Vancouver Scar Scale, mean time for complete wound healing, patient satisfaction assessed using a validated skin grafting questionnaire and incidence of adverse events.Of the 61 patients screened, 44 patients were randomized. There was no difference in the proportion of wounds healed at 6 weeks (p=0.366) and 3 months(p=0.24) as well as the mean time for wound healing (p=0.12). EG resulted in lower donor site morbidity (p=0.001), faster donor site healing time (EG: 4.86 days vs. SSG: 21.32 days) (p0.0001), and higher overall satisfaction (p0.001). There were no adverse events reported.This study demonstrated that EG has superior donor site outcomes with faster donor site healing and lower morbidity compared to SSG, while having comparable wound healing outcomes. Patients receiving EG also experienced higher donor site satisfaction compared to SSG. ClinicalTrials.gov identifier: NCT02535481.

Current wound management through the use of a split-thickness skin graft often requires hospital admission, a period of immobility, attentive donor site wound care and pain management. This study evaluates the feasibility of using a novel epidermal graft-harvesting device (CelluTome) that allows pain-free epidermal skin grafting in the outpatient clinic setting. A prospective series of 35 patients was performed in 2 centres, involving 10 acute and 25 chronic wounds. All patients were subjected to epidermal grafting in the outpatient specialist clinic, without the use of anaesthesia, and allowed to return home after the procedure. Completely healed wounds were noted in 22 patients (62·9%). The overall mean time for 50% and 100% reduction in wound size was 3·31 ± 2·33 and 5·91 ± 3·48 weeks, respectively. There was no significant difference in healing times between the acute and chronic wounds (50% reduction in wound size; acute 2·20 ± 0·91 weeks versus chronic 3·73 ± 2·63 weeks, P = 0·171. Hundred percent reduction in wound size; acute 4·80 ± 1·61 weeks versus chronic 6·83 ± 4·47 weeks, P = 0·183). The mean time for donor site healing was 5·49 ± 1·48 days. The mean pain score during graft harvest was 1·42 ± 0·95, and the donor site Vancouver Scar Scale was 0 for all cases at 6 weeks. This automated device offers autologous skin harvesting in the outpatient setting with minimal or no pain and a scar free donor site, equally benefiting both the acute and chronic wounds. It has the potential to save NHS resources by eliminating the need for theatre space and a hospital bed while at the same time benefiting patient care.

Autologous skin grafting is an important method for wound coverage; however, it is an invasive procedure and can cause donor site morbidity. Epidermal grafting (EG) enables epidermal transfer to wounds with minimal donor site morbidity. However, data to date have been heterogeneous. This study aims to synthesise the current evidence on EG for wound healing to establish the efficacy of this surgical technique. A comprehensive search in the MEDLINE, EMBASE and CENTRAL databases was conducted. The endpoints assessed were proportion of wounds healed and mean wound‐healing time. This systematic review was conducted and reported according to the Meta‐Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We identified 1568 articles, of which seven articles were included in this review – a total of 209 wounds in 190 patients. The mean wound duration was 17·06 weeks (95% CI 8·57–25·55). Of these, 71·5% (95% CI 56·7–84·2) of the wounds achieved complete healing. Mean time for complete wound healing was 5·53 weeks (95% CI 3·18–7·88). The mean donor site healing time was 7·48 days (95% CI 4·83–10·13), with no reported donor site morbidity. The current data are small and lack level 1 evidence.

Current wound management through the use of a split‐thickness skin graft often requires hospital admission, a period of immobility, attentive donor site wound care and pain management. This study evaluates the feasibility of using a novel epidermal graft‐harvesting device (CelluTome) that allows pain‐free epidermal skin grafting in the outpatient clinic setting. A prospective series of 35 patients was performed in 2 centres, involving 10 acute and 25 chronic wounds. All patients were subjected to epidermal grafting in the outpatient specialist clinic, without the use of anaesthesia, and allowed to return home after the procedure. Completely healed wounds were noted in 22 patients (62·9%). The overall mean time for 50% and 100% reduction in wound size was 3·31 ± 2·33 and 5·91 ± 3·48 weeks, respectively. There was no significant difference in healing times between the acute and chronic wounds (50% reduction in wound size; acute 2·20 ± 0·91 weeks versus chronic 3·73 ± 2·63 weeks, P = 0·171. Hundred percent reduction in wound size; acute 4·80 ± 1·61 weeks versus chronic 6·83 ± 4·47 weeks, P = 0·183). The mean time for donor site healing was 5·49 ± 1·48 days. The mean pain score during graft harvest was 1·42 ± 0·95, and the donor site Vancouver Scar Scale was 0 for all cases at 6 weeks. This automated device offers autologous skin harvesting in the outpatient setting with minimal or no pain and a scar free donor site, equally benefiting both the acute and chronic wounds. It has the potential to save NHS resources by eliminating the need for theatre space and a hospital bed while at the same time benefiting patient care.

Objectives The main objective of this study was to assess the impact of changes in care commissioning policies on National Health Service (NHS)-funded cosmetic procedures over an 11-year period at our centre. Setting The setting was a tertiary care hospital in London regulated by the North Central London Hospitals NHS Trust care commissioning group. Participants We included all patients logged on to our database at the time of the study which was 2087 but later excluded 61 from analysis due to insufficient information. Primary and secondary outcome measures The main outcome measures were the results of tribunal assessment for different cosmetic surgeries which were either accepted, rejected or inconclusive based on the panel meeting. Results There were a total of 2087 patient requests considered between 2004 and 2015, of which 715 (34%) were accepted, 1311 (63%) were declined and 61 (3%) had inconclusive results. The implementation of local care commissioning guidelines has reduced access to cosmetic surgeries. Within this period, the proportion of procedures accepted has fallen from 36% in 2004 to 21% in 2015 (χ2; p