Michael Solomons’s research while affiliated with University of Cape Town and other places

BACKGROUND: Mallet fracture with distal interphalangeal joint (DIPJ) subluxation remains a challenging problem, with numerous techniques proposed for repair of this fracture. METHODS: The authors present a modified approach to mallet fractures with volar subluxed DIPJ by K-wire fixation and intraosseus suture of the avulsed extensor tendon. RESULTS: The described technique resulted in successful clinical management of 12 patients with isolated mallet fractures with volar subluxation with 1/12 patients having a complication of stable non-union CONCLUSIONS: The intraosseous suture technique with K-wire stabilisation offers a simple and reproducible technique of fracture reduction and stabilisation of volar subluxed DIPJ mallet fractures.

BACKGROUND: Purely ligamentous lesser arc, Mayfield grade 3 and 4, perilunate dislocations (PLDs) are uncommon. Current recommendations are for open reduction and repair of the interosseous ligaments to prevent the development of scapholunate dissociation and degeneration to a scapholunate advance collapse (SLAC) wrist. This study proposes a less invasive treatment method which includes closed reduction and pinning alone without repair of the scapholunate interosseous ligament. We propose that most patients will obtain good function and pain scores and the few that develop instability may still have a reconstruction performed through a naïve surgical field METHODS: Dislocations were reduced anatomically and held with buried K-wires which were removed at 6 weeks with no specific rehabilitation protocol observed. Subjective assessment included Mayo wrist scoring system, wrist range of movement, instability and grip strength testing. Radiological measurements included scapholunate distance, scapholunate angle, radiolunate angle and osteoarthritis RESULTS: Ten male patients, median age of 35 years, were followed up for a median of 22 months. Seven patients underwent a closed reduction and anatomical pinning while three underwent open reduction due to unachievable reduction by closed means. All of these patients presented at a median of 14 days after the injury occurred. None of the patients had their scapholunate ligaments repaired or reconstructed. Mayo scores included three excellent scores, two good scores and five fair scores. Instability was found clinically in one asymptomatic patient who had a positive Watson shift test. Radiological scores include a median scapholunate distance of 2 mm, a scapholunate angle of 70° and a radiolunate angle of 15°. Osteoarthritis was found in two patients, all of whom were asymptomatic DISCUSSION: Current recommendations in the literature are that PLDs should be reduced via an open surgical technique with repair of the scapholunate interosseous ligament (SLIL) and percutaneous pinning. However, the results of this treatment strategy are not optimal and do not confer uniformly good results. We propose a closed anatomical reduction and percutaneous pinning of the PLD. Our study shows that most patients will demonstrate good function and pain scores when managed this way. A smaller number of these injured wrists will go on to develop instability. However, the advantage of our method over the current recommendations is that when this happens the reconstruction of the SLIL will be made easier through a naïve surgical field CONCLUSION: We recommend the closed reduction and anatomical pinning of a purely ligamentous lesser arc injury. This treatment strategy yields good results at medium term follow-up and preserves the option for the reconstruction of the scapholunate interosseous ligament should instability develop

Due to its mostly motor content, repair of the radial nerve is considered to yield favourable results. This is despite the fact that there are limited studies looking at the outcomes of end-to-end repair secondary to sharp penetrating trauma. We retrospectively reviewed the outcome of a series of repaired level 2 and level 3 radial nerves following penetrating stab injuries. Twenty-seven cases with adequate follow-up were included. All the patients underwent direct end-to-end repair. We evaluated the motor recovery of the target muscles using the British Medical Research Council (MRC) grading system. Wrist extension recovered in 93% of cases at a mean of six months. Finger extension recovered in 74% and thumb extension in 52% of cases within the follow-up period. We conclude that end-to-end repair is possible in the majority of level 2 and level 3 radial nerve lacerations secondary to penetrating stab injuries. Acceptable results can be expected.

Recent studies, using modalities other than laser Doppler, have indicated that perfusion during negative-pressure wound therapy (NPWT) is reduced, contrary to world literature. The aim of the present study was to evaluate whether the measuring technique of the laser Doppler could be influenced by the compressive nature of NPWT dressings and whether this could explain the conflicting findings. A hypothesis that it may be possible for laser Doppler to record similar readings to those obtained during NPWT by merely compressing tissues manually was tested on 12 NPWT dressings, with each undergoing an alternating series of manual compressive forces and NPWT (−125 mmHg). During the periods of NPWT (n = 12), the mean perfusion recording increased in five experiments, reduced in six, and remained unchanged in one. During the period when manual pressure was applied (n = 12), there was a mean increase in perfusion in six experiments and a reduction in six. The type of change in perfusion (increase or decrease) was the same for both NPWT and manual pressure in 10 of the 12 experiments. In conclusion, laser Doppler can incorrectly record increased perfusion when tissues are compressed, implying that it is flawed in the field of NPWT research as tissues are always compressed to some degree by the NPWT dressing.

Studies investigating the effects of negative-pressure wound therapy (NPWT) using the Chariker-Jeter system (gauze-based interface) and the Vacuum Assisted Closure (V.A.C.) system often have outcomes that favour one particular system. This study attempts to examine whether manufacturer involvement could be related to the outcomes of these scientific studies. A literature review was undertaken to identify a cohort of studies that compared these two forms of NPWT. Clinical outcomes studies, basic research studies and published conference abstracts were included.All the articles' abstracts and conclusions were given to five surgeons, who were blinded to the titles and authors. They were individually asked to record what they would consider to be the "take home" message of each article (in terms of which system is superior). After categorising each study according to the system that it appears to favour, the level of manufacturer involvement in each study was evaluated. The relationship between the outcome of a study and the level of manufacturer involvement in that study was then investigated. Of the total of 24 studies found to match the inclusion criteria 22 were considered to favour a particular system (the other two were categorised as "impartial"). Of the 24 studies, 19 had some form of manufacturer involvement. Of the 19 that had some form of manufacturer involvement, 18 had outcomes that were deemed beneficial to the involved manufacturer, while one was deemed to have an "impartial" outcome. This study suggests that manufacturer involvement in these studies (regardless of level) correlates with the outcomes being beneficial to the involved manufacturer in almost all cases. Potential reasons for this and the implications thereof are discussed.

Background: Although recent work has demonstrated that perfusion adjacent to a negative-pressure wound therapy dressing is decreased, laser Doppler studies have indicated that there is a zone of increased perfusion a couple of centimeters away. The existence of such a zone of increased perfusion is counterintuitive to the fact that negative-pressure wound therapy has been shown to increase tissue pressure. This study, using an alternative to laser Doppler, evaluated whether such a zone exists. Methods: Six volunteers were randomized into three groups to test different suction pressures (-75, -125, and -400 mmHg). Each volunteer would have two dressings applied on either side of the lower back. A thermal imaging camera was used to assess perfusion around the dressing during different phases (e.g., "Suction on" and "Suction off"). The mean area under the curve for each phase was compared with those of other phases by means of one-way analysis of variance. Each condition (phase) was compared in a systematic manner with every other by means of Fisher's least significant difference for post hoc comparisons. A Pearson's correlation was determined to test the effects of the different suction pressure groups. Results: No significant difference could be demonstrated for the area under the curve for the different phases. There was no significant correlation between the three suction pressures tested and the difference between the mean area under the curve for "Dressing on, no suction" and the two "Suction on" periods (Pearson correlation = 0.24; p > 0.4). Conclusions: Thermographic evaluation of tissue around a negative-pressure dressing did not demonstrate a zone of increased perfusion, contrary to other studies, which used laser Doppler. This is in keeping with recent work demonstrating that negative-pressure wound therapy increases tissue pressure while the dressing is applying suction. Clinical question/level of evidence: Therapeutic, V.