Background: Osteoradionecrosis (ORN) of the calvarium is a complex reconstructive problem that can have severe consequences if not identified and managed appropriately. This is a systematic review of the risk factors and treatment modalities for ORN of the calvarium and the associated patient outcomes. Methods: Two independent researchers conducted a computerised search via Ovid of MEDLINE, Embase and the Cochrane Library for studies relevant to ORN of the calvarium published up to and including 1 June 2024. The researchers extracted information including patient population, treatment modality, patient outcomes and study design. All study designs and patient populations were eligible to be included in the review. Results: Of a total of 1050 screened studies, 20 met criteria to be included in the systematic review. These studies involved a total of 79 patients with a mean age of 52.9 years. Risk factors for calvarial ORN included higher radiotherapy fractions, cumulative radiotherapy dose and skin grafting. Approximately half of the patients required surgical intervention (49%), including cranioplasty and soft tissue reconstruction, 32 per cent of patients were treated conservatively with debridement and dressings, and 24 per cent received hyperbaric oxygen therapy (HBOT) as part of their treatment. Surgical management was complicated by wound dehiscence, infection or failed reconstructions requiring revisions in 10 patients. Conservative management appeared to yield low rates of intracranial infection, but was also resource intensive with prolonged healing times. Conclusion: There is a paucity of high-quality evidence to inform the management of ORN of the calvarium, and both surgical and conservative strategies may be effective. Robust soft tissue reconstruction should be considered in patients undergoing adjuvant radiotherapy to mitigate the risk of ORN, and long-term follow-up is required to ensure early identification and intervention in patients who develop ORN of the calvarium.

Background: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome, often requiring carpal tunnel release surgery. Anatomical anomalies within the carpal tunnel, such as the palmaris profundus (PP) tendon, may contribute to symptomatology or complicate surgical management. The PP is a rare vestigial muscle, with a reported cadaveric incidence of 0.125 per cent. It may share a fascial sheath with the median nerve and increase local volume within the carpal tunnel, thereby contributing to CTS. This review provides the first systematic synthesis of published cases of CTS associated with the PP. Methods: A systematic literature search was conducted across MEDLINE, Embase, PubMed and Cochrane Library on March 22, 2025. Studies were included if the PP was associated with CTS and if they were published in English. Two independent reviewers screened titles, abstracts and full texts, with data extracted on patient demographics, diagnostic methods, surgical approach, intraoperative findings and outcomes. Results: Eighteen studies, reporting on 21 patients, met the inclusion criteria. The mean age was 59.0 years with 76.2 per cent of cases involving the right hand. The PP was most often found arising from the flexor digitorum superficialis fascia and inserting into the palmar aponeurosis. Open carpal tunnel release and PP resection was the predominant surgical intervention (95.2%), with symptom resolution in 85.7 per cent of cases. A bifid median nerve was observed in 33.3 per cent of patients. Preoperative imaging rarely identified the anomaly. Conclusion: The PP is a rare but clinically relevant anatomical variant that may cause or contribute to CTS. Surgical vigilance and resection when encountered are strongly recommended to improve outcomes and reduce recurrence.

Background: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome, often requiring carpal tunnel release surgery. Anatomical anomalies within the carpal tunnel, such as the palmaris profundus (PP) tendon, may contribute to symptomatology or complicate surgical management. The PP is a rare vestigial muscle, with a reported cadaveric incidence of 0.125 per cent. It may share a fascial sheath with the median nerve and increase local volume within the carpal tunnel, thereby contributing to CTS. This review provides the first systematic synthesis of published cases of CTS associated with the PP. Methods: A systematic literature search was conducted across MEDLINE, Embase, PubMed and Cochrane Library on March 22, 2025. Studies were included if the PP was associated with CTS and if they were published in English. Two independent reviewers screened titles, abstracts and full texts, with data extracted on patient demographics, diagnostic methods, surgical approach, intraoperative findings and outcomes. Results: Eighteen studies, reporting on 21 patients, met the inclusion criteria. The mean age was 59.0 years with 76.2 per cent of cases involving the right hand. The PP was most often found arising from the flexor digitorum superficialis fascia and inserting into the palmar aponeurosis. Open carpal tunnel release and PP resection was the predominant surgical intervention (95.2%), with symptom resolution in 85.7 per cent of cases. A bifid median nerve was observed in 33.3 per cent of patients. Preoperative imaging rarely identified the anomaly. Conclusion: The PP is a rare but clinically relevant anatomical variant that may cause or contribute to CTS. Surgical vigilance and resection when encountered are strongly recommended to improve outcomes and reduce recurrence.

The first successful free vascularised bone flap in a human was performed on 1 June 1974 (reported in 1975) using the fibula diaphysis supplied by the peroneal artery and vein to repair a tibial defect. This was followed by us with the iliac crest based on the superficial circumflex iliac artery in 1975 and then the deep circumflex iliac artery in 1978. On 29 November 1983, the fibula was transplanted for the first time on the anterior tibial vessels in a child to repair the tibia following tumour ablation. Finally on 7 May 1984 the growth plate in the proximal epiphysis of the fibula was transplanted successfully on the anterior tibial vessels, and especially its recurrent genicular branch, to repair the distal radius after a traumatic hand injury. The growth rate of this epiphysis matched that of the fibula in the opposite leg and fused at the same time. Fourteen cases of free vascularised fibula transfer are presented from a series of 397, including three unique transfers of the fibula diaphysis and epiphysis to repair the jaw, clavicle and long bones of the extremities. The blood supply to and within the fibula plus vascular anomalies are detailed following fresh cadaver India ink injection, bone histology and lead oxide radiography. Preoperative planning using angiography, computer-generated bone models of the donor and recipient bones to plan osteotomies for jaw reconstruction, trial runs in cadavers, Doppler perforator mapping for skin flaps and incision-marking before theatre are all prerequisites for success. Operative technique is outlined for each approach to the fibula and potential pitfalls are highlighted. The importance of protected stress on the fibula, especially in the lower extremity, is paramount. The fibula should be placed within the medullary cavity of the femur or tibia in the line of weight bearing and protected from rotational or angular stress by an external cast, a fixateur with pins placed before and beyond the fibula or, now it is becoming clear, transfixed with an intramedullary nail or rod. With large series worldwide, some in the thousands and with success rates in the high 90 per cents, the free vascularised fibula flap, especially when combined with skin and soft tissue, has emerged as the gold standard for reconstructing major congenital or acquired defects in the jaw and long bones of the extremities, facilitated by the large calibre of its supplying vessels. Now with the ability to transfer the fibula with the associated skin and deep tissues of its peroneal or anterior tibial angiosome, we have the ability in one day to replace the months and years of the multi-staged reconstructions that were endured by those that suffered the ravages of the two world wars.

By Michael P Chae, Yasiru G Karunaratne & 1 more. How to do a modified corset replication to provide functional integrity and a good aesthetic outcome to the abdominal donor site post DIEP flap reconstruction.

By Australian Society of Plastic Surgeons. Abstracts from the Australian Society of Plastic Surgeons Plastic Surgery Congress 2025, highlighting advancements and research in plastic, reconstructive and aesthetic surgery techniques.

Introduction: The aim of this study is to understand current practices in the use of computed tomography (CT) scans in the routine assessment and management of infants and children with craniosynostosis among surgeons in Australia and New Zealand. No consensus exists in the literature about the utility of CT scans in this patient population. Methods: A survey was distributed to craniofacial units across Australia and New Zealand, targeting nine paediatric craniofacial programs and requesting information about the routine use of CT scans in the management of craniosynostosis. Results: The response rate was 49 per cent with the majority (75%) of responding surgeons having more than 10 years of experience in craniofacial surgery. Input from all units was obtained. Ninety-five per cent of surgeons order preoperative CT scans for single-suture craniosynostosis, with the stated indication being confirmation of diagnosis (85%), characterisation of cranial morphology (70%), detection of raised intracranial pressure (65%) and screening for associated anomalies (85%). The majority (85%) of surgeons used standard radiologic protocols. Only 10 per cent of respondents do routine postoperative CT scans. In multiple-suture and syndromic craniosynostosis, the use of routine postoperative CT scans was greater. Access issues were a factor in many units due to rural locations. Conclusion: Routine CT scans are employed in the diagnosis and management of infants and children with craniosynostosis in craniofacial units in Australia and New Zealand. Variability in practice suggests an opportunity for standardisation of protocols. Accessibility to CT scans and ethical issues regarding radiation exposure are an issue in many units.

Introduction: The healthcare sector accounts for 5–10 per cent of global carbon emissions with a significant contribution from operating theatres. This study aims to comprehend the carbon footprint of waste generated in hand surgery. Methods: Waste generated from 21 surgical procedures done both in operating theatres under general anaesthetic and procedural suites under local anaesthetic was segregated into clean paper, contaminated paper, clean plastic and contaminated plastic, and weighed before routine disposal. The waste management policy of the institution was examined to estimate the financial and emissions burdens. Results: This study found a mean of 1.922 kg of waste was generated per procedure. More complex procedures, such as open reduction and internal fixation, generated more waste (mean = 5.182 kg) compared to less complex procedures, such as incision and drainage of abscess, tendon repair or nail bed repair (mean = 1.382 kg). A mean reduction in total waste of 0.86 kg per procedure was achieved by performing eligible, less complex procedures in the procedural suite under local anaesthetic. This translated to an annual reduction of 0.77 tonnes of total surgical waste with a cost saving of NZ$376.70 for disposal and a reduction of 252 kgCO2e in carbon emissions. Conclusion: This study sheds light on the carbon footprint of waste generated from hand surgery. A collaborative effort is required to mitigate the deleterious impact of surgical waste on climate change. Judicious use of procedural suites is a simple strategy to reduce waste and carbon emissions.