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Inflammatory reaction to subcuticular Vicryl suture following tuberculin test
Brim/~ Journd of Plastic Surgery (1997), 50,665-67 b 1997 The British Association of Plastic Surgeons
I
Letters to the Editor of the implant can stimulate a more severe foreign body reaction leading to osteolysis4 and synovitis.’ There are very few references linking Vicryl and tuberculosis. Literature search including the data base at Ethicon finds only two,6.7 both studies where Vicryl sutures were used in the presence of active tuberculosis with no adverse effect on wound healing. The reaction to the Heaf test is that of pure type IV hypersensitivity to tuberculin purified protein derivative (PPD), mediated by lymphocytes production of interferon gamma promoting monocyteslmacrophage killing activity. Immunomodulatory effects at remote sites to the test are not recognised. It is unlikely that T cell clones activated by the PPD antigens were cross-reacting with the peptides of the suture as these cells do not ‘see’ non-proteins and it would be expected for any reaction to occur in the regional lymph nodes and not at the site of the suture. It may be more plausible that the reaction to the suture was an antibody-mediated type II or III hypersensitivity reaction, or a non-specific effect due to endocrine effects of released proinflammatory cytokines or other mediators on quiescent inflammatory cells at or near to the suture. It is probably not justified to recommend any change in clinical practice from this single case but we think further studies would be feasible and worth undertaking. The phenomenon would be relatively easy to investigate in animals and even on human volunteers using a small subcutaneous implant of the suture. If the effect was reproduced then investigation of the mechanism of its occurrence would be justified.
Inflammatory reaction to subcuticular Vicryl suture following tuberculin test Sir, We should like to bring to your attention a reaction to a Vicryl (Ethicon, Edinburgh, UK) suture that we observed in a 13-year-old boy. He developed inflammation localised to the site of a subcuticular suture of 3/O Vicryl used to close skin, 29 days after removal of bone plates from the forearm. The plates had been inserted 1 year previously and Vicryl had not been used at that time. Prior to final review at 2 weeks the wounds had healed uneventfully. On questioning it was found that 6 days earlier he had been given a Heaf test at school. He had been treated with Flucloxacillin 250 mg QDS. On examination there was obvious inflammation around the wound clearly outlining the subcuticular suture. On the right forearm there was a grade 2 positive immune reaction to the Heaf test (Fig. I). Healing of the wound had not been affected and there was no sign of infection. No further treatment was given and at review 4 weeks later the inflammation had subsided. The biological process by which Vicryl sutures are absorbed has been studied’ and takes between 60 and 90 days. An infiltrate of inflammatory cells is seen which includes polymorphs, monocytes, eosinophils, fibroblasts, macrophages and multinucleate foreign body giant cells. The polymer is broken down by a combination of hydrolysis and enzyme degradation. Polymer fragments are found inside macrophages and giant cells. The suture is relatively inert eliciting only a mild tissue reaction during absorption. It is non-pyrogenic and nonantigenic. Minor reactions have been reported especially where it is knotted close to the surface of the skin. No severe adverse reactions have been reported.? Biodegradable polymers including polyglactin have been used in rod and screw form as implants for fracture fixation.3 In this form the bulk
Yours faithfully,
Mark J. Farrar MB, FRCSEd Orthopaedic Registrar, Hull Royal Infirmary, Anlaby Road, Hull HU3 252, UK.
Malcom S. Binns MB, FRCS(Orth)Ed Consultant Orthopaedic Surgeon, Pontefract General Infirmary, Friarwood Lane, Pontefract, West Yorkshire WF8 1PL, UK.
References 1.
2. 3.
4.
5. Fig. 1 665
Matlaga BF, Salthouse TN. Ultrastructural observations of cells at the interface of a biodegradable polymer: Polyglactin 910. J Biomedical Materials Res 1983; 17: 185-197. Day RP. Ethicon Limited, Edinburgh, UK. Personal communication 1995. Bostman 0, Hirvensalo F, Makinen J, Rokkanen P Foreign body reactions to fracture fixation implants of biodegradable synthetic polymers. .I Bone Joint Surg (Br) 1990; 72-B: 592-596. Fraser RK, Cole WG. Osteolysis after biodegradable pin fixation of fractures in children. J Bone Joint Surg (Br) 1992; 14-B: 929-930. Friden T, Rydholm U. Severe aseptic synovitis of the knee after biodegradable internal fixation. Acta Orthop Stand 1992: 63: 9&97.
666
British Journal of Plastic Surgery
6. Griffin SM, Chung SCS, Mok CO, Li ACK. Stapled Bilroth gastrectomy. Br J Surg 1990; 71: 712-773. 7. De Giacomo T, Francioni F, Venuta F, Rendina EA, Ricci C. Esophago-Respiratory Fistula. Surgical treatment and results of 10 cases (abstract). Minerva Chir 1993; 48: 311-316.
Tax allowance
for surgical telescopes
Sir, We write to inform you of a recent decision by the Inland Revenue in the UK, with regard to the eligibility of surgical trainees to claim for the cost of the provision of surgical loupes. Over the last 18 months, the first author (APA) has been pursuing a claim with the Inland Revenue to defray the cost of surgical loupes, some UK &1116, against tax. This has been an illuminating, frustrating, and in some part, humorous exercise into the world of tax schedules, tax law and ‘Sir Humphrey speak’. An initial request to allow a tax deduction under Schedule E, with regard to the necessary purchase of the surgical loupes to perform
plastic surgery on a regional basis,
was denied in that the request did not meet the requirements of Section 198(l) ICTA 1988. The wording of this section is as follows.. If the holder of an office or employment is necessarily obliged to incur and defray out of the emoluments of that office or employment
the expenses of travelling
in
the performance of the duties of the office or employment, or of keeping and maintaining a horse to enable him to perform those duties, or otherwise to expend money wholly, exclusively and necessarily in the performance of those duties, there may be deducted from the emoluments to be assessedthe expensesso necessarilyincurred and defrayed. The tax inspector went on to explain more clearly . . . ‘to satisfy the words, necessarily incurred, it is not enough for an expense to be unavoidable. Also the fact that an employer encourages or requires an employee to incur a particular expense is not conclusive that it is necessarily incurred in the sensethe words are used in the legislation’. Following several more letters and an imminent appeal against the ruling of the Inland Revenue Inspector, we sought the advice of a Specialist Tax Advisor. The consultancy fee (&50-100) was paid by the British Association of Plastic Surgeons, as it was felt that a ruling in our favour would benefit all trainees. In summary, the advice of the Tax Specialist was as follows: In general, the scope for deductions under the rules of Schedule E (by reference to which employee’s are taxed) is extremely narrow. To obtain a deduction it is necessaryto satisfy the provisions contained in section 198 ICTA 1988, namely that the expense must be incurred in the performance of the duties of the office or employment. The purpose of this section is not to permit but to prohibit the deduction for employee’s expensesand it is applied in such a way that virtually no item of expenditure ranks for allowance. Returning to the initial cost of the loupes, there existsthe possibility of a claim to Capital Allowances on the expenditure incurred. While it will not give immediate relief for the entire cost of the loupes, the individual will obtain a 25% reduction in the first year and, in subsequent years, a deduction of 25% of the written down value - effectively the cost will be
allowed over 9 years. To apply the Inland Revenue will
need to be convinced that the expenditure satisfies the terms of the relevant provision at section 27(2) CAA 1990. This specifiesthat the item has to be necessarily provided for use in the performance of the duties. The test is whether the employee is necessarilyobliged to incur and defray the expensein question out of his/her own pocket because, without doing so, it would be impossible for him/her to carry out their duties of employment. In short, the expenditure should not be optional, nor met by the NHS Trust, be essential for the work undertaken in plastic surgery and be imposed by the requirements of the duties of the employment. At a meeting with the Inland Revenue, the nature and structure of plastic surgery as a regional specialty, with several hospitals being covered by trainees was highlighted. Although an operating microscope was available at some sites, the portability of loupes for Accident & Emergency referrals, outpatient consultations, and operative procedures enabled trainees a flexibility of practice which could not be met without the individual provision of surgical loupes. Following an appeal against the original decision, a successful claim for Capital Allowances (on the basis outlined) was allowed in this case. We hope that by bringing this decision to the attention of all plastic surgery trainees, it will assistin clarifying the complex area of tax allowance for surgical loupes. Yours faithfully, A. P. Armstrong FDSRCS, FRCS Specialist Registrar in Plastic Surgery C. M. Caddy FRCSEd, FCS(SA) Consultant Plastic Surgeon Northern General Hospital NHS Trust, Herries Road, Sheflield S5 7AU, UK.
The distally-based foot flap
islanded
dorsal
Sir, It was encouraging to read yet another experience with the distally-based dorsalis pedis flap as discussedby Mr Quaba in the most recent issue of the British Journal of Plastic Surgery. ’
My personal experience with this flap was published in Annals of Plastic Surgery* in February of 1995. This experi-
ence occurred while I was a plastic surgery resident under the tutelage of Dr Anthony Smith who is now at the Mayo Clinic in Scottsdale, Arizona, USA. The patients were his, and the idea to use such a flap sprung from his own resourcefulness. I note that Mr Quaba’s paper was first presented in 1995, not long after ours was published in the US. Our research must have been overlapping which no doubt explains why it was overlooked in Mr Quaba’s literature search. Our research revealed that the vascular anatomy of this flap was first described by McGraw and Furlow in 1975.3In addition, it was not Earley and MilneI”’ who first described this flap; rather, it was Ishikawa et al. 2 years earlier, in 1987, in this very same British Journal of Plastic Surgery, who first reported their experience with a distally-based dorsalis pedis island flap.5 I am surprised the Editors of the British Journal of Plastic Surgery overlooked this. I certainly appreciated reading Mr Quaba’s experience with this particular
flap, but I thought
the Editors
and your
I
Letters to the Editor of the implant can stimulate a more severe foreign body reaction leading to osteolysis4 and synovitis.’ There are very few references linking Vicryl and tuberculosis. Literature search including the data base at Ethicon finds only two,6.7 both studies where Vicryl sutures were used in the presence of active tuberculosis with no adverse effect on wound healing. The reaction to the Heaf test is that of pure type IV hypersensitivity to tuberculin purified protein derivative (PPD), mediated by lymphocytes production of interferon gamma promoting monocyteslmacrophage killing activity. Immunomodulatory effects at remote sites to the test are not recognised. It is unlikely that T cell clones activated by the PPD antigens were cross-reacting with the peptides of the suture as these cells do not ‘see’ non-proteins and it would be expected for any reaction to occur in the regional lymph nodes and not at the site of the suture. It may be more plausible that the reaction to the suture was an antibody-mediated type II or III hypersensitivity reaction, or a non-specific effect due to endocrine effects of released proinflammatory cytokines or other mediators on quiescent inflammatory cells at or near to the suture. It is probably not justified to recommend any change in clinical practice from this single case but we think further studies would be feasible and worth undertaking. The phenomenon would be relatively easy to investigate in animals and even on human volunteers using a small subcutaneous implant of the suture. If the effect was reproduced then investigation of the mechanism of its occurrence would be justified.
Inflammatory reaction to subcuticular Vicryl suture following tuberculin test Sir, We should like to bring to your attention a reaction to a Vicryl (Ethicon, Edinburgh, UK) suture that we observed in a 13-year-old boy. He developed inflammation localised to the site of a subcuticular suture of 3/O Vicryl used to close skin, 29 days after removal of bone plates from the forearm. The plates had been inserted 1 year previously and Vicryl had not been used at that time. Prior to final review at 2 weeks the wounds had healed uneventfully. On questioning it was found that 6 days earlier he had been given a Heaf test at school. He had been treated with Flucloxacillin 250 mg QDS. On examination there was obvious inflammation around the wound clearly outlining the subcuticular suture. On the right forearm there was a grade 2 positive immune reaction to the Heaf test (Fig. I). Healing of the wound had not been affected and there was no sign of infection. No further treatment was given and at review 4 weeks later the inflammation had subsided. The biological process by which Vicryl sutures are absorbed has been studied’ and takes between 60 and 90 days. An infiltrate of inflammatory cells is seen which includes polymorphs, monocytes, eosinophils, fibroblasts, macrophages and multinucleate foreign body giant cells. The polymer is broken down by a combination of hydrolysis and enzyme degradation. Polymer fragments are found inside macrophages and giant cells. The suture is relatively inert eliciting only a mild tissue reaction during absorption. It is non-pyrogenic and nonantigenic. Minor reactions have been reported especially where it is knotted close to the surface of the skin. No severe adverse reactions have been reported.? Biodegradable polymers including polyglactin have been used in rod and screw form as implants for fracture fixation.3 In this form the bulk
Yours faithfully,
Mark J. Farrar MB, FRCSEd Orthopaedic Registrar, Hull Royal Infirmary, Anlaby Road, Hull HU3 252, UK.
Malcom S. Binns MB, FRCS(Orth)Ed Consultant Orthopaedic Surgeon, Pontefract General Infirmary, Friarwood Lane, Pontefract, West Yorkshire WF8 1PL, UK.
References 1.
2. 3.
4.
5. Fig. 1 665
Matlaga BF, Salthouse TN. Ultrastructural observations of cells at the interface of a biodegradable polymer: Polyglactin 910. J Biomedical Materials Res 1983; 17: 185-197. Day RP. Ethicon Limited, Edinburgh, UK. Personal communication 1995. Bostman 0, Hirvensalo F, Makinen J, Rokkanen P Foreign body reactions to fracture fixation implants of biodegradable synthetic polymers. .I Bone Joint Surg (Br) 1990; 72-B: 592-596. Fraser RK, Cole WG. Osteolysis after biodegradable pin fixation of fractures in children. J Bone Joint Surg (Br) 1992; 14-B: 929-930. Friden T, Rydholm U. Severe aseptic synovitis of the knee after biodegradable internal fixation. Acta Orthop Stand 1992: 63: 9&97.
666
British Journal of Plastic Surgery
6. Griffin SM, Chung SCS, Mok CO, Li ACK. Stapled Bilroth gastrectomy. Br J Surg 1990; 71: 712-773. 7. De Giacomo T, Francioni F, Venuta F, Rendina EA, Ricci C. Esophago-Respiratory Fistula. Surgical treatment and results of 10 cases (abstract). Minerva Chir 1993; 48: 311-316.
Tax allowance
for surgical telescopes
Sir, We write to inform you of a recent decision by the Inland Revenue in the UK, with regard to the eligibility of surgical trainees to claim for the cost of the provision of surgical loupes. Over the last 18 months, the first author (APA) has been pursuing a claim with the Inland Revenue to defray the cost of surgical loupes, some UK &1116, against tax. This has been an illuminating, frustrating, and in some part, humorous exercise into the world of tax schedules, tax law and ‘Sir Humphrey speak’. An initial request to allow a tax deduction under Schedule E, with regard to the necessary purchase of the surgical loupes to perform
plastic surgery on a regional basis,
was denied in that the request did not meet the requirements of Section 198(l) ICTA 1988. The wording of this section is as follows.. If the holder of an office or employment is necessarily obliged to incur and defray out of the emoluments of that office or employment
the expenses of travelling
in
the performance of the duties of the office or employment, or of keeping and maintaining a horse to enable him to perform those duties, or otherwise to expend money wholly, exclusively and necessarily in the performance of those duties, there may be deducted from the emoluments to be assessedthe expensesso necessarilyincurred and defrayed. The tax inspector went on to explain more clearly . . . ‘to satisfy the words, necessarily incurred, it is not enough for an expense to be unavoidable. Also the fact that an employer encourages or requires an employee to incur a particular expense is not conclusive that it is necessarily incurred in the sensethe words are used in the legislation’. Following several more letters and an imminent appeal against the ruling of the Inland Revenue Inspector, we sought the advice of a Specialist Tax Advisor. The consultancy fee (&50-100) was paid by the British Association of Plastic Surgeons, as it was felt that a ruling in our favour would benefit all trainees. In summary, the advice of the Tax Specialist was as follows: In general, the scope for deductions under the rules of Schedule E (by reference to which employee’s are taxed) is extremely narrow. To obtain a deduction it is necessaryto satisfy the provisions contained in section 198 ICTA 1988, namely that the expense must be incurred in the performance of the duties of the office or employment. The purpose of this section is not to permit but to prohibit the deduction for employee’s expensesand it is applied in such a way that virtually no item of expenditure ranks for allowance. Returning to the initial cost of the loupes, there existsthe possibility of a claim to Capital Allowances on the expenditure incurred. While it will not give immediate relief for the entire cost of the loupes, the individual will obtain a 25% reduction in the first year and, in subsequent years, a deduction of 25% of the written down value - effectively the cost will be
allowed over 9 years. To apply the Inland Revenue will
need to be convinced that the expenditure satisfies the terms of the relevant provision at section 27(2) CAA 1990. This specifiesthat the item has to be necessarily provided for use in the performance of the duties. The test is whether the employee is necessarilyobliged to incur and defray the expensein question out of his/her own pocket because, without doing so, it would be impossible for him/her to carry out their duties of employment. In short, the expenditure should not be optional, nor met by the NHS Trust, be essential for the work undertaken in plastic surgery and be imposed by the requirements of the duties of the employment. At a meeting with the Inland Revenue, the nature and structure of plastic surgery as a regional specialty, with several hospitals being covered by trainees was highlighted. Although an operating microscope was available at some sites, the portability of loupes for Accident & Emergency referrals, outpatient consultations, and operative procedures enabled trainees a flexibility of practice which could not be met without the individual provision of surgical loupes. Following an appeal against the original decision, a successful claim for Capital Allowances (on the basis outlined) was allowed in this case. We hope that by bringing this decision to the attention of all plastic surgery trainees, it will assistin clarifying the complex area of tax allowance for surgical loupes. Yours faithfully, A. P. Armstrong FDSRCS, FRCS Specialist Registrar in Plastic Surgery C. M. Caddy FRCSEd, FCS(SA) Consultant Plastic Surgeon Northern General Hospital NHS Trust, Herries Road, Sheflield S5 7AU, UK.
The distally-based foot flap
islanded
dorsal
Sir, It was encouraging to read yet another experience with the distally-based dorsalis pedis flap as discussedby Mr Quaba in the most recent issue of the British Journal of Plastic Surgery. ’
My personal experience with this flap was published in Annals of Plastic Surgery* in February of 1995. This experi-
ence occurred while I was a plastic surgery resident under the tutelage of Dr Anthony Smith who is now at the Mayo Clinic in Scottsdale, Arizona, USA. The patients were his, and the idea to use such a flap sprung from his own resourcefulness. I note that Mr Quaba’s paper was first presented in 1995, not long after ours was published in the US. Our research must have been overlapping which no doubt explains why it was overlooked in Mr Quaba’s literature search. Our research revealed that the vascular anatomy of this flap was first described by McGraw and Furlow in 1975.3In addition, it was not Earley and MilneI”’ who first described this flap; rather, it was Ishikawa et al. 2 years earlier, in 1987, in this very same British Journal of Plastic Surgery, who first reported their experience with a distally-based dorsalis pedis island flap.5 I am surprised the Editors of the British Journal of Plastic Surgery overlooked this. I certainly appreciated reading Mr Quaba’s experience with this particular
flap, but I thought
the Editors
and your