Recipient Vessel Dissection Technique in Diabetic Foot Patients with Perivascular Fibrosis.

Diabetic foot ulcers are becoming more prevalent, and microsurgical free flaps are gaining popularity in salvaging the foot after postdebridement. The perivascular fibrosis around the recipient vessels often makes the dissection of vessels difficult. In this article, we describe a technique of dissection in such situations where fibrosis and dissection of vessels are fraught with danger. In the period from November 2020 to May 2023, 72 free flap reconstructions of the diabetic foot were done at our institute using this technique, with a success rate of 95.8%.

Lipofilling-A Regenerative Alternate for Remodeling Burn Scars: A Clinico-Immunohistopathological Study.

Introduction Any injury involving the dermis will lead to scarring. Scar tissue can cause functional limitations, cosmetic impairments, pain, and itch. Adipose-derived stem cells have also been shown to play a role in scar modulation. This study evaluates changes in lipofilled scar over the period of time and compares it with non-lipofilled scar tissue. Materials and Methods A prospective case-control study with intraindividual follow-up was performed on 30 adult patients with post-burn scars from November 2016 to May 2019. Clinical, histopathological, and immunohistochemical parameters were assessed among the case and control regions of the scar. Results Mean age of the study population was 30.6 years. The duration of the scar included in this study ranged from 1 to 28 years, with a mean duration of 5.91 years. There was a significant reduction in pain, itch, stiffness, and an increase in the pliability of the scar, and a substantial improvement in the modified Vancouver Scar Score in the lipofilled group. In histopathological analysis, the case group showed organized parallel collagen fibers, a significant reduction in melanocytes, improvement in vascularity, and a significantly increased amount of collagen fibers at the reticular dermis. Immunohistochemical analysis indicated new cell synthesis in the scar tissue and reduced melanocytes. Conclusion The remodeling effect of adipocyte-derived stem cells is long-lasting, and there is a gradual improvement in most of the parameters. Lipofilling has regenerative capacity, which leads to the improved overall appearance of scar and improvement at the cellular level.

Outcomes of Keller Gap Arthroplasty for Plantar Hallux Interphalangeal Joint Ulcers in Patients With Diabetes Mellitus.

BACKGROUND: Hallux ulcers are known for their recurrence and associated risk for future amputations. Traditional nonsurgical external offloading methods have poor compliance rates, and the data is sparse on surgical offloading of hallux ulcers. We performed this study to analyze the outcomes of Keller excision gap arthroplasty of the first metatarsophalangeal joint in patients with a neuropathic plantar hallux interphalangeal joint (IPJ) ulcer in patients with diabetes mellitus. METHODS: A retrospective study of 105 diabetic patients with a plantar hallux IPJ ulcer who underwent a Keller excision gap arthroplasty between December 2014 and June 2020 was done. A total of 122 great toes had been operated upon for hallux IPJ ulcers. We studied the long-term wound healing rates from patient records and then did a prospective survey of the postreview period. RESULTS: All the hallux IPJ ulcers healed well in the immediate postoperative period. Six patients reported a recurrence of the ulcer at the original site during a mean follow-up period of 30 months. For these 6 patients, the mean time to recurrence of ulcer after operation was 2.5 years. CONCLUSION: At an average of 30 months, we found the Keller gap arthroplasty for treatment of noninfected and nonischemic diabetic foot hallux IPJ ulcers was associated with an ulcer recurrence rate of 5%. LEVEL OF EVIDENCE: Level IV, cohort study.

Single-stage Flexor Hallucis Longus transfer and Gracilis free flap cover for failed Achilles tendon repair with soft tissue defect.

INTRODUCTION: Reconstruction of failed Achilles tendon repair, with infection and loss of overlying skin, is a surgical challenge. This paper aims to deal with the technical considerations and study the outcome of reconstructing such defects by radical debridement and reconstruction with combined Flexor hallucis longus (FHL) transfer and free Gracilis flap cover. MATERIALS AND METHODS: A retrospective study of six patients with failed Achilles tendon repair with overlying skin and soft tissue loss reconstructed by FHL transfer and free Gracilis flap cover performed between January 2017 and August 2020 was conducted. Postoperatively, they were assessed with the Mean Functional Gait Assessment score(MFGA), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, the Achilles tendon Total Rupture Score (ATRS), and Modified Vancouver scar scale score (mVSS). RESULTS: All six patients reported a good gait at nine months of follow-up. The MFGA score at six months was 24.8. The mean ankle plantar flexion at nine months follow up was 39.1° . The mean nine-month postoperative AOFAS and ATRS scores were 86.33 ± 2.654 and 88.5 ± 5.54, respectively. At nine months, all the patients could perform a single-leg heel raise on the operated foot. The overall mean mVSS score was 1.41. In about 12 months, the peak forefoot to hindfoot ratio matched the uninjured opposite foot. CONCLUSION: Simultaneous reconstruction of the Achilles tendon with FHL transfer with free Gracilis flap for the coverage of overlying soft tissue loss is a good management option for failed Achilles tendon repair with overlying skin loss.

Postburn Reconstruction of the Face and Neck.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the cardinal principles in the management of postburn deformities in the face and neck. 2. Understand reconstruction of specific subsites in the face and neck affected by burn contracture. 3. Acquire knowledge about the various techniques of burn reconstruction of the face and neck. 4. Grasp technical nuances and select appropriate surgical options for individual cases. SUMMARY: Postburn contractures in the face and neck region are multifactorial in origin and difficult to prevent in extensive burns. Facial burns lead to distortion of anatomical landmarks, causing aesthetic, functional, and psychological problems. Each subunit of the face is unique in structure; thus, the surgeon needs to adjust the timing of surgery and the technique according to region and the severity of contracture. Contracture of one unit, especially that of the neck and forehead, can exaggerate the contracture in neighboring subunits. The role of these extrinsic influences must be considered while sequencing surgical procedures. The burn surgeon must be adept in all reconstructive surgery techniques from skin grafting to tissue expanders to microsurgery to obtain the best outcomes. Surgery must be followed up with long-term physical therapy and psychological rehabilitation to help burn survivors with head and neck contractures to integrate back into society.

Parachute Method: A Novel Method to Retrieve a Stuck Degloved Finger.

An entrapped finger is a relatively uncommon domestic injury. When the finger gets stuck proximal to the proximal interphalangeal joint, the resultant distal edema and inappropriate attempts at retrieval can result in circumferential degloving of the skin and injury to the neurovascular structures. We report a technique that can be used in such circumstances. Strategically placed skin sutures are used to get the skin through the constricting ring, and retrieval is aided by a cut finger glove that wraps the finger and can be lubricated. This non-cutting technique is named as the parachute technique since the withdrawn skin sutures look like the strings of the parachute. This technique is valuable when the finger gets stuck in an idli plate, a common South Indian kitchen utensil, where there is difficulty of access to cutting equipment and where inappropriate attempts at retrieval can result in skin injury making further attempts more difficult.

Study of clinical pattern of limb loss in electrical burn injuries.

INTRODUCTION: Electrical burn injuries are devastating and cause not only loss of life but also severe disabilities in the form of limb loss. Increase in urbanization, industrialization and overcrowding has led to an increase in electric injuries. MATERIAL AND METHODS: The study was prospective in nature evaluating electric burns and studied the pattern of limb loss for a duration of 18 months from October 2016 to March 2018. Parameters recorded were demographic data, clinical data regarding the electrical injuries, complications, and outcomes. RESULTS: Male patients made up 85.3% of cases. Mean TBSA was 24.76 ± 19.18%. Mean age was 27.59 ± 13.73 years. Pediatric patients made up 17%. High voltage burns constituted 68.2 %. Electric contact burn was the most common type making up 49.5% of cases. The most common cause was occupational (38.9%). A fasciotomy was required in 22% of cases with an amputation rate of 38% (209 out of 550). There were 190 major amputations and 106 minor amputations. Overall, the right upper limb amputations were twice as common as the left. The ratio of upper limb: lower limb amputation was 4:1. Fifty patients (23.9%) required revision amputation. The age group 11 to 30 years made up 55.5% of amputations. There was no statistical difference in amputation rates between males (31.31%) and females (41.97%). In patients with TBSA less than 25% amputation rate was 47.77% as compared to patients with more than 25% TBSA, 19.47% (p<0.001). Most amputations occurred due to electric contact burns (74.16%). In the high voltage group, 46.1% underwent amputation vs low voltage group -20.6% (p<0.001). Overall mortality rate was 12.7%. Three hundred patients (55%) had low level of awareness regarding consequences of electric injury. Thirty one percent had medium level of awareness and only 14 % had high level of awareness. There was a significant correlation between education level and awareness in adult patients (p<0.001). Seventy percent of persons with occupational injuries used only footwear and no other protective equipment. CONCLUSION: Increasing public awareness, safety measures at workplaces are measures that will help reducing electrical burns which reduce limb and life loss.

Cryogenic Refrigerant Burns: A Rare Occupational Hazard.

BACKGROUND: Cryogenic burns induced by coolant gases used in refrigerators and air conditioners are rarely encountered, despite the wide use of these gases. To date, only a few cases have been reported in the literature. This study examined the occupational circumstances leading to such injuries, relevant injury sites, types of chemicals involved, and treatment measures. METHODS: This study was conducted in a tertiary burn center in India between March 2015 and March 2019. The demographic details, chemicals involved, and burn regions and characteristics were analyzed. FINDINGS: There were 15 burn cases all involving injury to the hand. All injuries were managed initially with dressings and nonoperative management. One patient required anti-edema therapy with limb elevation and fingertip debridement, while another patient required skin grafting. All patients had satisfactory hand function after treatment. CONCLUSIONS/APPLICATION TO PRACTICE: Cryogenic burn injuries caused by refrigerants are rare, and their etiology varies considerably. Exposure time is the primary factor that determines burn depth and severity; hence, reducing exposure time is important in first aid. Our findings suggest that after exposure, the patient should be treated in a specialized burn center. Adequate knowledge regarding the pathophysiology of these types of burn injuries and their management is necessary; otherwise, misjudgments in the treatment plan can lead to adverse consequences.

Utility of Shoelace Technique in Closure of Fasciotomy Wounds in Electric Burns.

Fasciotomy is indicated to relieve compartment syndrome caused by electric burns. Many techniques are available to close the fasciotomy wounds including vacuum-assisted closure, skin grafting, and healing by secondary intention. This study assessed the shoelace technique in fasciotomy wound closure in patients with electric burns. The study included 19 fasciotomy wounds that were treated by shoelace technique (Group ST, n = 10 fasciotomy wounds) or by skin grafting/healing by secondary intention (Group C, n = 9 fasciotomy wounds). Data were collected for wound surface area, time to intervention, time to wound closure, rate of decrease in wound surface area after application of shoelace technique and associated complications. The mean time to intervention after fasciotomy was significantly lower in Group ST-7.6 ± 3.8 days as compared to 15.8 ± 5.3 days in Group C (P = .004). The median time to closure was also significantly lower in Group ST-7 days (range 6-10) as compared to Group C-20 days (range 12-48) (P < .001). Primary closure was achieved in 80% cases in the group ST and no complications were recorded. The shoelace technique is an economical, fast, and effective method of fasciotomy wound closure in electric burns, especially in high volume centers and resource-limited areas.

Trapezius Transfer to Restore Shoulder Function in Traumatic Brachial Plexus Injury: Revisited and Modified.

Background: Trapezius transfer has shown promise to restore shoulder movements and has stood through the passage of time. We here in describe a modification of trapezius transfer technique and review the current literature available. Methods: The modified trapezius transfer in which the trapezius muscle is extended with folded tensor fascia lata graft and attached as distally possible to the deltoid insertion was done in twelve patients at tertiary health care centre in India. Post-operative splinting and staged physiotherapy were given. Results: Results were described in the form of improvement in degree of shoulder abduction and Disabilities of the Arm, Shoulder and Hand (DASH) score. Six months post-surgery there were improvement in shoulder abduction and DASH score with mean 116 degrees (10-180 degree) and 38 (23-58) respectively. One patient showed poor results due to poor compliance in post-operative period. There were no major complications observed. Conclusions: The modified technique of trapezius transfer described here is a feasible option with good biomechanical outcomes. The technique is simple and can be adopted easily by emerging brachial plexus surgeon as a technique for secondary reconstruction of shoulder joint.

Role of systemic antibiotic prophylaxis in acute burns: A retrospective analysis from a tertiary care center.

INTRODUCTION: Burns are a worldwide problem with majority of them occurring in low and middle-income countries. The hurdles in treatment of burns in the resource restricted setting are unique and challenging. The role of intravenous antibiotics in reducing mortality and morbidity related to infection and sepsis has not been studied extensively in the Indian sub-continent. MATERIALS AND METHODS: This was a retrospective study conducted at a tertiary burn care center in India over a period of six months with follow up of one month from the day of burn injury. RESULTS: Data from a total of 157 patients were collected and analysed. In Prophylaxis group (n = 77), sepsis was detected in 33 patients and 38 patients expired. In No Prophylaxis group (n = 80), sepsis was detected in 37 patients and 40 patients expired. In Inhalational burns subgroup, patients belonging to Prophylaxis group (n = 30) had 20 patients diagnosed with pneumonia while 22 patients did not survive till 30th post burn day. Patients in No Prophylaxis group who had inhalational burns were 38 in number. Pneumonia was diagnosed in 29 of them while 27 did not survive till 30th post burn day. In Pneumonia subgroup, patients belonging to Prophylaxis group had lower mortality rate as compared to No Prophylaxis group. CONCLUSION: Our study does not support the routine usage of antibiotic prophylaxis in patients with burn injuries, but their administration can be considered in certain specific subgroups like patients with inhalational burns and patients developing pneumonia. Pneumonia is an independent risk factor for mortality when no antibiotic prophylaxis is used in burn patients.

Postburn Nasal Reconstruction With Distally Based Radial Artery Perforator Flap: A Novel Technique.

Postburn total nasal reconstruction associated with face burns is challenge to all reconstructive surgeons. The local tissue flaps for reconstruction is virtually out of options, forcing surgeons to opt for distant tissues for nasal reconstruction. Here in, we have described the use of distally based radial artery perforator flap for total postburn nasal reconstruction which has not been described for nasal reconstruction. The anatomy and technique of the flap and case series is presented in this report. Two cases of total nasal reconstruction using the distally based radial artery perforator flap are presented, one case post thermal burn and another post chemical burn. Radial artery distal perforator-based pedicled flap is a versatile option for nasal reconstruction especially when there is a paucity of unscarred skin in loco regional options.

Superstition, Misconceptions, and Magical Beliefs in Burns Patients-A Cross-Sectional Study of 100 Patients.

Superstitious beliefs have been frequently encountered in our day-to-day practices among patients and caretakers. Though this is a common phenomenon, there is a paucity of data pertaining to these beliefs due to various reasons. Many of these beliefs are deep engraved into the culture and mindsets of the population. This is an observational study performed in Tertiary burn care center in India during period October 1, 2018 to January 31, 2019. Data from 100 patient units were collected through a set of questionnaires given to each of patient and their caregivers/family members and responses were collected and analyzed. In the food category of superstitions, there was a thought that white colored foods had to be avoided to avoid pus discharge and wound healing in 60% of the response; eating pomegranate or drinking the juice of pomegranate improves the hemoglobin in 80% of the response. Wearing various colored strings in various parts of the body seemed to be a dominant practice in 85% of the responses, wearing the hair with origin from human, donkeys, horses, and various animals was practiced in 45% of people and wearing peacock feathers was seen in 40% of patients. About 95% of the patients thought adversely to the idea of bathing or even contact of the water with the wounds. This study is an attempt to analyze the different parameters of superstition, misconception, and magical beliefs.

"Namaste Flap": Modification of Subcutaneous Pedicle Propeller Flaps in the Reconstruction of Postburn Axillary and Elbow Contractures.

INTRODUCTION: The reconstruction of the postburn contracture area is always a challenge in the field of plastic surgery. Moreover, the joints are very sensitive to trauma and immobilization, showing a susceptibility to stiffness. The aim of this article is to emphasize the use of "Namaste flap"-modification of subcutaneous pedicle propeller flaps in the reconstruction of postburn axillary and elbow contractures. METHODOLOGY: This is a prospective case study of axillary and elbow contractures managed at a tertiary care hospital using Namaste flap-modification of subcutaneous pedicle propeller flaps from 2010 to 2016. The surgical technique involved raising 2-limbed subcutaneous pedicle-based propellar flap over the contracture using the unburnt skin at the axillary and cubital fossa. The flap with both the limb thus raised was rotated by 90 degrees in the same direction and inserted into the defect. RESULTS: Nine patients including 6 patients with elbow and 3 patients with axillary contractures were included in this study. The mean degree of contracture in axilla and elbow was 78.3 degrees and 59.1 degrees, respectively. The functional results postoperatively were satisfactory. The mean postoperative degree of joint movements in axilla and elbow was 176.3 degrees and 173.6 degrees, respectively. No major complications were encountered. There was a mean period of 12 months of follow-up. CONCLUSIONS: In cases where normal skin is still present on the axillary and cubital fossa with scar contracture caused by extensive burns, the subcutaneous propeller flap methods and their modifications should be considered one of the most useful versatile reconstruction methods. Namaste flap in addition to the advantages of subcutaneous pedicle propeller flap also negates the disadvantages caused by the use of split skin grafting of the donor area.

Synovial Sarcoma of Palm Masquerading as a Neural Tumor: A Challenging Differential Diagnosis.

Synovial sarcoma is one of the common soft-tissue tumors of the body and is usually found on the lower extremity, head-and-neck regions. Reports of monophasic variant of synovial sarcoma in the palm are a rare entity. It can present as a challenge for the surgeons mimicking other conditions. Very few cases of this malignancy are reported in the palm. Painful palmar mass is an unusual presentation for this variant of sarcoma. Preoperative suspicion and planned surgical approach pave the way for the proper management. Neoplasm of the hand is very challenging, as it needs surgical resection balancing with resection margin and functionality of the hand. These cases are notorious for late recurrences and metastasis. Long-term follow-up is of utmost importance. We are reporting a case of palmar monophasic synovial sarcoma with its management and follow-up.

Concept of Lethal Triad in Critical Care of Severe Burn Injury.

BACKGROUND: The trinity of hypothermia, acidosis and coagulopathy, the lethal triad in trauma setting is a well-known risk factor associated with high risk of death. Burn is also a pathological situation where inflammatory response, endothelial injury, hypovolemia, reduced end-organ perfusion, cellular hypoxia, and myocardial depression are frequently encountered. This study aimed to study the occurrence and outcome of patients presenting with the 'triad of death' in burn population. METHODS: The study population included patients between 18 years and 60 years presenting to the department with thermal and scald burns with total body surface area involving 50-70%. The study was conducted for a period of 180 days and patients were followed up for 30 days. A p value <0.05 was considered statistically significant. RESULTS: One hundred and ninety-six patients were admitted during study period. Fifty patients out of them were eligible and were included in the study. The average abbreviated burns score index was 11 in lethal triad subgroup when compared to eight in the subgroup without the lethal triad. The mortality in the subgroup with lethal triad was higher (68.8% vs 17.6%, p = 0.0009). The "on admission" acidosis, hypothermia, and coagulopathy were independently associated with significantly increased mortality. The overall relative risk of mortality in the presence of lethal triad was 3.896. CONCLUSION: This study reiterates the fact that the lethal triad is seen in burn patient. Burn associated with on admission lethal triad has significantly higher mortality rates. There are only countable studies addressing this issue in burn setting. HOW TO CITE THIS ARTICLE: Muthukumar V, Karki D, Jatin B. Concept of Lethal Triad in Critical Care of Severe Burn Injury. Indian J Crit Care Med 2019;23(5):206-209.