Long-term follow-up for keystone design perforator island flap for closure of myelomeningocele.

PURPOSE: We have previously reported a small series on the closure of large myelomeningocele (MMC) defects with a keystone design perforator island flap (KDPIF) in a paediatric neurosurgical centre in Australia. We are now presenting an updated longer term follow-up of an expanded series demonstrating longer term durability of this vascularized flap for large myelomeningocele defects. METHODS: The prospective data from the Monash Neurosurgical Database were used to select all cases of MMC between December 2008 and September 2016. Retrospective analysis of the neurosurgical database revealed an additional three patients who underwent KDPIF closure at the Monash Medical Centre for MMC repair at birth. RESULTS: Wound healing was satisfactory in all six cases. With delayed follow-up, there was no associated skin flap separation, skin flap dehiscence, skin flap necrosis, cerebro-spinal fluid leak, however two infections were encountered, both resolved with conservative management including antibiotics and simple washout. CONCLUSION: In this expanded case series with increased longevity of follow-up, the keystone design perforator island flap remains a robust alternative for closure of large myelomeningocele defects.

Acute Hemorrhagic Flexor Tenosynovitis due to Vincula Injury.

A 20-year-old previously well woman presented to the emergency department with classical signs of acute flexor tenosynovitis, 4 hours after a minor puncture wound over the volar aspect of her right middle finger distal interphalangeal joint. Exploration of the flexor sheath in theatre revealed frank blood within the sheath and extension of the puncture wound through the profundus tendon into the short vincula beneath. The blood was irrigated from the sheath, and the patient made a complete recovery by 2 weeks postoperatively. Although rare, irritation and distension of the flexor sheath caused by vincular hemorrhage can be an alternative mechanism for the development of acute flexor tenosynovitis, and as with pyogenic flexor tenosynovitis, prompt surgical treatment can minimize the risk of long-term functional impairment.

Closed digital artery injury.

Closed digital artery injury with secondary acute ischemia is a rare phenomenon. The most common injury pattern involves a crush mechanism with a resultant transverse fracture in proximity to the interphalangeal joints. Secondary acute ischemia requires urgent surgical exploration with digital arterial repair to avoid necrosis and associated decreased hand function. One should exercise an air of caution when examining significant closed trauma; neurovascular normality should be established by an adequately trained physician. We present a case of closed digital artery injury with secondary acute ischemia and a review of current literature.

Mandibular ameloblastoma: clinical experience and literature review.

BACKGROUND: Ameloblastoma is a locally aggressive odontogenic tumour of the mandible and maxilla that, if neglected, can cause severe facial disfigurement and functional impairment. A thorough understanding of its clinicopathological behaviour is essential to avoid recurrence associated with inadequately treated disease. Currently, wide resection and immediate reconstruction is the treatment of choice in most cases of mandibular ameloblastoma. We present our experience in the management of this disease and review the current status of the literature. METHOD: Retrospective review of all patients between 1996 and 2006 with histologically confirmed ameloblastoma. A literature review on the current understanding of this disease and its management is then presented. RESULTS: Six patients were identified, ranging between 23 and 54 years old. All were females. Two tumours involved the angle and posterior body of the mandible, one the angle and ramus, one the body and two the anterior mandibular. Four patients underwent mandibular reconstruction with free tissue transfer and two by non-vascularized bone grafts. All procedures were successful. One patient developed deep vein thrombosis requiring anticoagulation. Another developed a collection at the mandibular surgical site requiring drainage. Satisfactory union was achieved in all cases with no evidence of recurrence. All patients had adequate cosmesis, masticatory efforts and speech. CONCLUSION: Management of ameloblastoma remains a challenge and requires a thorough understanding of the behaviour of its different clinicopathological variants. We have found segmental mandibulectomy and immediate reconstruction to be an excellent treatment option in our series of patients.