Distally pedicled peroneus brevis muscle flap: a versatile lower leg and foot flap.

INTRODUCTION: The purpose of this study was to evaluate the outcome of our early experience with the distally pedicled peroneus brevis flap in the management of soft tissue defects of the lower leg, ankle and foot. METHODS: This was a non-randomised, retrospective study involving five patients who were treated with the peroneus brevis muscle flap for soft tissue defects over the lower leg. RESULTS: In all five patients, the flaps were viable and successful in providing satisfactory soft tissue coverage for the defects. In one diabetic patient, distal flap necrosis was observed, which was treated successfully with a local rotational skin flap. CONCLUSION: The distally pedicled peroneus brevis muscle flap is an economical, reliable and relatively easy procedure for treating defects of the distal third of the leg, ankle and foot.

Factors affecting the palpability of breast lesion by self-examination.

INTRODUCTION: This study aims to assess the accuracy of detection of breast lesion by breast self-examination and to assess different factors affecting the accuracy. METHODS: All consecutive Chinese female patients, who attended our breast imaging unit in 2001, completed our questionnaire, had retrievable hard copy films, and had more than three years clinical follow-up, were recruited for this study. Different factors, such as age, menopausal status, previous experience of breastfeeding, family history of breast cancer, previous history of mastectomy or lumpectomy, hormonal therapy, oral contraceptive pills and previous history of mammography, were correlated with accuracy in self-detection of breast lesions retrospectively. The nature, size and location of the lesion, and breast size based on imaging, were also correlated with the accuracy in self-detection of breast lesions. RESULTS: A total of 163 questionnaires were analysed. 111 patients detected a breast lesion themselves and 24 of these lesions were false-positives. A total of 173 lesions (27 cancerous, 146 benign lesions) were documented by either ultrasonography and/or mammography, and confirmed by either histology or three-year clinical follow-up. The overall sensitivity in detecting both benign and malignant breast lesions was 71% when number of breast lesions was used as the denominator, and up to 78% sensitivity was achieved when number of patients was used as the denominator. History of mastectomy, and size and nature of the lesions were found to affect the accuracy of self-detection of breast lesions. CONCLUSION: Overall, breast self-examinations were effective in the detection of breast lesions and factors such as size of lesion, nature of the lesion and history of mastectomy affect the accuracy of the detections. Breast self-examination should be promoted for early detection of breast cancer.

Stress fracture of the distal tibia secondary to severe knee osteoarthritis: a case report.

Stress fracture of the tibia secondary to sports-related activities is relatively common, but rarely occurs secondary to osteoarthritis of the knee. Such fractures usually involve the proximal tibia. We report a 61-year-old woman with osteoarthritis and severe varus deformity of the knee who had a stress fracture of the distal tibial shaft. The patient had declined total knee replacement for severe osteoarthritis. She developed a stress fracture that subsequently malunited. The patient presented late and the diagnosis was not made for several months. The pathomechanics, diagnosis, and management options for this patient are discussed.

The use of computer navigation in performing minimally invasive surgery for intertrochanteric hip fractures--The experience in Singapore.

OBJECTIVE: Intertrochanteric hip fractures are very common and early mobilisation correlates with a better outcome. The ideal surgical procedure should protect the soft tissue envelope, thereby preserving blood supply and reducing blood loss. Furthermore, occupational exposure to fluoroscopy that is used in hip fracture fixation remains a concern amongst orthopaedic surgeons. Computer-aided surgery can help to reduce reliance on fluoroscopy. We therefore combined the principles of minimally invasive plate osteosynthesis (MIPO) and computer navigation to describe a new procedure. We also present our results using this technique of minimally invasive computer-navigated dynamic hip screw fixation (navMIS-DHS), and compare it to computer-navigated open DHS fixation (nav-DHS) and to conventional open DHS fixation (conv-DHS). MATERIALS AND METHODS: This paper has three parts. In the first part, we describe the procedure of navMIS-DHS in detail. In the second part, we present our initial retrospective pilot series of 35 cases. Amongst them we performed 5 navMIS-DHS, 3 nav-DHS and 27 conv-DHS. There were also two cases of conv-DHS deliberately performed with a mini-incision in an attempt to see if we could duplicate the 5 cm incision that we achieved with navMIS-DHS. All patients were followed up for a minimum of 6 months. In the third part, we performed a single surgeon prospective evaluation of navMIS-DHS versus conv-DHS involving 43 fractures in two arms. RESULTS: We were able to achieve reduction in fluoroscopy time. There was also reduction in opiate requirement post-operatively in the minimally invasive procedure. The incision sizes were also smaller. The prospective study also showed less wound-related complications in navMIS-DHS and a shorter time to ambulation. Implant positions were acceptable but we have also described how it may be improved. CONCLUSIONS: Navigated MIS-DHS, by virtue of less pain, better healing, earlier rehabilitation and potentially shorter hospital stay, would benefit both the patients and reduce the economic strain on the health care system. It is a safe and reproducible procedure. Technical difficulties are present and these need to be addressed with further modifications of technique, and instrumentation.

Management of intraparotid facial nerve schwannomas.

BACKGROUND: The purpose of the present paper was to review the management of intraparotid facial nerve schwannoma so as to discuss its clinical presentation, evaluate the various possible diagnostic investigations, and compare the various surgical options and outcome. METHODS: Case series was undertaken of five (1.3%) patients with facial nerve schwannoma out of 400 consecutive parotidectomies at Singapore General Hospital. RESULTS: There were three men and two women with an age range of 29-65 years. Three patients presented with painless parotid lumps while two had painful parotid swellings. None had facial nerve paresis. Only one patient had preoperative diagnosis suspicious of schwannoma by fine-needle aspiration cytology (FNAC). Diagnoses were made intraoperatively. Four patients had excision with cable grafting of the nerve defect. achieving facial nerve grade II-IV (House-Brackmann scale). One patient who underwent enucleation of tumour with nerve preservation achieved grade II. CONCLUSIONS: Preoperative diagnosis is difficult but it is important for discussion of the extent and options of surgery. Fine-needle aspiration cytology holds promise in making a preoperative diagnosis. Enucleation with nerve preservation where possible seems to offer better facial function whereas nerve excision with cable graft can give satisfactory results.