Age correlation in upper brachial plexus injury patients undergoing nerve transfer surgeries.

•A patient's age can be a critical factor influencing the outcome following upper brachial plexus injury (BPI) reconstruction.•The favorable factor being younger patients with short denervation period.•In older patients early and more aggressive management for an optimal outcome.•This study supports the various correlation of age with the outcomes of upper brachial plexus reconstruction surgery.

The role of steroid receptors, peptides and growth factors in the aetiopathogenesis of idiopathic gynecomastia.

Idiopathic gynecomastia is a diagnosis of exclusion. We aimed to evaluate the role of steroids, peptides and growth factors in these patients. Those with bilateral idiopathic gynecomastia (n = 29) (Simon's grade IIb or III) who underwent gland excision were evaluated by immunohistochemical techniques using semi-quantitative grading for oestrogen receptor (ER), progesterone receptor (PR), aromatase, androgen receptor (AR), peptides (IGF-1, IGF-2, HER-2, parathyroid-hormone related peptide [PTHrP]) and growth factors (EGFR, TGFß). The cohort comprised 29 patients, with a mean age of 25.3 ± 5.1 years and a mean body mass index of 27.2 ± 2.3 kg/m2 . Grade IIb gynecomastia was present in 79.1% and moderate-to-severe insulin resistance (HOMA-IR >3) in 53.7% of patients. ER expression was positive in 100% samples, followed by AR (96.5%), aromatase (96.5%) and PR (93.1%). IGF-1 was expressed in 86.2% of the cohort, IGF2 in 27.5% and HER-2 in only two samples, with both showing weak immunoexpression. None of the patients had positive expression of EGFR, TGF-ß or PTHrP. There was no association between immunoexpression and gynecomastia grade. This study demonstrates the predominant role of oestrogen, aromatase and insulin resistance in the aetiopathogenesis of idiopathic gynecomastia and implicates the paracrine hyperestrogenic milieu in its causation as circulating hormones were normal.

Management of extra-articular shaft fractures of the non-thumb metacarpals: plate-screw fixation versus K-wire fixation.

Metacarpal fractures are common injuries and comprise nearly 36% to 42% of all fractures in the hand. The majority of these can be managed non-surgically. Operative fixation when needed, can be done by a variety of techniques. In this study, we have compared the outcomes of two techniques, plate-screw fixation and K-wire fixation. We have conducted a prospective, non-randomized, comparative study of patients who presented with extra-articular metacarpal shaft fractures of non-thumb metacarpals over a period of 18 months. 30 patients were enrolled according to the inclusion criteria and were alternately allotted to the plate-screw group and the K-wire group. At admission, patient demographics, clinical features, number of fractures, and fracture patterns were recorded, and radiographs were taken. In the plate-screw group, low-profile plates and screws were used, and in the K-wire group, 1 or 2 K-wires were used for fixation after fracture reduction. Hand mobilization exercises were started within one week in the plate-screw group, while in the K-wire group full mobilization was allowed at 4 weeks post-surgery. The Disabilities of Arm, Shoulder and Hand (DASH) score was calculated and compared between the two groups at 6 months and 12 months after surgery. The mean 6-month DASH score in the plate-screw group was 6.3287±2.2453, while it was 17.1627±6.2103 in the K-wire group (p value <0.001). At the end of 1-year follow-up, the mean DASH score in the plate-screw group was 5.1080±1.6637, and in the K-wire group, it was 5.1073±1.9392 (p value =0.848). In conclusion, extra-articular metacarpal shaft fractures of the non-thumb metacarpals treated by plate-screw fixation had significantly better DASH scores and hence better functional outcomes at the end of 6 months. However, at the end of 1 year, the DASH scores in both the groups were almost similar, suggesting similar functional outcomes in the long term.

Clinico-Epidemiological Characteristics of Hidradenitis Suppurativa: A Retrospective Cohort Study from a Tertiary Care Centre in Northern India.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic debilitating disease with a relapsing and remitting course. Due to delay in diagnosis, patients are often referred when the disease is very severe. Management strategies vary across multiple guidelines. AIMS: The aim of this study was to analyze the demographic and clinical characteristics of patients with HS among our outpatient attendees and to study the outcomes of various treatments offered. METHODOLOGY: This was a retrospective cohort study analyzing case files and photographic records of all patients diagnosed with HS, presenting to our tertiary care institute over 18 months. RESULTS: A total of 22 patients (10 males and 12 females) of HS were studied with majority having Hurley stage 2 and 3 diseases. The most common site affected was axilla. Overweight and obese patients were 45.4% and 18.1%, respectively. Rifampicin-clindamycin combination or doxycycline was the first line therapy offered. Adalimumab was given in only two patients but could not be continued for long term due to financial issues. Surgery was performed in six patients. Procedures included wide local excision and deroofing which is left to heal by secondary intention. Least number of remissions and most satisfactory improvement was seen with a combination of antibiotics and surgery compared to medical treatment alone. LIMITATIONS: Retrospective nature and a single center study were the major drawbacks. CONCLUSION: Patients undergoing procedural intervention in addition to pharmacotherapy have best overall outcomes and involvement of a multidisciplinary team plays a key role, however a larger follow-up study is required.

Clinical Outcomes of Surgical Management of Primary Brachial Plexus Tumors.

Introduction This study evaluates the clinical presentation, tumor characteristics, and clinical outcomes of surgically treated benign and malignant brachial plexus tumors (BPTs). Methods A prospective study of patients with BPTs from June 2015 to August 2020 was conducted. All patients underwent surgical resection with microneurolysis and intraoperative electrical stimulation to preserve the functioning nerve fascicles. Results Fourteen patients with 15 BPTs underwent surgical resection. Mean age was 37.8 ± 12.3 years; with male to female ratio 4:10. The clinical presentations were swelling (100%), pain (84.6%), and paresthesia (76.9%). The lesions involved roots (5/15), trunk (5/15), division (1/15), and cords (4/15). Thirteen patients had benign pathology (8 schwannomas, 3 neurofibromas, 2 lipomas) and two had malignant neurofibrosarcoma. Gross total resection was achieved in all cases except a dumbbell tumor. The mean follow-up period was 24 ± 5 months. Postoperatively, all patients reported improvement in pain and paresthesia with no new sensory deficit. All patients had developed initial motor weakness (Grades 2-4); however, full power (Grade 5) was recovered by 3 to 5 months. Conclusion Total resection can be achieved by appropriate microneural dissection and electrophysiologic monitoring and is potentially curative with preserving function.

A Novel Trapezoid Concept of Fibula Cutting Guide for Mandible Angle Reconstruction.

ABSTRACT: Virtual surgical planning (VSP) has revolutionized the planning process in the reconstruction of the mandible with a free fibula flap. The traditional planning and design use a triangular osteotomy guide with a closing wedge movement at the angle. With virtual surgical planning, the authors found an additional lateral mandibular tilt angle and tried to incorporate it in our design of osteotomy guide. The authors have proposed a novel design in a trapezoid shape to accommodate the lateral tilt angle in our osteotomy design. Incorporating the two angles in one angle design improves the aesthesis of the reconstructive procedure and saves operative time.

No Traces of SARS-CoV-2 In Wounds of COVID-19 Positive Patients: A Pilot Study.

Background This study was performed to investigate the presence of SARS-CoV-2 virus in wounds of COVID-19 positive patients. Methods This is a single-center observational study. COVID-19 patients with wounds (traumatic/infective/surgical) were included in this study. Preoperative, intraoperative, or postoperative specimens were collected and analyzed with real-time reverse transcriptase polymerase chain reaction (rRT-PCR) to know the presence of the virus. Results A total of eight patients were included in this study. Eleven samples were collected (seven wound swabs, two peritoneal fluids, and two tissue specimens) and analyzed. None of the samples from the wound tested positive for the virus while they were tested positive for nasal swab taken simultaneously or within 3 days prior. Conclusion The wounds of COVID-19 patients are considered negative and can be managed with routine wound precautions.

Tracing the Journey of Endometrium, from Womb to Arm: Deltoid Endometriosis.

BACKGROUND: Endometriosis is an enigma. Extrapelvic endometriosis is even more challenging, as theories of origin are difficult to explain. Very few cases of skeletal endometriosis have been reported in the literature. METHOD: We managed a case of 39-year-old nulliparous woman, who presented to the department of plastic surgery with complaints of a painful nodule measuring about 2 cm, in left upper arm since past 8 years. She had history of myomectomy 8 years back, while she was undergoing treatment for primary infertility. Differential diagnosis of extrapelvic endometriosis was made based on clinical history of cyclical pain and swelling, and she was referred to gynecology for hormonal treatment. MRI and FNAC were inconclusive. She underwent excision biopsy of the lesion. RESULT: Histopathology confirmed intramuscular endometriosis of left deltoid with positive margins. Postoperatively, she was started on dienogest 2 mg once daily and LNG IUS was inserted. Both were withdrawn a year later, due to side effects. It has been more than 6 months since removal of LNG IUS, and currently she is asymptomatic. CONCLUSION: To the best of our knowledge, this is the third case of deltoid endometriosis reported till date.

Quality of Life in Patients with Reconstructions After Resections for Oral Cavity Cancers.

To determine effects of reconstruction in advanced oral cavity cancers in achieving a quality of life (QOL), which can help patients to cope with their routine day to day activity. A Cross sectional analysis involving 32 patients of stage III and IV oral cavity cancers already operated in the department of otolaryngology and head and neck surgery was carried out. All these patients had resection of their tumors along with reconstruction. Patients who consented for QOL assessment and follow up through personal visit and telephonic interviews were included in the study. Voice related quality of life; Swallowing related QOL; overall Quality of life (WHO QOL BREF II) and disability assessment scale (WHO DAS II) were used for assessing the various QOL parameters during post-operative period. Patients with stage T3 tumors had better QOL compared to patients with T4 stage tumors. Patients who had reconstruction with free flaps had better QOL compared to those with Pectoralis Major myocutaneous (PMMC) flaps or those reconstructed with combinations of flaps involving delto-pectoral flaps or local flaps along with a free flap or PMMC. Patients with lower stage tumors have better QOL even after reconstruction. If available, free flaps should be preferred over local flaps. Delto-pectoral flaps should be a less preferred option in terms of QOL. Every patient should be counseled accordingly while any reconstruction plan is included in the management of cancers of oral cavity.

Assessing the Role of Virtual Surgical Planning in Mandibular Reconstruction With Free Fibula Osteocutaneous Graft.

BACKGROUND: The role of virtual surgical planning and three-dimensional printing in improving the accuracy, precision, functional and aesthetic outcomes have been demonstrated in the literature; however, there is a dearth of studies evaluating these parameters. OBJECTIVE: This study was carried out at a tertiary care center in North India to assess the accuracy of virtual surgical planning in mandibular reconstruction. METHOD: All the included patients were preoperatively assessed with a contrast enhanced computed tomography (CECT) of head and neck. Based on the dimensions a patient-specific fibula cutting guide was fabricated by three-dimensional printing. All patients were evaluated with a postoperative CECT at 6 months of follow-up. The precision outcomes were measured by comparing surgical results with the images of the preoperative virtual planning based on several measurements on the reconstructed mandible such as anteroposterior measurement, transverse measurement, height of the mandible, angle of the mandible, and lateral tilt.The secondary outcomes analyzed were the mean total operative time, mean ischemia time, and morbidity parameters. RESULT: Twelve consecutive patients (6 male, 6 female) with mean age of 33.1 ±â€Š11 years who underwent free fibula graft mandibular reconstruction were included in the study. The mean difference in the anteroposterior, transverse, and height dimensions were 0.87 ±â€Š0.43 mm (P = 0.24), 2.43 ±â€Š3.72 mm (P = 0.64), and 1.08 ±â€Š0.67 (P = 0.88), respectively. The difference in the angles of the reconstructed mandible was 2.37 ±â€Š3.92 degrees (P = 0.51) and of lateral tilt was 1.57 ±â€Š1.5 degrees (P = 0.54). The mean total operative time was 639 ±â€Š27.2 minutes and mean ischemia time was 88.4 ±â€Š8.6 minutes. CONCLUSION: All the patients had satisfactory aesthetic results and good oral function at 6 months postoperative period.

Harvesting split thickness costal cartilage graft.

AIM: There are few complications associated with harvesting of full thickness coastal cartilage grafts i.e., pneumothorax (0.9%), contour deformities and prolonged post-operative pain. To address these issues, authors devised special scalpel to harvest split-thickness costal cartilage grafts. MATERIALS AND METHODS: Standard inframammary incision was used for harvesting rib. Incision was made directly over the desired rib. Specially designed scalpel was used to cut through the rib cartilage to the half of the thickness. The study was conducted in two parts - cadaveric and clinical. RESULTS: There was significantly less pain and no pneumothorax in the patients in whom the split thickness graft was harvested. Wounds healed without any complication. DISCUSSION: Thus, newly devised angulated scalpel used in the current study, showed the potential to supply the reconstructive surgeon with split thickness rib graft without risk of complications such as pneumothorax or warping contour deformities and post-operative pain.

Superficial upper limb vasculature and its surgical implications.

Any kind of anatomical variation whether encountered during cadaveric dissections or routine clinical or surgical procedures needs to be reported and taken into account. This can be quite helpful in planning surgeries accordingly and avoid disastrous complications. During routine cadaveric dissection, authors found a superficial course of arteries of the arm as well as the forearm, unilaterally in one cadaver. In this case, there were two brachial arteries - superficial and deep. Superficial brachial artery terminated into superficial radial and superficial ulnar artery. Deep brachial artery was trifurcated into common interosseous, medial and lateral artery branches. Authors have also discussed the developmental anomaly, which could have led to the observed morphological variation. Superficial vessels can provide large size pedicles for raising flaps for local reconstructive surgeries in the region of axilla, elbow, wrist or hand, or other regions.

Primary Nasal Reconstruction in Self-Inflicted Nasal Injury.

Self-inflicted injury of the nose is extremely rare. It may be associated with severe psychopathology and suicidal ideation. The authors report a case of a 24-year-old man, who presented with soft-tissue loss over both the alae of his nose. He had cut off the alar rims with an ordinary razor blade. He was overtly concerned about his nose being excessively broad and fat. A diagnosis of body dysmorphic disorder with nonsuicidal self-injury was made. Patient was observed during 72 hours in hospital with psychiatric support and local dressings. The authors undertook primary nasal reconstruction with nasolabial flaps on both sides for coverage. In conclusion, self-inflicted nasal injury mandates a judicious balancing of psychiatric support and surgical reconstruction. This can prevent untoward sequelae including further self-harm and suicide.

The long-term fate of pedicled buccal pad fat used for interpositional arthroplasty in TMJ ankylosis.

BACKGROUND: Temporomandibular joint (TMJ) ankylosis is a common condition in the developing countries and has been managed by interposition arthroplasty. The pedicled buccal pad of fat (BPF) has also been used successfully for this purpose. The aim of this study was to assess the fate of BPF following interpositional arthroplasty. MATERIALS AND METHODS: A total of 23 joints were included in this prospective study (n = 18; 5 bilateral involvement). In 18 cases, magnetic resonance imaging (MRI) of the TMJ was done at 6- and 12-month intervals to assess the viability and fate of BPF. Postoperative mouth opening and pain scores were measured at 6-monthly intervals using visual analogue scale. RESULTS: During the first 6 months, the artefacts hampered the visualisation of BPF in 60% of cases and visualisation was possible in only 40% cases. During the next 6 months, we could visualise BPF in 65% TMJs on MRI. There was significantly less pain and better mouth opening in the BPF group. CONCLUSION: BPF is viable after 1 year and it prevents heterotopic bone formation following TMJ ankylosis release.