Clinical Study of the Lateral Supramalleolar Flap in the Soft Tissue Reconstruction around the Ankle Region.

Objective The purpose of this study is to present the efficiency of the lateral supramalleolar flap which is a very useful and yet underutilized in the soft tissue reconstruction of the regions extending from the distal leg, ankle, and foot. Methods Over a period of 3 years, 20 flaps were used in the reconstruction of soft tissue defects in the region extending from the distal leg, ankle, and foot. The location of the defects, the etiology, possible alternative flaps, outcome, and the complications were studied and presented. Results The follow-up period of the cases was from 1 month to 18 months after surgery. Seventeen flaps survived and three were lost. All the three lost flaps were those used over the tendocalcaneal region. The lost flaps were later replaced with split skin graft after the wound was debrided and was later covered with granulation tissue. Conclusion The lateral supramalleolar flap is a very useful flap in the regional soft tissue reconstruction around the ankle except in the tendocalcaneal region.

Single stage management of Gustilo type III A/B tibia fractures: Fixed with nail & covered with fasciocutaneous flap.

PURPOSE: To evaluate the role of immediate and definitive management of Gustilo type III A/B tibia fractures with intramedullary nailing and fasciocutaneous flap. METHODS: From August 2010 to July 2012, 22 patients with Gustilo Grade III A/B tibia fractures were managed with a single stage treatment of ipsilateral fasciocutaneous flap & reamed intramedullary nailing and were included in the study. The severity of the injury was calculated with Ganga Hospital injury severity score. RESULTS: The mean age of patients was 41 years and the follow-up time ranged from six months to one year. Among the 22 patients, 73% were type III B fractures with upper leg involved in 55% of them. The time interval from injury to completion of surgery was 8-14 h. The incidence of bone infection requiring secondary procedure was 9%; the major and minor soft tissue complication rate was 9% and 14% respectively. The limb salvage rate was 100%. CONCLUSION: Multidisciplinary management of severe lower limb trauma is important and provides good outcomes. Intramedullary nailing and immediate flap fixation can achieve early bone union and good soft tissue coverage, leading to good outcomes in patient with Grade III A & B tibia fractures.

Do autologous blood transfusion systems reduce allogeneic blood transfusion in total knee arthroplasty?

PURPOSE: To study whether autologus blood transfusion systems reduce the requirement of allogneic blood transfusion in patients undergoing total knee arthroplasty. METHODS: A comprehensive search of the published literature with PubMed, Scopus and Science direct database was performed. The following search terms were used: (total knee replacement) OR (total knee arthroplasty) OR (TKA) AND (blood transfusion) OR (autologous transfusion) OR (autologous transfusion system). Using search syntax, a total of 748 search results were obtained (79 from PubMed, 586 from Science direct and 83 from Scopus). Twenty-one randomized control trials were included for this meta-analysis. RESULTS: The allogenic transfusion rate in autologus blood transfusion (study) group was significantly lower than the control group (28.4 and 53.5 %, respectively) (p value 0.0001, Relative risk: 0.5). The median units of allogenic blood transfused in study control group and control group were 0.1 (0.1-3.0) and 1.3 (0.3-2.6), respectively. The median hospital stay in study group was 9 (6.7-15.6) days and control group was 8.7 (6.6-16.7) days. The median cost incurred for blood transfusion per patient in study and control groups was 175 (85.7-260) and 254.7 (235-300) euros, respectively. CONCLUSION: This meta-analysis demonstrates that the use of auto-transfusion systems is a cost-effective method to reduce the need for and quantity of allogenic transfusion in elective total knee arthroplasty. LEVEL OF EVIDENCE: Level I.

Intraosseous Ganglion Cyst of Scaphoid: An Uncommon Cause of Radial Wrist Pain.

Intraosseous ganglion cyst is a rare bone tumor and the lesion could often be missed. The diagnosis could be delayed so proper radiologic investigation and index of suspicion is necessary .Differential diagnoses of painful cystic radiolucent carpal lesion are osteoid osteoma, osteoblastoma and intraosseous ganglion. Curettage of the scaphoid lesion and filling of void with bone graft provides good functional outcomes. The cyst contains mucoid viscous material without epithelial or synovial lining. We present a case of 30 years old male with intraosseous ganglion cyst of scaphoid which was treated with curettage and bone grafting. Rarely ganglion cyst is found in small bones of hand and should be considered as differential diagnosis of chronic radial wrist pain.

Extended anterolateral thigh pedicled flap for reconstruction of trochanteric and gluteal defects: A new & innovative approach for reconstruction.

Descending branch of the lateral circumflex femoral artery (LCFA) is commonly used pedicle for ante- rolateral thigh (ALT) flap. Oblique branch of LCFA is an alternative pedicle that can be used in micro- vascular surgery. According to review of literature and to the best of our knowledge we could not find the use of oblique branch of LCFA as a pedicle of the ALT flap in regional soft tissue reconstruction. Here we presented a case of a 55-year-old man sustaining soft tissue injury and wound over the left trochanteric and gluteal region following a road traffic accident, who was treated by the use of extended ALT pedicle flap with oblique branch of LCFA as the pedicle for reconstruction of soft tissue defect in trochanteric and gluteal regions with successful outcome.

Single cannula versus double cannula tracheostomy tubes in major oral and oropharyngeal resections.

OBJECTIVE: To compare the outcomes of two types of tracheostomy tubes used in major head and neck surgery. METHODS: A retrospective study was conducted of prospectively collected data. The post-operative safety and adequacy of a single cannula tracheostomy tube was compared to a double cannula tracheostomy tube in patients undergoing tracheostomy during major oral and oropharyngeal resections. RESULTS: Out of 46 patients with the single cannula tube, 7 (15 per cent) experienced significant obstruction warranting immediate tube removal, while another 9 (20 per cent) needed a change of tube or tube re-insertion for continued airway protection. In contrast, out of 50 patients with the double cannula tube, the corresponding numbers were 0 (p = 0.004) and 1 (2 per cent; p = 0.007) respectively. CONCLUSION: Insertion of a double cannula (instead of a single cannula) tracheostomy tube in the course of major oral and oropharyngeal resections offers better airway protection during the post-operative period.

Propeller Flap Reconstruction in Post Oncological Thigh Defect: "The Move in Flap".

Reconstruction of soft tissue defects of the limb after tumor resection is challenging question for oncosurgeons. The management differs from reconstruction of post traumatic defects due to the complexity of the primary surgery and subsequent radiation. The conventional propeller flap is based on a perforator which is located close to the defect; but in present case the perforator was located far away from the defect. So we describe it as "Move in flap" as the flap rotated a large volume of soft tissue lying between the defect and the perforator. We present a case of post oncological thigh defect with reconstruction using a propeller flap based on distal anteromedial perforator.

Post chemotherapy extravasation injuries: Hypogastric flap for reconstruction of wounds over dorsum of hand.

CONTEXT: Management of extravasation injuries over the dorsum of hand after administration of chemotherapeutic agents. AIM: To study the results of hypogastric flap reconstruction in chemotherapy extravasation wounds over dorsum of hand. SETTINGS AND DESIGN: Retrospective study. SUBJECTS AND METHODS: At our center over 3-years period, 32 patients were treated for chemotherapy extravasation wounds. Out of these 32 patients, seven had wound over dorsum of hand. There were five males and two females, and their mean age was 45 years (range, 19 - 64 years). These patients with wound over the dorsum of hand were treated with multiple debridements and hypogastric flap reconstruction. RESULTS: The mean interval between extravasation wound and surgical treatment was 6.28 days (range, 4 - 10). The mean size of extravasation wound defect was 14 × 8 (range, 12 × 7 to 18 × 8). Non-dominant hand was involved in six patients and dominant hand in one patient. In four patients, the hypogastric flap was supplemented with skin graft. The hypogastric flap settled well in all patients and enabled a good wound cover. Complete division of the flap and final insetting was done under local anesthesia after 3 weeks; this was followed by limb mobilization exercises. Contour difference over the dorsum of hand was present in all the cases. The range of movement of the hand was functionally restricted in one patient. No patient in current series developed wound infection. CONCLUSION: Hypogastric flap is a reliable flap to cover wound over dorsum of hand after extravasation of chemotherapeutic agents.

Anterolateral Thigh Twin Free Flaps from a Single Donor Site-a Modification Based on the Oblique Branch of the Lateral Circumflex Femoral Artery.

The pedicle of the anterolateral thigh flap is formed by the descending branch of the lateral circumflex femoral artery. Recently, an oblique branch of lateral circumflex femoral artery was described by Wei et al., which can also be used as an alternative to the descending branch. We describe a case in which both the pedicles were used to create two free flaps (twin flaps) from the same thigh for post tumour reconstruction of breast.

Drain removal and aspiration to treat low output chylous fistula.

Chylous fistula following neck dissection is difficult to treat. We hypothesized that timely removal of the suction drain followed by daily aspiration might aid in resolution of the condition. The study model is prospective cohort study. Out of 170 consecutive neck dissections, 7 (4 %) developed chylous fistula postoperatively. Retaining the suction drain was associated with resolution of the fistula in only one case. The remaining six had peak 24 h outputs between 85 and 675 ml that showed no significant fall despite maximal conservative treatment. Suction drain removal followed by daily needle aspiration however led to cessation of the fistula in all six cases. No patient required surgical re-exploration. Drain removal was associated with a significant fall in the volume of chylous output (p = 0.002). In selected cases of low output chylous fistula, suction drain removal and daily needle aspiration is an effective treatment option.

Retrograde vascularisation of fibula free flap in composite oro-mandibular reconstruction.

We present a case of composite oromandibular reconstruction with fibula free flap in which the vascularity to the flap was established in a retrograde direction through the distal end of the peroneal pedicle vessels. The flap was initially designed in such a way so as to anastomose with superior thyroid artery. However after initial good flow, the superior thyroid artery flow became insufficient. Therefore, an attempt was made to vascularise the flap by anastomosing the distal end of peroneal vessels with the facial artery and a tributary of the internal jugular vein so that the flap was perfused in a retrograde direction. This was successful and the retrograde flow was adequate to ensure flap survival. We believe this to be the first successful case of reverse vascular flow reported for composite oromandibular reconstruction with the fibula free flap.

A simple and effective way of maintaining the microvascular field clean and dry during anastomosis.

During microvascular anastomosis, it is important to maintain the microsurgical field irrigated yet dry so as to achieve a good view of the vessels for approximation. In this method, an infant feeding tube (size 4), with its tip sandwiched between layers of dry gauze and a surgical glove component placed in the anastomotic field and the other end connected to a suction apparatus, is used to maintain the microsurgical field free from flooding. It also has the additional advantage of providing a stable platform for microvascular anastomosis.

Incidentaloma at radial artery forearm free flap harvest: an occult volar wrist ganglion.

Occult volar wrist ganglion originating from radioscaphoid interval and having adherence to flexor carpi radialis tendon [Fcr] and radial artery is an uncommon occurrence. We report such a case which was occult and asymptomatic during pre-operative assessment and presented as an incidentaloma during radial artery forearm free flap harvest for oral cancer reconstruction.

Traumatic Hematoma in a Palmoplantar wart Mimicking Acral Lentiginous Melanoma.

We describe a case where a secondary traumatic hematoma in a pre-existing palmoplantar wart of the sole was presenting a diagnostic dilemma where it simulated an acral lentiginous melanoma and was managed successfully with wide excision and local skin flap.

Skin paddle vascularity of free fibula flap - A study of 386 cases and a classification based on contribution from axial vessels of the leg.

OBJECTIVE: The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems. MATERIALS AND METHODS: A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study. RESULTS: The skin paddle of the free fibula flap was classified into four different types (a-d) based on the dominance of vascular contribution by axial vessels of the leg. CONCLUSION: The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.