Can locking plate fixation and free Vascularised fibular transfer with skin island achieve good functional outcome in the treatment of large bone defects of Tibia ? A study of 26 cases.

BACKGROUND: Despite the availability of multiple treatment options, management of tibial bone loss continues to be a challenge. Free vascularized fibula graft (FVFG) with a skin paddle offers better advantages over the other methods. We aimed to study the functional outcomes and QALY of patients with large tibial bone defects following FVFG with a locking plate in 26 patients. MATERIALS AND METHODS: We analyzed 26 consecutive patients with large tibial bone defects treated by free vascularized fibular graft (FVFG) and stabilization using a long locking plate between 2009 and 2018. All were followed up for a mean period of 42 months (24 months to 120 months). Bony union, graft hypertrophy, and complications such as stress fracture and infections were assessed. Multivariate regression analysis was performed to identify any association between demographic factors, injury characteristics, treatment-related factors, and fibular hypertrophy. Additionally, The EQ-5D quality-of-life (QOL) indices were obtained using the SF-12 score to evaluate the patients' overall quality of life. RESULTS: The mean age of the patients at the time of presentation was 36.26 yrs (range, 18-60 years). The cause of bone loss was open injury in 16 patients and infected nonunion in 10 patients. Complete union was achieved in 25 patients (96 %) without any requirement of additional surgical procedures. The mean union time of the graft was 4.04 months (range, 3-6 months). The mean fibular hypertrophy calculated by De Boer index was 0.61 %, 11 %, 28.24 % and 52.52 % at 3,6 months and 1 and 2 years respectively. Patients with metaphyseal bone loss have significant fibular hypertrophy. Participants in our study experienced a quality of life equivalent to 0.88 (range 0.79-0.99) of perfect health. CONCLUSIONS: FVFG with skin paddle and LCP fixation for massive tibial bone loss achieved satisfactory outcome and QALY even in the challenging healthcare environment of South India, a developing country.It maintains alignment, promotes graft hypertrophy, and prevents stress fractures. LEVEL OF EVIDENCE: Level 4 LEVEL OF CLINICAL CARE: Level I Tertiary trauma centre.

First Successful Separation of Craniopagus Twins in India-Plastic Surgical Considerations.

Separation of total vertical craniopagus with shared venous sinuses poses multiple challenges. Provision of soft-tissue cover to the exposed brains at the time of total separation is one of them, due to the large size of the defect and paucity of local tissues. Staged separation of twins is advised with partial venous and parenchymal disconnection in the first stage and total separation in the second stage. Tissue expanders are inserted in the first stage, and second stage planned to coincide with the period of adequate expansion. In the child being reported, emergency second stage was done due to the deteriorating general condition of the children. Left with inadequate expanded skin, the critical defect in a twin was managed with bilateral trapezius myocutaneous flaps. High ionotropic support of the postoperative period resulted in superficial necrosis of the flap, which was managed by debridement, allograft application and autograft later. Both twins had well-healed wounds by 3 months.

Is lower limb salvage worthwhile after severe open tibial fractures in a developing country? An analysis of surgical outcomes, quality of life and cost implications.

INTRODUCTION: Open tibial fractures are rare and difficult-to-treat injuries because of the involvement of bony, skin and neuromuscular injury along with co-morbidities. Often, during the management of very severe cases these injuries, the question arises, should we amputate or salvage the limb? This question has been explored previously in civilian and military contexts in the US and UK but remains unstudied in the alternative sociocultural and economic context of the developing world. METHODS: We studied 78 adult patients with severe open tibial fracture that presented to our institution, a Level 1 trauma center in India, from February 2018 to June 2019. 20 patients underwent above-knee amputation (AKA), 16 underwent below-knee amputation (BKA), and 42 underwent limb salvage. We assessed injury severity using [our institution's] Open Injury Severity Score (GHOISS), which has separate sub-scores for bony injury, skin injury, neuromuscular injury and co-morbidities, and patients were only included with GHOISS > 13. We assessed functional outcome measures as well as economic costs as primary cost levied by our institution and other secondary costs. RESULTS: Salvage (LEFS: mean=51, SF-12 PCS: mean=48, SF-12 MCS: mean=49) provided better outcomes to BKA (LEFS: mean=39, p=0.005, SF-12 PCS: mean=40, p=0.003, SF-12 MCS: mean=43, p=0.052) and AKA (LEFS: mean=31, p<0.001, SF-12 PCS: mean=34, p<0.001, SF-12 MCS: mean=43, p=0.043). Primary costs were higher for limb salvage (index: mean=$3100, total: mean=$4400) than both BKA (index: mean=$2500, p=0.012, total: mean=$2600, p<0.001) and AKA (index: mean=$2800, p=0.020, total: mean=$3200, p<0.001). Secondary costs were higher for limb salvage than both BKA and AKA (p<0.001). Patients who underwent salvage were more likely to return to work at 36 months post-injury compared to below-knee amputees (adjusted OR=0.11, p=0.010). CONCLUSIONS: Limb salvage results in better functional outcomes compared with amputation at a higher upfront cost but a likely lower lifetime cost. Unlike other literature on the topic, amputation carries a heavy mental and physical toll in India, likely due to sociocultural differences and stigma. Amputation is a difficult decision for patients to accept and results in poorer outcomes; therefore, we believe that limbs should be aggressively salvaged in our developing country. STUDY DESIGN: Therapeutic Level II Prospective Cohort Study.

Pedicled Split Hypogastric Flap (Superficial Inferior Epigastric Artery flap): A New Technique for Coverage of Nonadjacent Defects in the Hand.

Flap coverage of soft tissue defects on both surfaces of the hand or of nonadjacent defects in the hand is a challenge. Two flaps are needed or if a single flap is used, the intervening normal area or part of the flap must be deepithelialized or the flap tunneled under the normal bridge segment. We are presenting a new technique whereby the hypogastric flap based on the superficial inferior epigastric artery is split into 2 components for the coverage of such defects. The hypogastric flap is separated into a cutaneous component and an adipofascial component at the level of Scarpa fascia. The flaps are separated almost to the base to increase mobility. Now it can be used to cover 2 defects separated by 5 to 7 cm or for defects in the dorsum and the palm. We have used it in 3 patients, in 2 for the coverage of palmar and dorsal aspect of the hand and in one for the coverage of nonadjacent defects on the dorsum of the hand and distal forearm after postburn contracture release. We achieved good results with no flap-related complications.

Evaluation of Extensor Pollicis Brevis as a Recipient of Tendon Transfer for Thumb Extension.

Introduction Rerouting of the extensor pollicis longus (EPL) is the standard part of tendon transfer surgery for thumb extension. It is done to overcome the ulnar vector of the EPL action. Extensor pollicis brevis (EPB), however, produces better thumb abduction and extension by virtue of its radial vector. The described anatomical variation of EPB extending the thumb interphalangeal joint (IPJ), therefore, gives the "best combination" of movements by a single-thumb extensor tendon. Materials and Methods We performed this transfer in six patients in whom the EPB was found to be extending the IPJ while checked intraoperatively. Three of these six patients were cases of radial nerve palsy and the other three presented with brachial plexus palsy. The outcome was assessed by measuring palmar and radial abduction of the thumb, Kapandji's score, and Bincaz's scale. Results We found satisfactory results in all the six patients. In our series, patients had an average radial extension of the thumb of 29.2 degrees and an average palmar abduction of the thumb of 65.7 degrees. On evaluation with the Bincaz score; one patient had excellent result, three patients had good results, and two patients had fair results. Conclusion In situations where EPL rerouting is not possible (as in cases where the donor tendon needs to reach the thumb from the ulnar side, for example, flexor carpi ulnaris), transfer to the EPB, provided it is extending the thumb IPJ, would produce better extension and abduction of the thumb than the transfer to the EPL.

One-Bone Forearm Reconstruction: A Salvage Solution for the Forearm with Massive Bone Loss.

BACKGROUND: Salvaging the forearm is a major challenge in cases of massive bone loss from injuries in which the extremity is severely mangled or following bone resection secondary to pathological tissue excision. The purpose of this study was to evaluate the role of one-bone forearm (OBF) reconstruction as a salvage option in these difficult situations. METHODS: A total of 38 patients with forearm segmental bone loss (acute and chronic) treated between 1995 and 2014 were included (range of follow-up, 2 to 20 years). Sixteen of the patients, 8 with avulsion amputations and 8 with severely mangled extremities, were managed in the emergency department because they required immediate replantation and revascularization, respectively. In the chronic setting, bone loss was due to infection with nonunion in 16 patients, tumor of the radius in 2 patients, and pseudarthrosis of the forearm in 4 patients. The surgical technique included conversion to OBF by achieving union between the distal part of the radius and the proximal part of the ulna in the majority of cases, with distal radioulnar joint (DRUJ) fusion in 4 cases, and ulna to carpals in 5 cases. Direct bone contact was achieved in 16 patients, a free vascularized fibular graft was used to bridge the bone gap in 10 patients, and 12 patients required iliac crest bone-grafting. RESULTS: The mean patient age was 35.5 years (range, 6 to 87 years); there were 23 male and 15 female patients. Among those who underwent OBF for acute injuries, the mean time to union was 7.3 months; 14 patients had complete union, and 2 patients had infection with nonunion requiring secondary procedures. As assessed using the criteria of Chen, 10 patients had a grade-I functional outcome, 3 patients had a grade-II outcome, and 3 patients had a grade-III outcome. In the elective group of 22 patients, the average time to union was 7.1 months. Nonunion was reported for 2 patients. On the basis of the Peterson scoring system, the outcome was excellent for 12 patients, good for 6 patients, fair for 2 patients, and poor for 2 patients. CONCLUSIONS: OBF reconstruction is a viable surgical treatment alternative. It is a demanding reconstruction but functions better and is cosmetically more appealing than a forearm amputation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modified Capanna's Technique (Vascularized Free Fibula Combined with Allograft) as a Single-Stage Procedure in Post-traumatic Long-Segment Defects of the Lower End of the Femur: Outcome Analysis of a Series of 19 Patients with an Average Gap of 14 cm.

Objectives Salvage and reconstruction of posttraumatic defects of the long bone are complex due to the multiple procedures involved and increased chances of poor outcomes. We present the outcomes of the modified Capanna's technique-a reliable single-stage procedure of combining allograft and free vascularized fibular graft-in treating large posttraumatic bone defects in the distal third of the femur. Study Design This is a retrospective analysis. Materials and Methods Between April 2012 and September 2016, 19 patients with an average age of 33.8 years (range: 18-49 years) and an average defect of 14.5 cm (range: 9.5-20 cm) in the distal femur were managed by the modified Capanna's technique. Bone union time and functional outcome using lower extremity functional score (LEFS) after union were noted. Outcomes and Results Eighteen grafts went onto achieve bony union at an average of 6.6 months (range: 5-9), with an average knee flexion of 80 degrees (range: 45-110 degrees) and an average LEFS of 63 (range: 46-72). One patient had a nonunion with graft resorption at 8 months following persistent infection and was revised with debridement and augmenting the vascularized fibula from the other leg which went on to achieve union. Three patients had superficial infection, and three patients had delayed union. Conclusion The modified Capanna's technique provided increased biology and enhanced structural stability and therefore is a good single-stage procedure in the reconstruction of posttraumatic long-segment defects of the distal femur. Level of Evidence Level 4. Level of Clinical Care Level I tertiary trauma center.

Birth palsy in congenital varicella syndrome: A lesson in anatomy.

While brachial plexus palsy sustained due to birth trauma is well known, congenital palsies are decidedly rare. We report such a case caused by congenital varicella syndrome, with associated congenital Horner's syndrome and heterochromia iridis. The surprising juxtaposition of a classic upper plexus palsy and a Horner's syndrome raises points of interest. Similar reports in literature are reviewed, and the genesis of a very characteristic group of findings is discussed.

Vascularized lymph node transfer from thoracodorsal axis for congenital and post filarial lymphedema of the lower limb.

Vascularized lymph node transfer is becoming a popular method to treat lymphedema. We have performed vascularized lymph node transfer for two patients, one with congenital and the other with post filarial lymphedema of the lower limb. Lymph node transfer was performed from the thoracodorsal axis. Both cases exhibited improved results in both limb circumference and quality of life measurements. J. Surg. Oncol. 2017;115:78-83. © 2016 Wiley Periodicals, Inc.

Primary Index Finger Pollicization for Thumb Reconstruction Following Soft Tissue Sarcoma Excision.

Soft tissue sarcomas in the thumb are rare, but often require amputation to ensure tumour clearance. This can severely impair the use of the entire upper limb and negatively impact quality of life. We describe a 63-year-old male patient with a large malignant fibrous histiocytoma affecting the base of his dominant right thumb. A wide resection of this tumour was performed, followed immediately by index finger pollicization and first web space reconstruction with a reverse pedicled posterior interosseous artery flap. The patient was able to continue using his right hand for functions of daily living and was free from local recurrence until he died from distant metastases 2 years later. Primary thumb reconstruction following amputation for sarcoma can allow a patient to retain useful hand function postoperatively. Provided that strict principles of tumour clearance are adhered to, this need not compromise local recurrence rates.

Tips to orient pedicled groin flap for hand defects.

A groin flap is an axial-patterned cutaneous flap based on the superficial circumflex iliac arteriovenous system, which can provide soft-tissue coverage to defects on any aspect of the hand and the distal two thirds of the forearm. One of the presumed disadvantages of the pedicled groin flap is the discomfort experienced by the patient during the time required before flap division. These disadvantages can be greatly reduced by proper planning to orient the flap toward the defect, avoid any kinking at the base, and increasing the inset. We present our technique of orienting the flap to fit to the defect to be covered with ease. This technique avoids a lengthy flap and tubing, increases the patients comfort, and also makes the division and inset of the flap easier. As described, we have found this method simple and easy to duplicate.