Superficial Circumflex Iliac Artery Free Flap for Coverage of Hand Injuries.

Open de-gloving hand injuries with exposed tendons and bones require coverage by a flap. Conventionally used groin or abdominal flaps are cumbersome to patients due to extensive dressing and prolonged passive positioning of the hand until pedicle division. Superficial circumflex iliac artery (SCIA) flap is evolved from a traditional groin flap, and because of its thinness, pliability, and concealed donor site, it is an ideal option for single-stage reconstruction of traumatic hand defects avoiding discomforting passive hand position, joint stiffness, and unexpected flap avulsion which were associated with traditional groin flap. All patients with exposed bones or tendons due to traumatic hand injuries who opted for free flap coverage during the year 2018 to 2020 were enrolled in our study. After initial debridement, the wound was covered with a free SCIA flap. Duration of hospital stay, days out of work, the number of dressings required, postoperative complications, and any secondary procedures for flap readjustment were noted till six months postoperatively. A total of eight patients were included in the study. The mechanism of injury was road traffic accidents in a single patient and occupational injury in eight patients. The average duration of hospital stay was six days after reconstructive surgery. The average number of dressings a patient had was 18, and only two patients required flap thinning. Only one patient had a postoperative infection which was managed with dressings and antibiotics. One patient had peripheral flap necrosis. We had zero flap re-exploration. Therefore, we conclude that hand defects coverage with SCIA flap leads to a smaller number of working days lost and rarely requires secondary procedures.

Comparison of Anterior vs. Dorsal Approach for Spinal Accessory to Suprascapular Nerve Transfer in Patients With a Brachial Plexus Injury and Its Outcome on Shoulder Function.

Background Brachial plexus injuries are frequently encountered in the domain of plastic surgery, mostly secondary to road traffic accidents, gunshot injuries, or falls from a height. Many modalities have been described in the management, depending on the level and duration of the injury. C5, C6 and C5, C6, C7 are two common patterns in which nerve repair and transfers are described. At our center, we practice spinal accessory to suprascapular nerve transfer in all patients with upper trunk brachial plexus injury. There are two described approaches for the spinal accessory nerve to suprascapular nerve transfer, i.e. anterior or dorsal. The rationale for doing the posterior approach is that this approach avoids damaging the suprascapular nerve at its entrance in the suprascapular notch under the suprascapular ligament during exploration due to traction. Materials and methods This is a retrospective study with a consecutive sampling of 23 patients presenting at Liaquat National Hospital, Karachi, with upper trunk brachial plexus injuries during the time period from January 2016 to December 2017, i.e. two years. We divided these 23 patients into two groups, one with the anterior approach and the other with a dorsal approach for spinal accessory to suprascapular nerve transfer for shoulder abduction. The mean duration of post-surgical follow-up was from 18 to 24 months and recovery and functional outcomes were assessed. Results Out of the 23 patients that were included, 10 patients were operated on with an anterior approach and 13 with a posterior approach. Fifty percent (50%) of patients operated with the anterior approach and 84% of patients with the posterior showed the best motor grade recovery of M4, respectively, with better performance in patients with the posterior approach as compared to the anterior approach. Conclusion We advocate taking a posterior approach for spinal accessory to suprascapular nerve transfer for shoulder abduction, as it has shown better results with reliable outcomes concerning shoulder abduction, angle of abduction, and range of motion.

Ptosis Correction: Our Modification and Experience.

Background Congenital ptosis not only results in an asymmetric facial appearance but can lead to permanent visual disturbances if not addressed at an appropriate time. Crawford used fascia lata for suspension of the eyelid to frontalis muscle, which remains a standard procedure for congenital ptosis correction to date, with an acceptable recurrence rate due to graft slippage. There are many modifications in this technique to reduce this complication; hence, in this study, we share our experience of a modification to improve the outcomes. Methodology This retrospective study was conducted at a private tertiary care hospital in Karachi for 10 years. In total, 26 patients fulfilled our inclusion criteria. All patients underwent a modified Crawford's procedure under general anesthesia. Results In this study, the male-to-female ratio was 1:1.5. In total, 17 (65%) patients had unilateral ptosis. The mean age of presentation was 7 ± 3 years. All of our patients had poor levator function (<5 mm excursion) with a mean of 3 mm and mean grade of ptosis of 4 ± 1.6 mm. The mean preoperative marginal reflex distance (MRD) was +1.8 ± 0.6 mm. In this study, the patients had a mean postoperative MRD of 4.2 ± 0.7 mm at the four-week follow-up. Conclusions Although Crawford's procedure gives promising results for ptosis correction, suturing the fascial sling to the tarsal plate ensures good anchorage and prevents relapse.

Our Experience With the Correction of Prominent Ear Deformity.

The ear has a unique architecture of cartilage and skin. The incidence of the prominent ear is about 5%. Surgical correction of the prominent or protruding ear can be carried out either by anterior or posterior approach. We created antihelical fold of cartilage by utilizing a posterior incision to score the anterior cartilage of the lateral scapha with a knife. Sutures were often used to uphold the produced fold. The additional procedure of conchal reduction and concho-mastoid suture was done when required. The objective of our research is to evaluate the patient's and surgeon's satisfaction with our technique of prominent ear correction and identify any complication if it occurs post-operatively. This is a retrospective study over a period of eight years (2011-2018) which includes all patients presented to Liaquat National Hospital with prominent ear. A total of 47 patients were included. Patients with a previous history of otoplasty were excluded. Patients were followed up for at least six months postoperatively. The outcome was assessed via Visual Analogue Score by a patient, surgeon, and a third observer (assessor). The average score by the surgeon was 7.9, by the patient it was 8.4 and by the assessor it was 8.1. The average pre-operative concho-mastoid distance was 2.2 cm which decreases to 1.4 cm post-operatively. Correction of the prominent ear by this technique is safe and easy. We did not experience any major complication, giving reproducible and good aesthetic results.

Tibialis Posterior Transfer for Foot Drop: The Difference in Outcome for Two Different Attachment Sites.

Introduction Common peroneal nerve injury leading to foot drop is of multifactorial etiology. The goal is to restore a normal toe-heel gait. Various static or dynamic surgical options are being performed. Among all, tendon transfer is the most commonly performed procedure with its different dorsal attachment sites on the foot i.e. tendon to bone or tendon to tendon transfer. The objective of our study was to evaluate the outcomes of two methods of transfer in terms of attachments sites on functional outcomes. Materials and methods In a retrospective study conducted at Liaquat National Hospital Karachi, a total of 38 patients were included. All of them were operated upon for foot drop from June 2015 to May 2018. A total of 32 patients showed up for the follow-up, 17 patients underwent tibialis posterior transfer with attachment on the second metatarsal and 15 on the tibialis anterior tendon. Functional outcome was assessed by grading of active foot dorsiflexion at six months and at the time of the study by and categorized as excellent, good, moderate, and poor. Results Most of the patients in both groups were male, and the mechanism of injury was penetrating trauma. At six months post-operatively, the majority of the patients in both groups showed excellent to good category of active dorsiflexion. At the time of the study (mean 34.4 months postoperatively) patients with insertion at second metatarsal were found to have active dorsiflexion as: excellent: 6 (35.3%), good: 8 (47.1%), moderate: 3 (17.6%), and for insertion at Tibialis Anterior tendon: excellent: 1 (6.7%), good: 6 (40.0%), moderate: 6 (40.0%) and poor: 2 (6.2%). These results were compared using the chi-square test and it was found to be statistically significant (p-value: 0.016). Conclusion Insertion at second metatarsal gives more favorable results as compared to insertion at tibialis anterior with balanced dorsiflexion.

The Application of Buccal Fat Pad to Cover Lateral Palatal Defect Causes Early Mucolization.

Introduction Cleft lip and cleft palate are among the most common birth defects. These deformities lead to profound psychosocial and functional effects on cleft palate patients. Several surgical techniques have been described for the repair of the cleft. The defects lateral to mucoperiosteal flaps closure are sometimes covered with sterile gauze soaked with soft paraffin or tincture of benzoin or are left open for mucolization by means of secondary intention. The buccal fat pad (BFP) is used as a pedicled graft to cover the exposed bone of the lateral palatal defect, and it is associated with proposed benefits of early healing and fewer effects on transverse growth of the maxilla. Materials and methods This was a prospective study involving 42 cleft palate patients who underwent cleft palate repair; 21 patients received BFP as an additional step to cover lateral palatal defect while the rest of the patients (n=21) underwent conventional surgical cleft palate repair and the defect was covered with Surgicel (Ethicon, Inc., Bridgewater, NJ). Postoperative follow-up was conducted at first, second, and third weeks postoperatively to assess the time required for mucolization. Results Our cohort of 42 patients included an equal number of complete and incomplete cleft palate patients. Follow-up at the first postoperative week showed an equal number (n=21, 100%) patients with incomplete mucolization on both groups, while at the second postoperative follow-up, only one (4.8%) of the patients who underwent conventional cleft palate repair had complete mucolization while 20 (95.2%) among the patients who underwent BFP had complete mucolization. At the third-week postoperative follow-up, three (14.3%) patients from the conventional group had complete mucolization, while 18 (85.7%) had incomplete mucolization. Only two patients (4.8%) developed recipient area complications, and they were managed conservatively. Conclusion BFP is a good source of vascularized tissue to cover the hard palate bones after primary cleft repair. It is easy to harvest as a local tissue with a low learning curve. The epithelialization rate is faster than conventional methods with minimal complication rates.

Comparison of Kirschner Wire Versus Screw Fixation in 1,2 Inter-Compartment Supra Retinaculum Artery Pedicle-Vascularized Bone Graft for Scaphoid Fractures.

INTRODUCTION: The purpose of the study was to compare the outcomes of the Kirschner wires (k-wires) versus screw fixation in 1,2 inter-compartment supra retinaculum artery (ICSRA) pedicle-vascularized bone graft for scaphoid non-union treatment. METHOD: A retrospective study that included all patients with scaphoid nonunion underwent pedicle-vascularized bone graft and fixated with either k-wire or screw from 2010 through 2019 in the Department of Plastic and Reconstructive Surgery at Liaquat National Hospital and Medical College. Clinical outcomes were compared between k-wire and screw fixation, which were measured in terms of union rate, time of healing, pre and post-operative Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion at wrist, and grip strength of hand. RESULTS: A total of 33 patients were included in the study. All of them had scaphoid non-union and were treated with 1,2 ICSRA pedicle-vascularized bone graft; 20 patients had a fixation with k-wire and 13 with a screw. Radiological healing was achieved in 18 patients with k-wire and 11 patients with screw fixation, with healing rates of 90% and 84.6%, respectively. There was a significant decrease in DASH score postoperatively in both groups. Although no significant difference between the outcomes of both groups whether on union rate, DASH score, or range of motion at the wrist. CONCLUSION: Hence, there is no significant difference in outcome between k-wire and screw fixation methods. We concluded k-wire as a more acceptable option with vascularized bone graft fixation as less technically demanding and low cost as compared to screw fixation.

Metacarpal Fractures, Management Techniques, and Outcomes in Our Center.

Introduction/background Metacarpal fractures comprise approximately 35.5% of cases in daily emergencies, mostly due to road traffic accidents (RTA), fall, and assault. The classification is based on the site and pattern of fracture. High-level evidence is lacking for the management of metacarpal fractures. The primary goals of treatment are to achieve acceptable alignment, stable reduction, strong bony union, and unrestricted motion. It can be managed by non-operative methods like close reduction and splintage. Operative management will be required if there is shortening, rotation, and angulation in different planes including close reduction and fixation with percutaneous intramedullary pining/k-wires and open reduction and fixation with screws, plates (compression/locking), and external fixators. This study was done to compare the efficacy of k-wire, screws, and plates in the management of metacarpal fractures and their outcomes based on their union, postoperative pain, range of movement, and grip strength in a tertiary care center, i.e., Liaquat National Hospital and Medical College. Methods It was a retrospective study conducted at the Department of Plastics and Reconstruction Surgery, of a tertiary care hospital. A total of 113 patients who were operated upon for metacarpal fracture were included in the study (open/close) without soft tissue loss or tendon injury, were divided into three groups according to the technique of fracture fixation, i.e., group 1 (k-wire), group 2 (screw), and group 3 (plates). The data like post-operative pain (visual analog scale, VAS) and radiological evidence of union were extracted from the registry. All the patients were called for follow-up in the outpatient department. Out of 113, 97 patients showed up for follow-up and were examined by a hand surgeon, and range of movement (goniometer) and grip strength (sphygmomanometer method) were assessed. Results A total of 97 patients were included in the study (male 66%, female 34%). Group 1 (K-wire) includes n = 61 (62.9%), group 2 (screw) n = 15 (15.5%), and group 3 (plate) n = 21 (21.6%). The mean follow-up time was 12 + 2 weeks after the surgery for post-operative pain and radiological evidence of union while 24 + 6 months for a range of movement and grip strength. Less post-operative pain was noted in group 1 patients while no significant difference was noted in the evidence of radiological union in all groups. Range of movement was better in group 1 patients (89.74 + 0.750) than in group 2 (80 + 0.37°) or group 3 (80.2 + 0.62°). The grip strength (compared to the normal contralateral hand) was normal in the majority of the patients in group 1, i.e., 94% while it was 80% in group 2 and 82% in group 3. Conclusion The significance of these reported findings suggests that open reduction and internal fixation with screw or plate might be a less preferable surgical technique in comparison to k-wire fixation in the treatment of a metacarpal fracture.

Comparison of the Interrupted and Continuous Suture Techniques for the Closure of Oral and Nasal Mucosal Layers in Cleft Palate Surgery.

Background Cleft lip and palate are common congenital craniofacial anomalies, treated conventionally by surgery at the ages of six to 18 months. Mostly, the interrupted suture technique is used to close the nasal and oral layers of the palate. In some studies, the interrupted suture technique was compared with continuous suture techniques for the closure of oral and nasal layers and found that there was less utilization of time and suture materials in the continuous technique. This study was designed to see the outcomes of interrupted versus continuous suture techniques. Materials & methods A total of 36 patients were included in the study and were divided into two groups according to the type of suturing technique. The time utilized for the repair of the oral and nasal layers of the cleft palate, the number of suture packs utilized, and the incidence of fistula formation were noted and compared between the two groups. Out of 36 patients, 17 were included in group A (operated by interrupted techniques), and 19 were included in group B (operated by the continuous technique). Results The mean time taken to close nasal layer in Group A was 18.12 ± 1.16 minutes and in Group B was 8.37 ± 0.89 minutes (p-value < 0.001), whereas for oral layer closure, it was 14.00 ± 1.17 minutes in group A and 6.00 ± 0.57 minutes in group B (p-value < 0.001). The average usage was 2.26 ± 0.45 suture packs for repair with the continuous technique and 4.00 ± 0.35 suture packs when repaired via interrupted stitches. There was no difference noted in postoperative outcomes in both groups in terms of postoperative fistula and wound dehiscence. Conclusion A continuous suture technique for closing the oral and nasal layers in patients with cleft palate is recommended, as it is more beneficial in terms of time, cost-effectiveness, and utilization of suture material.