An objective functional evaluation of the flexor carpi ulnaris set of triple tendon transfer in radial nerve palsy.

This study reports an objective assessment of postoperative function of 11 triple transfers for high radial palsies, using pronator teres for wrist extension, flexor carpi ulnaris for finger extension and palmaris longus for thumb extension. The mean follow-up was 3.3 years. Assessment was done by recording the active ranges of wrist motion, grip strength, wrist and finger strength and work simulation. The mean strength and range of wrist extension were 42% and 86%, respectively, of the contralateral wrist. Other measured movements were within the functional range and work simulation confirmed good restoration of function. The mean DASH score was 3.45, with no patient reporting any specific functional complaints. This study shows that even though the range of wrist motion and the strength of the wrist and fingers are less than normal, hand function remains good. We conclude that the flexor carpi ulnaris set of tendon transfer works well. LEVEL OF EVIDENCE: 3.

Ganga hospital open injury score in management of open injuries.

INTRODUCTION: Open injuries of the limbs offer challenges in management as there are still many grey zones in decision making regarding salvage, timing and type of reconstruction. As a result, there is still an unacceptable rate of secondary amputations which lead to tremendous waste of resources and psychological devastation of the patient and his family. Gustilo Anderson's classification was a major milestone in grading the severity of injury but however suffers from the disadvantages of imprecise definition, a poor interobserver correlation, inability to address the issue of salvage and inclusion of a wide spectrum of injuries in Type IIIb category. Numerous scores such as Mangled Extremity Severity Score, the Predictive Salvage Index, the Limb Salvage Index, Hannover Fracture Scale-97 etc have been proposed but all have the disadvantage of retrospective evaluation, inadequate sample sizes and poor sensitivity and specificity to amputation, especially in IIIb injuries. METHODS: The Ganga Hospital Open Injury Score (GHOIS) was proposed in 2004 and is designed to specifically address the outcome in IIIb injuries of the tibia without vascular deficit. It evaluates the severity of injury to the three components of the limb--the skin, the bone and the musculotendinous structures separately on a grade from 0 to 5. Seven comorbid factors which influence the treatment and the outcome are included in the score with two marks each. The application of the total score and the individual tissue scores in management of IIIB injuries is discussed. RESULTS: The total score was shown to predict salvage when the value was 14 or less; amputation when the score was 17 and more. A grey zone of 15 and 16 is provided where the decision making had to be made on a case to case basis. The additional value of GHOIS was its ability to guide the timing and type of reconstruction. A skin score of more than 3 always required a flap and hence it indicated the need for an orthoplastic approach from the index procedure. Bone score of 4 and 5 will require complex reconstruction procedures like bone transport, extensive bone grafting or free fibular graft. Regarding the timing of reconstruction, injuries with a score of 9 or less indicated a low violence trauma and were amenable for early soft tissue reconstruction whereas injuries with a score of 10 or more indicated high violence injuries where a staged reconstruction policy must be followed. CONCLUSIONS: Ganga Hospital Open Injury Score was found to be highly useful in decision making regarding salvage in IIIB injuries. The individual tissue scores were also useful to provide guidance regarding the timing and type of bone and soft tissue reconstruction.

Reconstruction of post-traumatic long segment bone defects of the lower end of the femur by free vascularized fibula combined with allograft (modified Capanna's technique).

PURPOSE: Salvage of long segment bone loss in the limbs particularly near the joints continues to be a challenge to the trauma surgeon. None of the techniques available are universally successful and all share the disadvantages of multi-staged procedures. A reliable single-stage technique would be ideal to reduce the treatment time and the cost of care. We are presenting here our experience of successfully using the modified Capanna technique of combining allograft and free vascularized fibular graft in treating large bone defects in the distal third of the femur. METHODS: Between April 2012 and October 2013, six patients with post-traumatic long segment bone loss in the distal femur had reconstruction of the bone defect by the Capanna technique. The average age was 33 years (range of 18-49 years). The bone defect ranged from 10 to 20 cm (average 15 cm). Five patients had primary reconstruction while one was done after allograft failure. Bone union time and occurrence of any complications were noted. Follow-up ranged from 7 to 24 months (average 15 months). RESULTS: All grafts went onto union. No patient required secondary procedure to achieve union. Average time to union was 6 months. One patient had deep infection and delayed union of distal end of the fibula graft. CONCLUSION: Free vascularized fibular graft combined with allograft increases initial stability, allows early weight bearing, has higher chances of union and is a good single-stage technique of reconstruction of distal third femur defects.

Free-flap cover of complex defects around the knee using the descending genicular artery as the recipient pedicle.

BACKGROUND: Selection of ideal recipient vessels is one of the most important factors determining success in free-flap reconstruction of the lower limb. At the knee, the choice of vessels has traditionally been either the common femoral or the popliteal vessels and their branches but these are often difficult to use or cannot be used. METHODS: A series of 32 free flaps for cover of complex injuries of the knee involving the distal femur, the knee joint and the upper tibia were reconstructed using the descending genicular branch of the femoral artery in the adductor canal and its muscular branches to the vastus medialis as the recipient vessels. RESULT: All but one flap survived with no major complications. CONCLUSION: The use of the descending genicular artery as the recipient vessel for reconstruction with free flaps around the knee has various advantages including: (i) it is mostly remote from the zone of trauma, (ii) it is constant in location, (iii) the recipient vessels are an excellent size match for end-to-end anastomosis, (iv) there is no need for changes of position of the patient when using most free flaps commonly used for knee reconstruction, (v) it is easy to harvest these simultaneously, (vi) secondary exposure of the underlying skeleton from all quadrants is unlikely to divide the flap pedicle as it is superior and (vii), perhaps most important of all, it obviates the need for exploration of the popliteal fossa.

The relation of patient satisfaction and functional and cosmetic outcome after correction of the wrist flexion deformity in cerebral palsy.

Wrist flexion deformity in cerebral palsy is treated with flexor carpi ulnaris to extensor carpi radialis brevis transfer. The aim of the study was to assess the outcome of this procedure and analyse the determining factors for patient satisfaction. Fifteen patients were reviewed after a mean follow-up of 23 months. The functional and cosmetic outcome and patient satisfaction were evaluated using patient rated scales. There was a strong and significant correlation between the cosmetic outcome and patient satisfaction, but there was no significant correlation between functional improvement and patient satisfaction. When analysing the cosmetic outcome in relation to the time since surgery, there was a decrease in the patient rated improvement over time. It seems that patient satisfaction is mainly determined by the cosmetic result, but the improvement, or the perception of it, tends to diminish over time. Fourteen out of 15 patients felt that the procedure was worthwhile and eight of them felt that the result was good or excellent.

Immediate primary skin closure in type-III A and B open fractures: results after a minimum of five years.

Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded. At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion. Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.

Primary bone grafting with pedicled flap cover for dorsal combined injuries of the digits.

Twenty digits in 15 patients with dorsal combined tissue loss were treated by radical debridement, primary non-vascularised iliac crest bone graft and immediate lower abdominal flap cover between 1996 and 2006. The average length of the bone grafts was 3.3 (range 2.5-5) cm. No extensor tendon reconstruction was carried out. The flaps were divided at 3 weeks without delay. Permissible thinning of the flap was done at the time of division of flaps. No secondary procedure was done. All patients were retrospectively reviewed and X-rays obtained. Radiological union was achieved in 18 of 20 digits. One bone graft was removed because of infection. One bridging bone graft united with the distal phalanx but had a painless non-union with the proximal phalanx. There were no flap complications. Bone graft length resorptions of 20% and 15% occurred in two terminal bone grafts. We recommend this protocol as a solution to this challenging problem.

Functional evaluation of a great toe transfer and the osteoplastic technique for thumb reconstruction in the same individual.

Since the popularization of microvascular toe transfer, there has been a tendency to relegate osteoplastic reconstruction techniques for the thumb to history. A case is presented which shows that a successful and well-planned osteoplastic thumb reconstruction can match microsurgical reconstruction in all functional activities. Cosmetically, the toe transfer is the better reconstructive option but it may cause significant donor site morbidity.

'Jumping' cross finger flaps: a useful technique for salvaging parts in mutilating hand injuries.

In multi-digital injuries, soft tissue from non-adjacent injured fingers, which would have otherwise been discarded, can be used to cover small defects in salvageable digits. This was found useful in the salvage of four digits and one thumb. Anticipation of the need for a flap cover, and the possible availability of tissue in non-adjacent digits, is of paramount importance during the planning process in these injuries. This technique of using 'jumping' cross finger flaps is a useful method, when dealing with multiple finger mutilations that need soft tissue cover.

Evaluation of sympathetic control of digital blood flow.

A noninvasive strain-gauge method of measuring blood flow in the digit was used to assess the influence of the sympathetic system in the digit. The sympathetic system was stimulated by the sudden application of ice to the neck, thus avoiding in the hand local reflexes and responses to cold. Seventeen normal subjects responded in similar fashion. Maximum flow reduction ranged from 26% to 92%, with a mean of 61%. This method should be useful diagnostically and for research when sympathetic reactivity, in contrast to basal sympathetic tone, needs to be determined.

Revascularization of a finger with a thenar mini-free flap.

A devascularized index finger with a soft tissue defect on its palmar side was managed by using a small free flap raised at the level of the metacarpophalangeal joint of the thumb. The radial digital artery was included in the flap and used to revascularize the index finger, and a palmar vein was used to drain the flap. This resulted in minimal donor side morbidity.

Pedal macrodactyly treated by digital shortening and free nail graft; a report of two cases.

Two cases of macrosyndactyly of the foot are reported which were successfully treated by shortening of the affected digits and free nail grafting.