Propeller vs. free fasciocutaneous flap in reconstruction of complex lower limb defects-A prospective study.

BACKGROUND: Of all body regions, lower extremity wounds have been and remain the greatest challenge. Free flaps have been accepted as a reasonable option to solve this dilemma, but they require the complexity of microsurgery. This study aimed to compare the postoperative and clinical outcomes of propeller flap and fasciocutaneous free flap in the reconstruction of complex lower limb defects. MATERIALS AND METHODS: This randomized controlled trial was conducted from July 2021 to June 2023. Selected patients were randomized into two groups: the propeller flap group and fasciocutaneous free flap group. Demographic data, preoperative parameters, and postoperative parameter, including esthetic analysis, scar assessment, neurosensory analysis, psychosocial analysis, and lower extremity function, were estimated and statistically significant compared between the two study groups. RESULTS: Road traffic accident (73.3%) was the most common etiology for lower limb defects in both groups. The foot and lower third of the leg were the most common site of defect, constituting 79.99%. The duration of surgery was significantly shorter in propeller flap as compared to fasciocutaneous free flaps. Flap size was smaller, with better neurosensory improvements in propeller flap group. Esthetic analysis, scar assessment, psychosocial analysis, and lower extremity functional analysis yielded similar results in both study groups. CONCLUSION: Propeller flap has better outcomes compared to free flap in terms of smaller size of flap, shorter duration of surgery, and reduced length of hospital stay. Comparable results were obtained with respect to esthetic score, scar assessment score, psychosocial analysis, and neurosensory recovery and lower extremity functional score.

Innervated vastus lateralis muscle: complementing and completing the anterolateral thigh flap for abdominal wall reconstruction.

Reconstruction of composite abdominal wall defects is challenging. An anterolateral thigh (ALT) flap has established itself in the algorithm for abdominal wall reconstruction. Augmenting innervated vastus lateralis (iVL) muscle to ALT has added advantages. We describe previously unreported advantage of ALT with iVL.A woman in her 30s, suffering from Mullerian adenocarcinoma with metastasis to the right anterior abdominal wall and right inguinal lymph node, was taken for wide local excision and reconstruction. After excision, there was a 15×12 cm defect of the anterior abdominal wall. We reconstructed the defect with prosthetic mesh and pedicled composite ALT and iVL. There was venous congestion in the ALT flap and it could not be salvaged. We debrided the ALT flap and applied split skin graft over iVL. The grafted and donor sites healed well. The patient was able to do moderate strenuous activities. The presence of iVL allowed us to get away with minor procedure and averted the need for another flap.

Takotsubo cardiomyopathy following head and neck surgery: Can the fear of disfigurement be blamed?

Takotsubo cardiomyopathy is accompanied by transitory left ventricular dysfunction without substantial coronary artery disease. A history of acute physical or mental stress typically precedes such a presentation. We want to highlight a case of Takotsubo cardiomyopathy in the early postoperative period in a young female patient who underwent extensive surgery for buccal mucosal carcinoma. The onset of this cardiomyopathy can be ascribed to a fear of disfigurement and prolonged surgical stress.

An Unreported Variation of Origin of Posterior Tibial Artery Encountered During Free Fibula Flap Harvest.

ABSTRACT: Variations in the division of popliteal artery and origin of the 3 vascular systems are well documented. Here, we report a case in which the posterior tibial artery originated from the peroneal artery, in lower leg and then followed the normal course. The anomaly was detected intraoperatively precluding the harvest of free fibula flap. The procedure was abandoned and fibula was fixed using plates and screws and a free radial forearm flap was done over 2 mini-plates, which spanned the bone gap. A second bone flap procedure was to be planned in another sitting.The anomalous origin of posterior tibial artery from the peroneal artery in lower leg did not fall into any of the categories described previously by Kim et al (Ann Surg 1989;210:776-81.). In the event such atypical anatomy is encountered, it must be delineated, and the surgical plan adjusted accordingly. Flexibility in surgical approach can prevent vascular catastrophe.

Schwannoma of Posterior Interosseous Nerve: A Case Report and Review of Literature.

Schwannomas constitute only 5% of tumors of upper limb. Schwannoma of the posterior interosseous nerve is rare. A thorough search of literature revealed only three case reports of this entity. A 33-year old female presented with insidious onset swelling over extensor aspect of right forearm for one year and deficit of extension of fourth and fifth finger for a month. Magnetic Resonance Imaging and Fine Needle Aspiration Cytology were suggestive of low- grade nerve sheath tumor. The tumor was excised under tourniquet control and magnification, using microsurgical technique. Histopathology confirmed schwannoma. Result. Patient regained her full extension of fourth and fifth finger within 1.5 months. As schwannoma does not infiltrate the nerve fibers, so a complete surgical excision is the treatment of choice. We wrote this article to draw clinicians' attention to this unusual entity. Schwannoma of PIN is a relatively rare condition. Till date, there are only three cases reported in literature. Meticulous attention to detail is required while excising large schwannomas, as there is a risk of fascicular injury during dissection. Use of magnification and microsurgical technique prevents inadvertent nerve injury.

An Uncommon Presentation of Constriction Band Syndrome: A Case Report and Review of Literature.

One of the rarer manifestations of constriction band syndrome (CBS) is peripheral nerve palsy. We report a 6-year-old child presenting with motor deficits of the median, ulnar and radial nerves and atrophy of the biceps and brachialis atrophy due to CBS. We were unable to find any similar reports in the literature. He had a constriction ring at the upper arm that had undergone multiple z-plasty by another surgeon. On examination, he had medical research council (MRC) grade 1 elbow flexion, weak flexion of fingers and absent extension of fingers and wrist. We used a pedicled pectoralis major myocutaneous flap to restore elbow flexion and the patient achieved M4 flexion of the elbow. Level of Evidence: Level V (Therapeutic).

A study of the pattern of sensory return in various flaps in different body areas.

Insensate flaps are used in several reconstructions. A search of the literature showed that most studies are limited to particular flaps in specific body areas. There is a lack of uniform scientific data on the pattern of sensory recovery in various body parts for different kinds of flaps. We conducted a prospective observational study for over one year to study the pattern of sensory return in 74 flaps and studied the disparity in the return of sensation of touch, pain, warmth and cold. After that, we analyzed the relationship between sensory return in flaps and the region of the body (head and neck/upper limb/lower limb), type of flap (cutaneous/fasciocutaneous/musculocutaneous), age of patient and type of wound bed (surgically created defect/raw area such as post trauma, post debridement). Touch sensations were assessed by Semmes-Weinstein (SW) monofilament of 5.01 number, pain was assessed using a sterile 26 G needle, cold sensation was assessed using water at 4 °C and warm sensation was assessed using water at 44 °C. The sensations were evaluated at one-fourth and one-half of distance from the periphery to the center, at eight equidistant points along the circumference and at the center of the flap. Sensations were observed to return in the periphery of the flap earlier and in the center later. Touch sensation was recovered the earliest (three months onwards), followed by sensations of pain, warmth and cold (around the sixth month). Flaps performed in the head and neck showed the best recovery of sensation. Best recovery of sensation was observed in cutaneous flaps. Flaps performed on surgically created defects showed better recovery of sensation compared with flaps performed to cover raw areas; however, the differences were statistically nonsignificant. Children showed better recovery of sensations; however, this was not statistically significant. Sensory nerve coaptation is recommended in flaps folded on themselves and in fasciocutaneous flaps of the lower limb.

Studies Directed towards the Synthesis of the Acridone Family of Natural Products: Total Synthesis of Acronycines and Atalaphyllidines.

A modular and flexible three-step synthetic strategy has been developed for the synthesis of acridone natural products of biological significance. The tetracyclic core of acridone derivatives has been achieved efficiently in high yield from commercially available anthranilic acid and phenol derivatives via condensation reaction, followed by regioselective annulation. Acridone alkaloids acronycine and noracronycine are synthesized in improved overall yields in fewer steps than the previously reported approaches. The method has further been used for the synthesis of atalaphyllidine and 5-hydroxynoracronycine in excellent yields for the first time. Moreover, the synthetic utility of the present strategy has been showcased by the synthesis of oxa and thia analogues of acronycine alkaloid.

Divergent and Orthogonal Approach to Carbazoles and Pyridoindoles from Oxindoles via Indole Intermediates.

The previously unexplored Grignard addition to oxindoles provides a regiospecific approach to 2- and 2,3-disubstituted indole derivatives in high yields via a one-pot aromatization driven dehydration pathway. This method allows a convenient preparation of diallyl indoles that are used as ring-closing metathesis (RCM) precursors for the orthogonal synthesis of pyrido[1,2- a]indoles and carbazoles. The synthetic utility of this method is illustrated by the synthesis of a microtubulin inhibitor and naturally occurring carbazole alkaloids.

Gallbladder cancer presenting with brain and bone metastasis: case report.

Although gallbladder cancer is a rare disease worldwide, north India has one of the highest incidences of this disease. We report a case of asymptomatic gall bladder cancer with brain metastasis. The patient presented with a scalp lump as the sole presenting feature, with no symptoms attributable to abdominal malignancy. Previously, the lump had been incised by a local practitioner who had probably misdiagnosed it as an abscess.

Probing the hydrogen equilibrium and kinetics in zeolite imidazolate frameworks via molecular dynamics and quasi-elastic neutron scattering experiments.

The problem of simulating processes involving equilibria and dynamics of guest sorbates within zeolitic imidazolate frameworks (ZIF) by means of molecular dynamics (MD) computer experiments is of growing importance because of the promising role of ZIFs as molecular "traps" for clean energy applications. A key issue for validating such an atomistic modeling attempt is the possibility of comparing the MD results, with real experiments being able to capture analogous space and time scales to the ones pertained to the computer experiments. In the present study, this prerequisite is fulfilled through the quasi-elastic neutron scattering technique (QENS) for measuring self-diffusivity, by elaborating the incoherent scattering signal of hydrogen nuclei. QENS and MD experiments were performed in parallel to probe the hydrogen motion, for the first time in ZIF members. The predicted and measured dynamics behaviors show considerable concentration variation of the hydrogen self-diffusion coefficient in the two topologically different ZIF pore networks of this study, the ZIF-3 and ZIF-8. Modeling options such as the flexibility of the entire matrix versus a rigid framework version, the mobility of the imidazolate ligand, and the inclusion of quantum mechanical effects in the potential functions were examined in detail for the sorption thermodynamics and kinetics of hydrogen and also of deuterium, by employing MD combined with Widom averaging towards studying phase equilibria. The latter methodology ensures a rigorous and efficient way for post-processing the dynamics trajectory, thereby avoiding stochastic moves via Monte Carlo simulation, over the large number of configurational degrees of freedom a nonrigid framework encompasses.

Single electron tunneling in large scale nanojunction arrays with bisferrocene-nanoparticle hybrids.

We report on the fabrication and single electron tunneling behaviour of large scale arrays of nanogap electrodes bridged by bisferrocene-gold nanoparticle hybrids (BFc-AuNP). Coulomb staircase was observed in the low temperature current-voltage curves measured on the junctions with asymmetric tunnel barriers. On the other hand, junctions with symmetric tunneling barrier exhibited mere nonlinear current voltage characteristics without discrete staircase. The experimental results agreed well with simulations based on the orthodox theory. The junction resistance showed thermally activated conduction behaviour at higher temperature. The overall voltage and temperature dependent results show that the transport behaviour of the large arrays of single particle devices obtained by a facile optical lithography and chemical etching process corresponds with the behaviour of single particle devices fabricated by other techniques like e-beam lithography and mechanical breaking methods.

Dilated cardiomyopathy following trastuzumab chemotherapy.

The war against cancer has seen a proliferation in armamentarium over the last decades. A new antineoplastic agent, trastuzumab, was synthesized in 1991 and gained United States Food and Drug Administration approval in 1998 for treatment of metastatic breast cancer. Cardiotoxicity manifesting as dilated cardiomyopathy is a rarely reported adverse effect of trastuzumab. We hereby report a case of dilated cardiomyopathy, which occurred following trastuzumab chemotherapy in a 32-year-old female. The patient responded to discontinuation of trastuzumab and standard medical treatment. Extensive search of Indian literature revealed no reported case of dilated cardiomyopathy occurring due to trastuzumab.

Bilateral hemorrhagic pleural effusion due to kerosene aspiration.

Kerosene ingested, intentionally or accidentally, is toxic. Data is scarce on complications and outcomes of hydrocarbon poisoning following kerosene aspiration in adults and there has been no known case of bilateral hemorrhagic effusion occurring due to it in literature. We, hereby, report a case of a bilateral hemorrhagic pleural effusion secondary to hydrocarbon aspiration in a 40-year old adult.