Duragen: A dermal substitute for the management of suboptimal wounds.

Using a flap in a large wound with a very small area of exposed vital structures may be an excessive intrusion and cause unnecessary donor site morbidity. Dermal matrix (DuraGen) was applied onto critical areas where bone or tendons were exposed and a split skin graft was placed thereon. All patients had satisfactory wound closure without the need for a flap. DuraGen appears to be a safe, single-stage alternative, to a flap for the healing of complex wounds.

Delayed revascularization of extremities following vascular injuries: Challenges and outcome.

Purpose: In developing countries delayed presentation following major vascular injury is common due to limited vascular trauma units; delay in diagnosis and time lost in transit which pose a major challenge for limb salvage. Aim of this study was to assess limb survival and complications after delayed revascularization of extremity following major vascular injury. Method: 20 patients, (19 males and 1 female, mean age 31.55 years) with major extremity vascular injury who presented >8 h after vascular trauma were included in this study. All patients had road traffic accidents as the cause of extremity injury. These patients were operated by primary vascular repairs, thrombectomy and/or interposition vein graft along with fixation of concomitant skeletal trauma. Results: The commonest vessel injured was popliteal artery. The mean time of limb revascularization was 30.8 h. Limb salvage rate was 95% and there was no perioperative mortality. 9 patients developed postoperative complications including sloughing of leg muscles (4), foot drop (3) pseudo aneurysm (1) and reperfusion injury (1). At 6 months follow-up all the patients were able to walk with full weight bearing and there was no chronic ischemia, pain or sinuses. Conclusion: Limb salvage can be achieved with good results in patients with delayed revascularization in selected cases. However; delayed revascularization leads to long and protracted postoperative course with high chances of vascular and neurological complications.

A Technique of Immobilization of Digits by Spinal or Intracath Needle Following Soft Tissue Surgery.

After release of post burn flexion contracture and repair of soft tissue injury of digits, it is desirable to maintain the digits in full extension. This is conventionally done by insertion of Kirschner wires across the interphalangeal or metacarpophalangeal joints. We have been inserting a spinal or intracath needle in a dorsal supra-periosteal plane for immobilizing digits after release of post burn contractures or repair of soft tissue injury. The needle is maintained for 2-3 weeks, and all patients achieved stable immobilization of digits. There were no major complications. This procedure is minimally invasive, simple to perform, and provides stable immobilization. Level of Evidence: Level V (Therapeutic).

Erratum to: Double Rectangle Fascia Lata Frontalis Sling: A Rationale Approach for Ptosis.

[This corrects the article DOI: 10.1055/s-0041-1723909.].

Arteriovenous supercharging: A novel approach to improve reliability of the distally based sural flap.

Complex soft-tissue defects of the distal third of the leg, foot and ankle with exposed bones/joints, tendons and implants need a flap for their closure. Distally based sural flap is commonly used, but it has a high partial necrosis rate due to venous insufficiency. We addressed this issue with AV supercharging by dorsalis pedis artery with short saphenous vein. Eight patients (seven males, mean age 34.12 years) with post traumatic lower limb defects over heel and foot were included. All flaps survived and healed although four flaps developed superficial partial epidermolysis. Average healing time was 20.12 days. Closure of the AV fistula was not required in any of the patients. At mean follow-up of two months, all patients were ambulatory with well settled flap. Arteriovenous supercharging of distally based sural flap through short saphenous vein improves the distal arterial perfusion in the flap and prevents distal flap necrosis.

Double Rectangle Fascia Lata Frontalis Sling: A Rationale Approach for Ptosis.

Background The purpose of this study was to evaluate the functional outcomes of a modified technique of double rectangle pattern for correction of severe ptosis. Methods This is a retrospective study over a period of 8 years including patients who underwent correction of ptosis by double rectangle using autologous fascia lata sling. Surgical outcomes were assessed postoperatively by distance from the corneal light reflex to the upper eyelid margin (MRD1) and levator function. Results Twenty-six eyelids were operated in 20 patients. There were 9 males and 11 females, with age ranging from 4 to 35 years. Preoperatively, all patients had poor MRD1 and poor levator function. Postoperative MRD1 was good in 13 patients (17 eyelids), fair in 5 (7eyelids), and poor in 2 patients (2 eyelids). Postoperative levator function was excellent in 12 patients (15 eyelids), good in 6 (9 eyelids), and fair in 2 patients (2 eyelids). At a mean follow-up of 12 months, adequate correction was achieved in 24 eyelids, and 2 eyelids had undercorrection. Conclusion Frontalis sling with a double rectangle is simple and more efficient, as it provides a straight line of pull to the eyelid for correction of severe ptosis.

Simple Indigenous Two-Point Discrimination Testing Device.

BACKGROUND: Measurement of two-point discrimination (2-PD) is used in clinical practice to evaluate the severity of nerve injuries, neuropathy, and recovery of patients following nerve repair. Commercially available 2-PD testing devices are costly and therefore not available everywhere. METHODS AND MATERIAL: We made an economical indigenous 2-PD testing device from off-the-shelf components and tested its efficacy in volunteers. STATISTICAL ANALYSIS: The data were analyzed using Minitab Statistical Software Version 17.0 and Kappa statistics were used in the assessment of agreement between two devices. RESULTS: A total of 30 (23 men, 7 women) subjects were included in the study. There was good agreement between the measurements of static 2-PD with the two different test devices: from fair (Kappa = 0.408, P = 0.018) to strong (Kappa = 0.618-0.795, P = 0.000). CONCLUSIONS: This device is simple to make, very economical, and obtains accurate 2-PD measurements.

Saphenous nerve to posterior tibial nerve transfer: A new approach to restore sensations of sole in diabetic sensory polyneuropathy.

BACKGROUND: Loss of sensations in the sole following diabetic sensorimotor polyneuropathy (DSPN) leads to diabetic foot ulcers and its sequelae. We hypothesized that sensory reinnervation of sole by transfer of saphenous nerve (SN) to sensory fascicles of posterior tibial nerve (PTN) in these patients may reverse the neuropathy. METHODS: This prospective interventional case series included patients with advanced DSPN and intact sensory supply of SN. PTN was neurotized by transfer of SN nerve in the tarsal tunnel and postoperatively sensations of the sole were tested. Any existing ulcers on sole were noted and their healing was monitored. FINDING: A total of 17 patients (22 feet), 9 male and 8 female, were included. Seven patients had ulcers in the feet. At 6 months follow-up all patients developed protective sensation in the sole. The average 2 PD improved from 60 mm to 45.5 mm, average vibration perception improved from 34.12 V to 24.33, Medical Research Council (MRC) score improved from S0 in 12 feet and S1 in 10 feet to S3+ in 13 feet, S3 in 5 feet, and S2 in 2 feet at 6 months along with healing of ulcers in all 7 feet. INTERPRETATION: Transfer of SN to PTN for sensory neurotization is an innovative and simple option to prevent complications of DSPN. This procedure has the potential to change the natural history of DSPN.

Perforator-based propeller flap for coverage of lower leg: Single centre experience.

This study was conducted to assess outcomes of propeller flaps for reconstruction of small- to medium-sized defects in the distal third of the leg. Of 53 lower third leg defects covered using the propeller flap, 43 survived without complications. Only minor complications were seen and no flap was lost completely. The propeller flap is thus a safe option for medium-sized defects of the lower leg.

In-growing toe nail results of segmental matrix excision.

INTRODUCTION: In-growing toenails commonly affect young men hampering the quality of life. There are many methods to treat in-growing toe nail but most of them have high recurrence rates and poor patient satisfaction. We describe our results of segmental matrix excision for correction of ingrowing toe nails. MATERIAL AND METHODS: It is a retrospective study over a period of 2 years. Patients with symptomatic in-growing toe nails with stage II and III were operated by technique of segmental matrix excision. All patients were available for follow-up at ∼1 year. RESULTS: 90 patients, 59 males and 31females with ingrowing nail of great toe (108 toes and 120 surgical sites) that underwent correction of by segmental matrix excision. Patient's age ranged from 19 to 59 years. There was involvement of right great toe in 42 patients, left great toe in 30 patients and bilateral toes in 18 patients. 12 great toes were affected on both sides (74 lateral sides and 46 medial sides of toes). 15/90 (16.6%) patients had history of previous failed surgery by nail plate avulsion. Complications include bleeding (n = 1), infection (n = 2). On average follow up of ∼1 year, there was only 1 recurrence. There was no loss of cutaneous innervation or osteomyelitis. All patients went back to their normal activity on 10th day. CONCLUSION: Segmental matrix excision should be considered as the treatment of choice for ingrowing toe nail because of high cure rate, less pain, low risk of postoperative infection, and results in good cosmetic result.

Anatomical feasibility of anastomosing intercostal nerves (D10&D11) and subcostal nerve (D12) to S2 ventral root and lumbar plexus for management of bladder function after spinal cord injury.

OBJECTIVE: The transfer of peripheral nerves originating above the level of injured spinal cord into the nerves/roots below the injury is a promising approach. It facilitates the functional recovery in lower extremity, bladder/bowel and sexual function in paraplegics. We assessed anatomical feasibility of transfer of lower intercostal nerves to S2 ventral root in human cadaver for management of neurogenic bladder dysfunction in patients with spinal cord injury. METHODS: Study was performed in five formalin fixed cadavers. Cadavers were placed in prone position. A transverse incision was made along 11th ribs on both sides and 10th, 11th Intercostal nerves (ICN) and subcostal nerve were harvested up to maximum possible length. In four cadavers the ventral root of S2 was exposed by endoscope and in one by the standard open laminectomy. Intercostal nerves were brought down to lumbo-sacral region, S2 ventral root was cut cranially and feasibility of intercostal to S2 anastomosis was assessed. RESULTS: The mean length of intercostal nerves was 18.4 cm for the 10th 19.5 cm for the 11th and 22.15 cm for the subcostal nerve. The length of harvested nerve and the nerve length necessary to perform sacral roots neurotization were possible in all cases by only by subcostal nerve while T11 and T10 ICN fall short of the required length. CONCLUSION: For Spinal cord lesions located at the conus, subcostal nerve could be connected to ventral root of S2 in an attempt to restore bladder function while 10th and 11th ICN had enough length to neurotize lumbar plexus.

Outcome of tendon transfer for radial nerve palsy using Flexor Carpi Radialis combination (Brands transfer).

INTRODUCTION: -Loss of radial nerve function leads to severe weakness of grip and tendon transfer is considered the standard treatment. However; there is continuing debate as to the best combination of tendon transfers in such patients. The aim of this study is to present the results of Flexor carpi radialis (FCR) combination of triple tendon transfer for radial nerve palsy. MATERIAL AND METHODS: It is a retrospective study conducted over 15 years. 58 patients of with irreversible radial nerve paralysis were included. Brands transfer was performed in all cases. The ranges of movement of the wrist, fingers and thumb were evaluated pre-operatively and postoperatively using Bincaz scale. RESULTS: Total 58 patients were included in the study, 47 were male and 11 female patients with mean age of 35.27 years. Causes of radial nerve palsy were comminuted open humeral fracture (n = 42), penetrating injuries (n = 13) and brachial plexus palsy (n = 3). Mean duration of palsy was 9.37 months (range = 9-12 months). The mean post-operative follow-up was 10 (range = 2-15) years. On evaluation with the Bincaz score, 6 patients had excellent results, 49 patients had good results, and 3 patients had poor results. There were 3 complications in 5 patients, including radial deviation of wrist, inadequate abduction of thumb and restricted wrist flexion. 55 patients (94.82%) were able to return to their normal daily work after ∼8 weeks. Conclusions - Tendon transfer is a standard procedure for radial nerve palsy but potential advantage of one method over the other has not been demonstrated. Brand's transfer results in an acceptable restoration of hand function.

Tibialis posterior (TP) tendon transfer for foot drop: A single center experience.

BACKGROUND: Foot drop defined as a significant weakness of ankle and toe dorsiflexion. It leads to high stepping gait, functional impairment and deformity of the foot. Objective of this study was to assess the functional outcome of tibialis posterior (TP) transfer for patient with foot drop in a single center. METHODS: This is a retrospective study included 20 patients operated for foot drop of >1 year duration in the last 5 years. Preoperative assessment of muscles of all the three compartment of leg along with radiological assessment of ankle to rule out tarsal disintegration and ankle instability was done. Postoperatively gait, active dorsi/plantar flexion and the range of movement of the ankle and toes were assessed. RESULTS: Tibialis posterior transfer was performed on 20 patients (16 males and 4 females, mean age 31.4 years). Commonest cause of foot drop was Hansen's disease followed by post traumatic peroneal nerve damage and post injection sciatic neuropathy. At mean follow-up of 2 years, all patients, except one, could walk with heel-toe gait without any orthotic support. There was no pain, ruptures or infections of the transferred tendons. 19 of the 20 operated ankles had mean active dorsiflexion of 7.5°, the active plantar flexion of 36.25°, and the total range of movement 43.75°. The active dorsiflexion of the toes ranged from 5-20°. CONCLUSION: Dynamic tibialis posterior transfer gives good results in terms of normal gait, high patients' satisfaction with minimal donor site morbidity and low complication rate.

Vacuum assisted closure (VAC)/negative pressure wound therapy (NPWT) for difficult wounds: A review.

Delayed wound healing particularly in difficult wounds and in elderly with co morbidities is a major concern. It leads to the pain, morbidity, prolonged treatment, and require major reconstructive surgery which imposes enormous social and financial burden. Vacuum-assisted closure (VAC) is an alternative method of wound management, which uses the negative pressure to prepare the wound for spontaneous healing or by lesser reconstructive options. Method of VAC application includes thorough debridement, adequate haemostasis and application of sterile foams dressing. A fenestrated tube is embedded in the foam and wound is sealed with adhesive tape to make it air tight. The fenestrate tube is connected to a vacuum pump with fluid collection container. The machine delivers continuous or intermittent suction, ranging from 50 to 125 mmHg. The VAC dressings are changed on 3rd day. Negative pressure therapy stabilizes the wound environment, reduces wound edema/bacterial load, improves tissue perfusion, and stimulates granulation tissue and angiogenesis. All this improves the possibility of primary closure of wounds and reduce the need for plastic procedures. VAC therapy appears to be a simple and more effective than conventional dressings for the management of difficult wound in terms of reduction in wound volume, depth, treatment duration and cost.