Tropical Pyomyositis: Revisited.

Since the initial description of tropical pyomyositis 130 years ago, this disease continues to retain some mystery for physicians and surgeons. The infrequency, variable epidemiologic and demographic profile, diagnostic dilemmas and limited literature continue to make it an enigma with limited understanding. In the span of nearly 130 years, worldwide English literature search has revealed an average of only two to three reported cases every year globally. We recently managed a case of tropical pyomyositis which posed a clinical and radiologic diagnostic dilemma. The rarity of disease and published literature prompted us to garner demographic and disease characteristics data from historical review of two Pan-Indian journals, with the aim of aiding management. Data has been screened since 1950 from the Medical Journal Armed Forces India (MJAFI) and the Indian Journal of Surgery (IJS), which report cases from different geographical conditions and ethnicity all over the nation. We found only six case reports in the MJAFI, while there was surprisingly no publication regarding pyomyositis in the IJS. We present a case report of a 39-year-old male who developed pyomyositis of the left calf muscle and review published data from these journals over the last 65 years.

Base of Skull Blocks for Open Reduction and Internal Fixation of Faciomaxillary Fractures.

INTRODUCTION: Faciomaxillary fractures (FMF) occur in a significant proportion of trauma patients. Nearly all polytrauma patients and even those with isolated FMF are managed under general anesthesia for definitive management. We propose the use of regional nerve blocks as a safe and effective means for open reduction and fixation of isolated FMF. AIM AND OBJECTIVES: The aim is to evaluate the feasibility, effectiveness and safety of base of skull maxillomandibular and distal trigeminal nerve blocks in the management of FMF. MATERIALS AND METHODS: Ten young adults with fractures of the zygoma, mandible and Le Fort I/II injuries were included in the study. Patients with associated craniocervical and abdominothoracic injuries were excluded. RESULTS: The patients' ages ranged from 21 to 40 years, with a mean time of onset of anesthesia being 5 to 12 minutes and total duration of 105 to 220 minutes. Supplementary block for patchy anesthesia was needed in three. All underwent unhindered surgery without complication. CONCLUSION: Base of skull maxillary-mandibular and distal trigeminal blocks are an effective and efficient alternative to general anesthesia for the open reduction and internal fixation of FMF.

Learning Curve for Pilonidal Sinus Surgery: The Best Option for Budding Surgeons.

BACKGROUND: Surgery for pilonidal sinus has no gold standard, and results depend purely on surgeon preference of procedure and experience. Till date, there has been no study comparing the surgical outcomes when performed by residents. Therefore, we designed our study to compare the short-term outcomes of Karydakis' and Limberg's flap procedures in the treatment of pilonidal disease when performed by surgical residents. METHOD: A prospective, double-blinded, observational study was carried out at Command Hospital, Pune, India. Twenty-five consecutive patients undergoing each of the Karydakis' and Limberg's flap procedures (n = 50) were enrolled in the study. All patients had a primary sinus opening. Patients with a frank pilonidal abscess were excluded, but patients with history of intermittent purulent discharge even during time of surgery were included. RESULTS: There was a significantly higher rate of infection in the Karydakis' group (9/25) as compared to the Limberg's flap group (3/25) and also a higher rate of complete wound dehiscence (2/25 vs 1/25). CONCLUSION: Limberg's flap procedure appears to be superior to Karydakis' procedure, and the results are reproducible even by budding surgeons with little experience in the procedure.

Perforator plus flaps: Optimizing results while preserving function and esthesis.

BACKGROUND: The tenuous blood supply of traditional flaps for wound cover combined with collateral damage by sacrifice of functional muscle, truncal vessels, or nerves has been the bane of reconstructive procedures. The concept of perforator plus flaps employs dual vascular supply to flaps. By safeguarding perforators along with supply from its base, robust flaps can be raised in diverse situations. This is achieved while limiting collateral damage and preserving nerves, vessels, and functioning muscle with better function and aesthesis. MATERIALS AND METHODS: The perforator plus concept was applied in seven different clinical situations. Functional muscle and fasciocutaneous flaps were employed in five and adipofascial flaps in two cases, primarily involving lower extremity defects and back. Adipofascial perforator plus flaps were employed to provide cover for tibial fracture in one patients and chronic venous ulcer in another. RESULTS: All flaps survived without any loss and provided long-term stable cover, both over soft tissue and bone. Functional preservation was achieved in all cases where muscle flaps were employed with no clinical evidence of loss of power. There was no sensory loss or significant oedema in or distal to the flap in both cases where neurovascular continuity was preserved during flap elevation. Fracture union and consolidation were satisfactory. One patient had minimal graft loss over fascia which required application of stored grafts with subsequent take. No patient required re-operation. CONCLUSIONS: Perforator plus concept is holistic and applicable to most flap types in varied situations. It permits the exercise of many locoregional flap options while limiting collateral functional damage. Aesthetic considerations are also addressed while raising adipofascial flaps because of no appreciable donor defects. With quick operating times and low failure risk, these flaps can be a better substitute to traditional flaps and at times even free tissue transfers.

Giant trochanteric pressure sore: Use of a pedicled chimeric perforator flap for cover.

Pressure sores are increasing in frequency commensurate with an ageing population with multi-system disorders and trauma. Numerous classic options are described for providing stable wound cover. With the burgeoning knowledge on perforator anatomy, recent approaches focus on the use of perforator-based flaps in bedsore surgery. A giant neglected trochanteric pressure sore in a paraplegic is presented. Since conventional options of reconstruction appeared remote, the massive ulcer was successfully managed by a chimeric perforator-based flap. The combined muscle and fasciocutaneous flaps were raised as separate paddles based on the anterolateral thigh perforator branches and provided stable cover without complications. Perforators allow versatility in managing complex wounds without compromising on established principles.

Perforator-plus flaps: a new concept in traditional flap design.

BACKGROUND: Conventional fasciocutaneous flaps in reconstructive surgery, especially in the lower extremities, have limited utility. Traditional flaps are essentially random pattern, often require delays, and are limited in mobility and reach. Islanded fasciocutaneous flaps pedicled on perforators can be raised anywhere on the body and have a reliable blood supply and greater freedom of movement. However, venous compromise is a common problem. METHODS: A new approach to raising conventional fasciocutaneous flaps while including and retaining perforators in their substance was used to offset these disadvantages. This concept offers a dual blood supply to the flap from the dissected perforator plus the flap base. The approach was attempted in 12 cases and used successfully in 10. In two cases, the flaps were converted to pure islanded perforator flaps because of limited movement. Fasciocutaneous perforator-plus flaps were used in six patients with lower limb trauma and one patient with postburn elbow contracture. Peninsular flaps were planned to include known or identified perforators, which were dissected to allow mobility. RESULTS: All flaps survived completely and none exhibited venous compromise. In three patients, perforator-plus flaps were used to the medial hemisoleus muscle while providing coverage to exposed tibial fractures. The muscle flap was based either proximally or distally, and a segmental perforator was dissected and retained. There were no complications relating to flap congestion or necrosis except wound infection in two patients, one each in the fasciocutaneous and muscle flap groups. Both responded to conservative treatment. No case required reoperation. CONCLUSION: The perforator-plus flap appears to be a versatile and reliable option in lower limb injuries and other diverse indications, in both the emergency and the elective settings.

'Extended deep inferior epigastric artery flaps' for reconstruction after excision of chondrosarcoma sternum.

We describe a case of chondrosarcoma of the sternum requiring wide full thickness chest wall excision thereby creating a difficult defect for reconstruction. A mesh was used for support and two extended deep inferior epigastric artery fasciocutaneous flaps were mobilised medially into the defect.

Regional Block Anaesthesia - How Effective is it for Extremity Trauma?

Regional block anaesthesia (RBA) techniques are eclipsed by the widespread use of general anaesthesia (GA), especially in trauma surgery. This is despite the numerous advantages that regional blocks have to offer. We conducted a study to evaluate efficacy, safety and feasibility of RBA in isolated extremity trauma in war scenario. A prospective study was carried out over a period of eight months. There were a total of 96 patients with splinter, mine blast and gun shot wounds. Supraclavicular or axillary brachial block was employed for upper extremity surgery. 3 in 1 femoral block with classical sciatic block at hip or popliteal fossa was administered for lower limb operations. All patients were stabilized prior to the procedure. A combination of lignocaine 3 mg/kg of 2% and bupivacaine 1.5 mg/kg of 0-5% with dilution to make a volume of 0.75 ml/kg was employed. Assessment was made for onset, duration and degree of anaesthesia. Haemodynamic parameters and oxygen saturation were measured during the peritraumatic period. 92.5% cases had good motor and sensory anaesthesia and permitted unhindered surgery without supplementation. The rest required GA/dissociative anaesthesia (DA). Post operative pain relief lasted for an average of 4-5 hours. No patient had derangement of haemodynamic parameters or oxygen saturation. There was no systemic drug toxicity, local complications or mortality in our series. We found RBA for isolated extremity trauma to be simple, safe and effective with consistent results.