Holistic Approach to Burn Reconstruction and Scar Rehabilitation.

More than 11 million burn injuries occur each year across the world. Many people with burn injuries, regardless of injury size, develop hypertrophic scar, contracture, unstable scar, heterotopic ossification, and disability resulting from these sequelae. Advances in trauma systems, critical care, safe surgery, and multidisciplinary burn care have markedly improved the survival of people who have experienced extensive burn injuries. Burn scar reconstruction aims to improve or restore physical function, confidence, and body image. Like acute burn care, burn scar reconstruction requires thoughtful, coordinated approaches along the continuum of burn injury, recovery, and rehabilitation.

A task-shifted speech therapy program for cleft palate patients in rural Nepal: Evaluating impact and associated healthcare barriers.

INTRODUCTION: Though access to surgical care for cleft lip/palate has expanded in low- and middle-income countries (LMICs), post-palatoplasty speech therapy is often lacking due to limited healthcare infrastructure and personnel. This mixed-methods study seeks to: 1) evaluate the impact of task-shifted speech therapy on a standardized speech score; 2) describe the experiences of families with post-operative cleft care and associated barriers; and 3) understand how to optimize cleft care by exploring the experiences of children who had nominal improvements after task-shifted speech therapy. METHODS: A convergent parallel mixed-methods study was conducted in Nepal. Standardized speech scores were compared by a blinded speech-language pathologist before and after the speech intervention. Semi-structured interviews (SSIs) and focus groups with families evaluated cleft care experiences and barriers. Qualitative and quantitative data were merged and analyzed. RESULTS: Thirty-nine post-palatoplasty children with speech deficits (ages 3-18) underwent task-shifted speech therapy, and demonstrated significant improvements in composite speech scores targeted by exercises (p<0.0001) and weakness (p=0.0002), with improvements in misarticulation (p=0.07) and glottal stop (p=0.05) that trended towards significance. Forty-seven SSIs demonstrated that the greatest barriers to follow-up were family responsibilities (62%), travel/distance (53%), and work (34%). In five focus groups, families expressed a desire to improve their child's speech and seek formal speech therapy. The speech intervention was found to be beneficial because of the compassionate staff, free lodging/food, and ability to socialize with other cleft patients and families. After merging quantitative and qualitative data, we noted that younger children between 3 and 5 years old and families who traveled greater distances for healthcare access benefited less from the speech therapy intervention. CONCLUSIONS: Task-shifted speech therapy has the potential to improve cleft lip/palate speech in LMICs. Multiple biosocial issues limit access to appropriate post-operative care.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

On-top Plasty for Reconstruction of Thumb Using Index Finger.

Thumb is very important for hand function. Many options are available to reconstruct injured thumb from simple dressing (pulp injury without bone exposure) to replantation and toe transfer (significant loss of thumb length). In chronic setting, where other fingers are intact, on-top plasty can be used to reconstruct injured thumb. In this study, a case of a boy who lost his thumb in a road accident is presented. Thumb reconstruction was performed using partially injured ipsilateral index finger. At two months, successful restoration of form and function were noted. Keywords: Index finger on-top plasty; thumb injury; thumb reconstruction.

Review of the First 108 Free Flaps at Public Health Concern Trust-NEPAL Hospitals: Challenges and Opportunities in Developing Countries.

BACKGROUND: Free tissue transfer is one of the most important and essential techniques in reconstructive surgery. The underlying complexity, steep learning curve, high cost, and fear of failure make it very difficult to establish as a regular service in developing countries such as Nepal. METHODS: A retrospective cohort study design was used to analyze the challenges with and opportunities for reconstructive surgery in Nepal. Medical records were reviewed for patient demographics, indications, types of free flaps, hospital stay, complications, and involvement of a microsurgery teaching workshop. RESULTS: A total of 16 microsurgical workshops were carried out by 3 international organizations over the study period (2007-2017). Altogether 108 free flaps in 103 subjects were reviewed during the study period at different hospitals of the Public Health Concern Trust-NEPAL (phect-NEPAL) and National Trauma Center. Of 103 patients, 60 were males and 43 were females with an average age of 34.5 years (range, 8-73 years). The most common indications for microsurgical reconstruction were tumor, trauma, and burns. Radial artery forearm flap, anterolateral thigh flap, and free fibular flap were the most common types of flaps. Ten different types of flaps were performed. Four cases needed more than 1 flap; one of them needed 3 flaps. Flap success rate approached 90%. Four patients died in the hospital postoperatively. CONCLUSION: Reconstructive microsurgery is challenging in Nepal and more generally in developing settings. However, persistent technical support such as training and workshops can make it feasible.