Management of Soft Tissue Defects of the Ankle and Foot

Background

Treatment of soft tissue defect of ankle and foot has always been a challenging problem.

Methods

Thirty patients with soft tissue defects of the ankle and foot who underwent various reconstructive procedures in two tertiary care teaching hospitals were studied.

Results

Most of the defects (33%) were located in and around the ankle. Trauma was the major cause (56.6%). Defects were reconstructed with a variety of local, regional, distant and microvascular free flaps. Distally based superficial sural artery flap was used in majority of the cases (40%). Free tissue transfer using radial artery forearm flap was done in three (10%) complex wounds where other flaps were not found to be suitable. Superficial soft tissue defects on the dorsum of foot were resurfaced with split thickness skin grafts in 3 (10%) cases. Out of 27 flaps used, 26 survived completely. One inferiorly based fasciocutaneous flap developed partial necrosis. There was graft loss in one patient which required regrafting with the stored autograft.

Conclusion

Distally based superficial sural artery flap remains the choice for reconstruction of soft tissue defects of ankle and foot because of its reliable blood supply and easy elevation.Key Words: Soft tissue defects, Ankle and foot reconstruction     

Perforator flap: A novel method for providing skin cover to lower limb defects

Background

Soft tissue defects in the lower limb pose a formidable challenge due to lack of reliable local flap options. Due to thin non-expendable soft tissues and predisposition to massive edema formation, even small defects become problematic. Perforator flaps represent the latest trends in soft tissue coverage. The aim of this study was to evaluate the effectiveness of perforator flaps as coverage of soft tissue defects in lower limbs.

Material and methods

A series of patients with soft tissue defects of various etiologies in the lower limb were treated using perforator flap at a tertiary care service hospital. Six were free flaps and fourteen pedicled flaps. Doppler ultrasound was used to identify recipient and donor vessels pre-operatively.

Results

Only one flap was lost due to venous congestion. In another case of carcinoma penis there was delayed healing due to persistent lymphorrhoea as a result of post-operative status following lymph node dissection and radiotherapy. Fifteen donor sites required split skin grafting, as they could not be closed directly.

Conclusion

Perforator flaps are a reliable option for closure of soft tissue defects of lower limb irrespective of size, location and depth. There is minimal donor site morbidity. It has the advantage of rapid dissection, flap elevation and reliable skin territory. As no special equipment is required it can be replicated in smaller centers also.     

Reconstruction of Complex Abdominal Wall Defects

Introduction

Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. These defects result from trauma, previous surgery, infection and tumour resection. The primary objectives of abdominal wall reconstructions are to protect abdominal contents and provide functional support. The abdominal wall reconstruction aims at providing basic component parts, i.e. skin, soft tissue and fascia. For large soft tissue defects, pedicled or free flap closure can be used. In clean wounds, fascial replacement is accomplished with synthetic mesh provided there is adequate soft tissue coverage.

Methods

We treated a total of 20 consecutive patients with complex abdominal wall defects utilizing various reconstructive procedures. There were 15 males (75%) and 5 females (25%). The aetiology included dehiscence of laparotomy wounds in eight (40%), following ablative surgery for malignant tumours in seven (35%), trauma in three (15%) and congenital defects in two (10%) cases. The reconstructive procedures consisted of onlay prolene mesh in seven (35%), Gore-Tex (PTFE) dual mesh both as inlay and onlay in five (25%), facial partition release technique in three (15%), inlay prolene mesh covered with omentum and split skin graft in two (10%), inlay prolene mesh covered with expanded skin in two (10%), and Gore-Tex dual mesh covered with latissimus dorsi myocutaneous flap in one (5%) case. Postoperatively none developed mesh infection or extrusion. Three patients with malignant aetiology received postoperative radiotherapy. During follow up, one patient developed ventral hernia cephalad to the repair and one died due to recurrence of abdominal wall malignancy.

Conclusion

The reconstruction of an abdominal wall defect requires a comprehensive plan of preoperative and post operative care of the patient and aims toward restoration of abdominal structural integrity by a variety of procedures. The use of new biomaterials and tissue expanders provides reliable and durable abdominal wall closure along with good aesthetic results.Key Words: Abdominal wall defect, Mesh repair, Abdominal wall reconstruction     

Comparative evaluation of bioglass with calcium sulphate β-hemihydrate for the treatment of intraosseous defects—a clinico-radiological study

Background

The aim of the present clinical and radiological study was to compare bioglass and calcium sulphate β-hemihydrate in the treatment of intraosseous defect in chronic periodontitis.

Method

A total of 50 subjects with bilaterally symmetrical periodontal osseous defects with probing pocket depth = 5 mm and intraosseous defects ≥ 3 mm as seen on the radiographs were undertaken for the study. In one site (group A) bioactive glass was placed in defect and in contralateral site (group B) calcium sulphate β-hemihydrate was used in the defect site.

Results

Clinical improvement was noted in all patients at the end of study. Both the groups showed reduction in probing pocket depth, increase in clinical attachment level, and reduction in osseous defect. Both materials were effective in achieving osseous gain.

Conclusion

The osseous gain in group A subjects was 58.93%, whereas in group B subjects it was 48.56%. Calcium sulphate β-hemihydrates showed promising results and were cost effective.Key Words: bone grafts, periodontal osseous defects     

Reconstruction of Cranial Defects in Armed Forces Personnel - Our Experience

Background

The aim of this study was to evaluate the efficacy of heat cured ‘poly methyl methacrylate resin prosthesis and to assess the acceptability of the indigenously manufactured titanium mini bone plate and screws in patients treated for repair of cranial defects.

Methods

17 patients with cranial defect were treated for reconstruction of the skull defect with two types of implants i.e. Acrylic resin plate prosthesis and titanium minibone plates, either in combination or singularly. In these cases, the skull defects resulted from trauma (88.23%) or due to ablative tumour surgery (11.96%). Acrylic implant was used in 12 cases (70.85%), titanium plates and screws in 2 cases (11.76%) and a combination of both of the above in 3 cases (17.64).

Results

The primary reconstruction was carried out in 2 cases (11.96%) and secondary reconstruction was done in 15 cases (88.23%). Majority of the cases underwent secondary reconstruction because of the initial surgical emergency requiring quick debulking and closure. In 2 cases where primary reconstruction was done, the second surgery could be avoided with gratifying results.

Conclusion

70.85% underwent reconstruction with polymethyl methacrylate resin prosthesis and in the rest either titanium plates were used singly or in combination. Only in one patient, there was rejection of the implant due to infection. In 94% cases the graft was well taken up with excellent results.Key Words: Cranial reconstruction, Mini bone plates, Cranial prosthesis     

Multidetector CT Evaluation in Arterial Stenting

Background

Multidetector CT (MDCT) represents breakthrough in CT technology, significantly improving CT Angiography applications.

Methods

Twenty one patients with aortoiliac & branch aneurysms or stenosis were evaluated by Digital Subtraction Angiography (DSA) and Multidetector CT (MDCT) before and after endovascular repair.

Results

There were eight cases of aortic & branch aneurysms and 13 with stenosis. Four cases had aortic aneurysms, while one case had left subclavian artery aneurysm, thoracic aneurysm, femoral and popliteal artery pseudoaneurysms. Of the 13 cases with stenotic lesions, iliac stenosis was seen in eight patients. The others included carotid, vertebral, aortic, renal and aortic bifurcation stenotic. MDCT offered accurate information on shape and size of aneurysm, shape and patency of graft, the presence or absence of perigraft thrombosis or endoleaks, while in stenotic lesions it provided useful information on shape of graft, its location, its patency and the presence and quantity of distal flow.

Conclusion

MDCT was found to be a potentially useful modality during initial evaluation and follow up of patient undergoing endovascular repair.Key Words: Multidetector Computed Tomography, Endovascular stents, Arterial disease     

AC/PC Intraocular Lens Exchange with Penetrating Keratoplasty in Pseudophakic Bullous Keratopathy

Background

Evaluation of penetrating keratoplasty in cases of pseudophakic bullous keratopathy with AC/PC IOL exchange.

Methods

This retrospective study included 120 cases of pseudophakic bullous keratopathy managed over 9 years at three tertiary care eye centres followed up for 4 years. Cases were taken up for penetrating keratoplasty along within adjuvant procedures like IOL explantation and Secondary Posterior Chamber IOL implantation over the frill of posterior capsule.

Results

Lens exchange with Penetrating Keratoplasty (PK) was done in 93 and PK without lens exchange in 27 cases. 25% required systemic steroids for 2-3 weeks. Re-grafting was performed in 5% and 85% attained moderate visual acuity.

Conclusion

Intra ocular lens exchange and Posterior chamber IOL are suitable for penetrating keratoplasty in terms of optical clarity, graft survival and visual outcome.Key Words: PBK, IOL exchange (AC/PC)     

Prevalence of patent foramen ovale in a consecutive cohort of 261 patients undergoing routine "coronary" 64-multi-detector cardiac computed tomography

Background

A patent foramen ovale (PFO) is strongly associated with cryptogenic stroke (CS), neurological and other phenomena. The reported prevalence of PFO varies according to the imaging technique used and population studied.

Purpose

To measure prospectively, the prevalence of PFO in a cohort of consecutive patients attending for routine “coronary” CT angiography using standard, everyday coronary protocols including low-dose prospective ECG gated studies.

Methods

Standard coronary imaging protocols were used. PFOs were graded according to the classification of Williamson et al.¹

Results

261 patients were studied. A PFO was identified in 22.6% (11.5% grade 1 (closed flap), 6.5% grade 2 (open flap) and 4.6% grade 3 (open flap with jet)). A further 6.1% had an atrial septal aneurysm.

Conclusions

The prevalence of all grades of PFO (22.6%) and open flap PFO (11.1% = grade 2 and 3) with this technique compares with 24.3% by trans-oesophageal echocardiography (TOE) and 14.9% by saline contrast echocardiography (SCE)^{2, 3} Further comparative studies are required but we believe an open flap PFO or ASA should be identified and recorded during cardiac CT. This approach may identify those at risk of cryptogenic stroke as well as avoid unnecessary tests in stroke patients.     

Modifications to Norman's procedure for hypermobility of the TMJ

Background

Norman''s procedure is a well known surgical technique for the hypermobility of temporomandibular joint. In this procedure after performing glenotemporal osteotomy the augmentation of the zygomatic root of the temporal bone is done by placing a bone graft from the iliac crest to prevent forward movement of the condyle beyond the eminence. This paper describes the clinical outcome of two modifications added to Norman''s procedure. In addition to the conventional procedure inferiorly based pedicled flap from the temporal fascia was sutured to the antero-lateral aspect of the capsule. Intraorally pterygoid disjunction was carried out only in those case in which hypermobility was associated with painful temporomandibular joint disorder.

Methods

Modified Norman’s procedure was performed in 10 patients (4 females & 6 males), 7 of them were bilateral and 3 cases were unilateral under general anesthesia.

Results

After one year follow up in none of the cases graft failed or rejected though recurrence along with TMJ pain was noticed in 2 cases.

Conclusion

This technique is versatile but long-term follow up on a larger number of patients is necessary to be able to draw definitive conclusions.     

Non Surgical Management of Pseudoaneurysms

Background

The incidence of pseudoaneurysm has increased due to the large number of vascular procedures performed and the widespread use of anticoagulation therapy during procedures. Non-invasive methods for management of pseudoaneurysms comprise of ultrasound guided compression (USGC), thrombin therapy, arterial embolisation and endovascular stent graft insertion. We discuss our experience in the management of fourteen cases of pseudoaneurysms using non surgical techniques.

Methods

During a two year period, fourteen patients presenting with pseudoaneurysms of different regions were treated.

Result

Of the fourteen patients, eleven were iatrogenic and three were attributable to trauma. There were six cases of pseudoaneurysms of the femoral artery following coronary angiography studies. One patient developed pseudoaneurysm of right popliteal artery after external fixation of fracture right tibia and fibula. Three cases of renal artery pseudoaneurysms occurred following percutaneous nephrolithotomy (PCNL). The cases were evaluated using a varying combination of color doppler, multidetector computerised tomography (CT) and angiography. These cases were treated with ultrasound guided compression (USGC), stent graft and coil embolisation. The selection of method was based on the location and size of pseudoaneurysms besides the efficacy of the technique. USGC was performed in seven, of which six were in the femoral artery and one supraorbital. The technique was unsuccessful in three of the seven, wherein stent graft was deployed in the femoral artery. Coil embolisation was utilised in three cases of renal artery pseudoaneurysms following PCNL.

Conclusion

Follow up with color doppler and CT angiography within a week, 6 and 12 months period showed successful regression of pseudoaneurysms in all cases.Key Words: Pseudoaneurysm, Arterial trauma, Ultrasound guided compression, Coil embolisation, Endovascular stent graft     

Effects of maleimide-polyethylene glycol-modified human hemoglobin (MP4) on tissue necrosis in SKH1-hr hairless mice

Objective

Tissue hypoxia after blood loss, replantation and flap reperfusion remains a challenging task in surgery. Normovolemic hemodilution improves hemorheologic properties without increasing oxygen carrying capacity. Red blood cell transfusion is the current standard of treatment with its attendant risks. The aim of this study was to investigate the potential of the chemically modified hemoglobin, MP4, to reduce skin flap necrosis and its effect on selected blood markers and kidneys.

Materials and methods

Tissue ischemia was induced in the ear of hairless mice (n = 26). Hemodilution was performed by replacing one third of blood volume with the similar amount of MP4, dextran, or blood. The extent of non-perfused tissue was assessed by intravital fluorescent microscopy.

Results

Of all groups, MP4 showed the smallest area of no perfusion (in percentage of the ear ± SEM: 16.3% ± 2.4), the control group the largest (22.4% ± 3.5). Leukocytes showed a significant increase in the MP4 and dextran group (from 8.7 to 13.6 respectively 15.4*10⁹/l). On histology no changes of the kidneys could be observed.

Conclusion

MP4 causes an increase of leukocytes, improves the oxygen supply of the tissue and shows no evidence of renal impairment.     

Percutaneous Closure of Perimembranous Ventricular Septal Defect with Amplatzer Device

Background

The Amplatzer perimembranous ventricular septal occluder is an innovative device for percutaneous closure of perimembranous ventricular septal defects (PMVSD). In appropriately selected cases this procedure is safe and effective.

Methods

Fourteen patients with the mean age 10.53 years (range 18 months to 55 years) and mean body weight 20.64 kg (range 6 to 52 kg) underwent PMVSD closure.

Result

The PMVSD mean diameter was 5.28 mm (range from 4 to 9 mm). Implantation was successful in 92% of the cases and all patients had complete occlusion of the shunt within three months.

Conclusion

Device orientation was excellent in all cases. Device-related aortic insufficiency, tricuspid insufficiency or left ventricular dysfunction was not observed. One patient had embolisation of the device and another had complete heart block which required a permanent pacemaker implantation. The excellent short term results need to be confirmed over long-term follow-up.Key Words: Perimembranous ventricular septal defect, Arrhythmias, Percutaneous closure     

Exomphalos Defects : A Review of 15 Cases

Background

The outcome after repair of exomphalos defects has improved significantly with refinements in surgical techniques, multidisciplinary management and monitoring of intra-abdominal pressures.

Methods

A retrospective study of medical records of 15 cases with omphalocele was done.

Results

Antenatal diagnosis was available in six cases. There were eight females and seven males with a mean birth weight of 2.2 kg. Nine babies had associated anomalies. There were nine major (defect size> 5 cm) and six minor defects. Immediate closure in neonatal period was carried out in 12 cases. Urinary bladder pressure (UBP) was measured to assess intra-abdominal pressure in cases where primary closure was difficult. Primary closure was omitted in the event of intravesical pressures exceeding 20 mm Hg (~ 25 cms of water). Primary surgical closure was possible in five (56%) major cases. Two cases were subjected to silo repair followed by delayed primary closure whereas the other two required a Goretex mesh closure. Three minor defects could be repaired primarily whereas the remaining three were managed conservatively and closed at age of 9 to 12 months. There were no significant anaesthetic complications. Elective postoperative ventilation was required in one baby. There were three deaths at ages five, nine and ten months due to unrelated causes.

Conclusion

Satisfactory outcome is possible in cases with exomphalos defects with intra-operative intravesical pressure assessment forming a convenient method for excluding abdominal compartment syndrome.Key Words: Abdominal wall defects, Omphalocele, Intra-abdominal pressure, Intravesical pressure measurement     

Evolving surgical prosthetic rehabilitation protocol for success of dental implant placed in distracted alveolar ridge

Background

Remodelling of bone in the form of resorption generally follows the extraction of a tooth. During all stages of atrophy of the alveolar ridge, characteristic shapes result from the resorptive process, as influenced by anatomic alterations in the alveolar bone. Various ridge augmentation procedures have been documented as predictable means of establishing new vital bone for implant placement, out of which distraction osteogenesis is one such modality. Hence the following study has been conducted to evolve a surgico- prosthetic rehabilitation protocol in grossly atrophic alveolar ridge by distraction osteogenesis and subsequent implant placement and to provide an effective alternative to lost dental tissue to serving soldiers, their families and ex-servicemen of the Indian Army in a cost effective manner.

Methods

A total of 30 patients with ridge defects in age group between 18 to 70 years were selected for the study. The net success rate of distraction procedure was 93.33% (100% in maxilla and 80% in mandible) with 2 cases deemed as failures out of a total of 30 cases. The average amount of defect compensated was 76.1% (85.1% and 59.5% in maxilla and mandible respectively).

Results

For the implant surgical procedure the success rate was 100% and subsequently prosthetic rehabilitation on implants was proved to be successful.

Conclusion

Distraction ostoeogenesis of an atrophied ridge for further implant placement certainly proves to be successful procedure by this study. Further studies in the same procedure using a larger sample size will definitely be more beneficial.     

The use of chicken legs for teaching wound closure skills

Objective

Training models are required to impart surgical skills, like wound closure techniques, prior to practice in patients. In an ideal case, the tissue characteristics of the model are close to those of humans, easy to create and of low cost.

Methods

Here, we describe a model to train students in wound closure technique using conventional chicken legs obtained from the supermarket.

Results

The described model has good tissue characteristics, does not require any lavish preparation and is of minimal cost (0.62 Euro or 0.78 USD).

Conclusions

Chicken legs appear to be an appropriate tool for teaching wound closure techniques.     

前臂骨间背侧动脉逆行岛状皮瓣的临床应用

目的 :证实骨间背动脉为蒂逆行岛状皮瓣修复手背皮肤缺损的临床应用可靠性。方法 :对 2例手背皮肤缺损的病例 ,取前臂骨间背动脉逆行岛状皮瓣转位修复。皮瓣面积最大 7cm× 8cm。结果 :皮瓣均成活 ,随诊 16个月效果满意。结论 :前臂背侧骨间背动脉为蒂逆行岛状皮瓣血供充分 ,血管变异少 ,不牺牲前臂主干血管 ,为临床治疗较困难的手背皮肤大面积缺损 ,提供一个可靠的治疗手段。     

Clinical evaluation of Deep Anterior Lamellar Keratoplasty (DALK) for stromal corneal opacities

Background

Corneal scars are commonly formed following many diseases of the eye like trauma, inflammation and infections. They lead to permanent diminution of vision which can be managed by Penetrating Keratoplasty (PK). PK is removing diseased as well as healthy tissues and is associated with many post-operative complications. Deep Anterior Lamellar Keratoplasty (DALK) is a relatively newer procedure which replaces only the diseased stroma, leaving the original corneal endothelium intact. This procedure is associated with lesser incidence of post-operative complications.

Methods

The study was conducted at a large tertiary care centre. 10 patients with stromal corneal scars were subjected to DALK and results were analysed after 06 months. Poor quality donor corneal tissue of B− and C grade was used in all cases.

Results

7 out of 10 patients (70%) undergoing DALK had post-operative visual acuity of 6/24 or better. 03 patients who did not have adequate recovery of visual acuity were due to over-riding of the graft in 01 case (10%), fungal keratitis in 01 case (10%) and interface haze in 01 case (10%).

Conclusion

DALK is a promising new technique for management of superficial corneal stromal scars using poor quality donor corneal tissue. Initial results are encouraging with minimal complications.     

Detection of Entamoeba histolytica in experimentally induced amoebic liver abscess: comparison of three staining methods

Objective

To compare the efficacy of three different tissue stains, namely haematoxylin and eosin (H&E), periodic-acid Schiff (PAS) and immunohistochemical (IHC) stains for detection of Entamoeba histolytica (E. histolytica) trophozoites in abscessed liver tissues of hamster.

Methods

Amoebic liver abscess was experimentally induced in a hamster by injecting 1 × 10⁶ of axenically cultured virulent E. histolytica trophozoites (HM1-IMSS strain) into the portal vein. After a week post-inoculation, the hamster was sacrificed and the liver tissue sections were stained with H&E, PAS and IHC stains to detect the amoebic trophozoite.

Results

The three stains revealed tissue necrosis and amoebic trophozoites, but with varying clarity. H&E and PAS stained the trophozoites pink and magenta, respectively, however it was difficult to differentiate the stained trophozoites from the macrophages because of their similarity in size and morphology. On the other hand, IHC stain revealed distinct brown appearance of the trophozoites in the infected liver tissues.

Conclusions

It can be concluded that out of the three stains, IHC is the best for identification of E. histolytica trophozoites in tissue sections.     

Management of Nucleus and IOL Drop

Background

Thirty six cases of lenticular nucleus drop following phacoemulsification and 43 cases of posterior dislocation of intraocular lens (IOL) inclusive of two paediatric cases were managed by a modified vitrectomy procedure without using perfluorocarbon liquid (PFCL).

Methods

In these cases the incision was placed inferotemporally at pars plana. The limbal sites of the earlier cataract surgery were utilised as the other two ports. In either case adequate vitrectomy was performed first. In cases of nuclear drop, the nucleus was impaled (speared) with a micro vitreo retinal blade and brought into the anterior chamber from where it was delivered out. In cases of IOL drop the same was picked up by an intra-vitreal forceps.

Result

Of the 77 adult cases treated 57 (74%) of the eyes had a visual recovery of 6/18 or more.

Conclusion

Prompt surgical management in cases of nuclear drop or posterior dislocation of IOL yields good results.Key Words: Phaco-emulsification, Intraocular lens drop, Nucleus drop, Vitrectomy     

Endothelial Injury Preceding Intracranial Aneurysm Formation in Rabbits

Objective:

This study investigates the change of endothelial cell morphology and function at the rabbit basilar bifurcations in response to sustained high blood flow after bilateral common carotid artery ligation.

Methods:

Fifteen adult female New Zealand white rabbits were divided into experimental and sham control groups. The experimental group was subjected to bilateral common carotid artery ligation to increase the compensatory basilar artery flow. Basilar artery flow was monitored by transcranial Doppler after surgery. The endothelial cells at the arterial bifurcations were studied morphologically by electron microscopy and immunohistochemistry using β-catenin antibodies. Basilar artery flow increased significantly following common carotid artery ligation.

Results:

Early-stage basilar artery bifurcation aneurysms were present in all rabbits at three months after ligation. The endothelial cells changed from a fusiform to column shape at the basilar artery bifurcation. Gaps between endothelial cells of the experimental group appeared wider in the electron microscopic photographs compared with those of the control group. The expression of endothelial β-catenin at the arterial bifurcations also decreased.

Conclusion:

This study is the first to present endothelial cell changes of basilar artery bifurcation in response to sustained high blood flow in rabbits. Endothelial cell impairment possibly initiates aneurysm formation.