Evaluation of Non-vascular Fibula Graft for Mandibular Reconstruction

Introduction

Functional and cosmetic defects in maxillofacial region are caused by various ailments like trauma, neoplasm, developmental, infections and iatrogenic causes. Reconstruction of these defects with free flaps remains the gold standard but demerits like need for surgical expertise and equipment, prolonged duration of surgery, compliance of the patient and increased cost are associated with microvascular reconstruction. Hence reconstruction with nonvascular bone grafts can be considered when defect is nonirradiated and <9 cm and with sufficient soft tissue cover available.

Purpose

To retrospectively evaluate clinical, radiological outcome and complications encountered with mandibular reconstruction using non vascular fibula graft.

Patients and Methods

This retrospective study included 7 patients who were treated in the Department of Oral and Maxillofacial Surgery, Narayana Dental College and Hospital, Nellore, AP between 2011 and 2013 with histologically proven benign osteolytic lesions of mandible that require a segmental mandibulectomy and primary reconstruction using autogenous non-vascularised fibular graft. The clinical case records of the patients and personal patient assessment forms (Quality of Life Assessment Forms) were analysed. They were recalled every 3rd, 6th and 9th month after surgery for evaluation of clinical, radiological outcome of the graft and complications occurring at recipient and donor sites.

Results

In all the 7 patients, the lower border continuity was maintained except in one where the graft was dislodged. Tongue movements in all the patients were unrestricted. Jaw movements were affected in cases of ramus defects with slight deviation to operated side and reduced mouth opening. Radiological observations revealed no significant changes in 3 months except for slight reduction in graft height. The radioopaque bridging with continuity of lower border of mandible was noticed in 6th month indicating the take of the graft. This was achieved in every case except in one where the graft was lost due to dislodged reconstruction plate. In 9th month the edges of the graft i.e., graft to native mandible junction showed more resorption (3 mm) especially where there is >2 mm of gap. Whereas increase in height of graft in other areas especially in graft to graft junction was seen. Significant graft resorption was seen in two cases. There were no major complications associated with the donor site.

Conclusion

Avascular fibula graft although a second choice to vascularised fibula, is a favourable option for mandible defects of 6–10 cm under optimum conditions especially in developing countries where financial and/or surgical resources are limited. An attempt for primary reconstruction with this is never futile as it prevents aesthetic deformity even in the event of failure and thus makes secondary reconstruction easy. However in order to confirm the results a prospective study with large scale of patients is necessary.

Electronic supplementary material

The online version of this article (doi:10.1007/s12663-014-0657-1) contains supplementary material, which is available to authorized users.     

Effects of neem limonoids on the malaria vector Anopheles stephensi Liston (Diptera: Culicidae)

The effects of the neem (Azadirachta indica A. Juss) limonoids azadirachtin, salannin, deacetylgedunin, gedunin, 17-hydroxyazadiradione and deacetylnimbin on Anopheles stephensi Liston (Diptera: Culicidae) were investigated. In exploring advantages of pure neem limonoids, we studied the larvicidal, pupicidal, adulticidal and antiovipositional activity of neem limonoids. Azadirachtin, salannin and deacetylgedunin showed high bioactivity at all doses, while the rest of the neem limonoids were less active, and were only biologically active at high doses. Azadirachtin was the most potent in all experiments and produced almost 100% larval mortality at 1 ppm concentration. In general, first to third larval instars were more susceptible to the neem limonoids. Neem products may have benefits in mosquito control programs.     

Evaluation of larvicidal and pupicidal activity of Morinda citrifolia L. (Noni) (Family: Rubiaceae) against three mosquito vectors

ObjectiveTo evaluate the mosquito larvicidal and pupicidal activity against three important medically mosquito vector such as malarial vector, Anopheles stephensi (An. stephensi), dengue vector, Aedes aegypti (Ae. aegypti) and filarial vector Culex quinquefasciatus (Cx. quinquefasciatus).MethodsMorinda citrifolia (M. citrifolia) leaf was collected in and around Alleppy districts, Kerala, India. M. citrifolia leaf was washed with tap water and shade dried at room temperature. An electrical blender powdered the dried plant materials (leaves). From the leaf, 1 kg powdered was macerated with 3.0 L of methanol sequentially for a period 72 h and filtered. The crude plant extracts were evaporated to dryness in rotary vacuum evaporator. The larvicidal and pupicidal activity was assayed at various concentrations ranging from (100–500 ppm) under the laboratory as well as field conditions. The LC₅₀and LC₉₀value of the M. citrifolia leaf extract was determined by Probit analysis.ResultsThe plant extract showed larvicidal and pupicidal effects after 24 and 48 hrs of exposure; All larval instars and pupae have considerably moderate mortality; however, the highest larval and pupal mortality was methanolic extract of M. citrifolia observed in three mosquito vectors at 48 h. The LC₅₀and LC₉₀of M. citrifolia against the first to fourth instar larvae and pupae against mosquito vectors. An. stephensi had values of LC₅₀=146.08, 159.07, 172.16, 185.08 and 202.68 ppm and LC₉₀=322.12, 363.48, 388.56, 436.51 and 513.56 ppm, respectively. The Ae. aegypti had values of LC₅₀=181.27, 210.40, 229.80, 256.73 and 292.01 ppm and LC₉₀=407.99, 485.65, 534.14, 624.16 and 756.79 ppm, respectively. The Cx. quinquefasciatus had values of LC₅₀=226.70, 256.97, 290.05, 316.33 and 358.11 ppm and LC₉₀=560.35, 652.07, 733.03, 797.09 and 875.25 ppm, respectively at 24 h.ConclusionsThe results of the leaf extract of M. citrifolia are promising as good larvicidal and pupicidal activity against the mosquito vector, An. stephensi, Ae. aegypti, Cx. quinquefasciatus. This is a new eco-friendly approach for the control of vector control programs. Therefore, this study provides first report on the larvicidal and pupicidal activities against three species of mosquito vectors of this plant extract from India.     

Retrospective study of antibiotic resistance among uropathogens from rural teaching hospital,Tamilnadu, India

ObjectiveTo determine the community associated urinary tract infection (UTI) causing uropathogen's prevalence, antibiotic resistance pattern and the risk factors predisposing infection in Indian rural settings.MethodsA pilot study was conducted between January and December 2010 among out patients attending rural teaching medical college hospital at Tamilnadu, India. The demographic details, culture, common antibiotic Kirby-Bauer disc diffusion assay susceptibility profiles of the isolates and the resistance analysis by WHONET 5.6 software were performed.ResultsDuring this surveillance study, a total number of 1 359 urinary samples were collected, among which 309 (22.78%) gave positive culture. The common uropathogens encountered were Escherichia coli (66.02%), Staphylococcus sp. (12.62%), Klebsiella sp. (5.83%), Streptococcus sp. (5.18%), Enterococcus sp. (2.59%) and Proteus sp., (2.26%). Antibiotic resistance analysis revealed the multiple drug resistance nature of the isolates to the commonly used antibiotics. It is also found that both genders at the specific age group of 40-50 were more prone to infection and seasonal variations also play an important role in their establishment.ConclusionsThe obtained results suggest that antibiotic selection for empirical treatment should be based on individual drug-sensitive test results. There is also an urgent need to develop a new combination of chemotherapeutic agents and awareness on antibiotic use for the effective UTI management in rural settings.     

Origin of an Anomalous Left Coronary Artery from a Left Hilar Pulmonary Artery

Anomalous coronaries arising in nontruncal regions of the pulmonary artery are exceedingly rare. We report an autopsy case of an anomalous left coronary artery that arose from the distal pulmonary artery at the hilum of the left lung in an infant with complex congenital heart disease. To the best of our knowledge, this is the first such report. This previously unknown coronary malformation led to a fatal intraoperative complication during a pulmonary angioplasty procedure.     

Movement disorder emergencies in childhood

The literature on paediatric acute-onset movement disorders is scattered. In a prospective cohort of 52 children (21 male; age range 2mo-15y), the commonest were chorea, dystonia, tremor, myoclonus, and Parkinsonism in descending order of frequency. In this series of mainly previously well children with cryptogenic acute movement disorders, three groups were recognised: (1) Psychogenic disorders (n = 12), typically >10 years of age, more likely to be female and to have tremor and myoclonus (2) Inflammatory or autoimmune disorders (n = 22), including N-methyl-d-aspartate receptor encephalitis, opsoclonus-myoclonus, Sydenham chorea, systemic lupus erythematosus, acute necrotizing encephalopathy (which may be autosomal dominant), and other encephalitides and (3) Non-inflammatory disorders (n = 18), including drug-induced movement disorder, post-pump chorea, metabolic, e.g. glutaric aciduria, and vascular disease, e.g. moyamoya. Other important non-inflammatory movement disorders, typically seen in symptomatic children with underlying aetiologies such as trauma, severe cerebral palsy, epileptic encephalopathy, Down syndrome and Rett syndrome, include dystonic posturing secondary to gastro-oesophageal reflux (Sandifer syndrome) and Paroxysmal Autonomic Instability with Dystonia (PAID) or autonomic ‘storming’. Status dystonicus may present in children with known extrapyramidal disorders, such as cerebral palsy or during changes in management e.g. introduction or withdrawal of neuroleptic drugs or failure of intrathecal baclofen infusion; the main risk in terms of mortality is renal failure from rhabdomyolysis. Although the evidence base is weak, as many of the inflammatory/autoimmune conditions are treatable with steroids, immunoglobulin, plasmapheresis, or cyclophosphamide, it is important to make an early diagnosis where possible. Outcome in survivors is variable. Using illustrative case histories, this review draws attention to the practical difficulties in diagnosis and management of this important group of patients.     

Bifurcation of brachial artery into a common radial–interosseous trunk and superficial ulnar artery: a rare variation

Variations in the branching pattern of brachial artery and abnormal course of its branches are not uncommon. The present article describes a case of bifurcation of the brachial artery into a common radial–interosseous trunk and superficial ulnar artery. The embryological basis behind the present case report could be, the radial artery establishing a connection with the axis artery just below the level of origin of ulnar artery, the posterior interosseous artery arising from the axis artery distal to the origin of the radial artery. The part of axis artery between origin of ulnar and radial artery must have developed into the common radial–interosseous trunk. The part of axis artery between origin of radial and posterior interosseous arteries develops as the common interosseous artery. The superficial position of ulnar artery could enable the surgeons in raising a free ulnar forearm flap for head and neck reconstructive surgeries.