Reconstruction of hind foot defects; a simplified workable solution

Reconstruction of traumatic as well as non-traumatic hind foot defects is always a challenging task. We share here a simple and practical protocol [working solution] to select the most suitable method for soft tissue coverage of hind foot defects, customizable for every patient. We carried out this study, in our department on 75 cases from March 2009 to May 2012. All cases with wound/defect in hind foot area were included. Majority of cases were traumatic rest included cases of malignancy, Trophic ulcers, infection. Patient's data including age, sex, site of injury, mode of injury, extent of injury [isolated or combined], if combined structures involved, type of wound, management of wound, wound healing time and complications were noted. Once optimal wound conditions were achieved the best possible reconstructive option was selected. The various reconstructive options include VAC therapy, Skin graft, local transposition flap, perforator based flapspedicled faciocutaneous/ muscle flaps, intrinsic foot muscles, Medial plantar artery flap and distant flaps like cross leg flap and micro vascular free flaps. All patients had satisfactory and stable reconstruction. They were ambulating freely by 4-6 weeks post operatively. There were few complications like patchy graft loss, peripheral flap necrosis, flap congestion, but none was serious and did not require repeat surgery. The simplified protocol followed by us is a practical customizable solution for difficult task of hind foot reconstruction. The choice of one or multiple techniques will vary from time to time from one surgeon to another depending upon his or her experience and liking

Mass Casualty management after a suicidal terrorist attack on a religious procession in Quetta, Pakistan

To determine the effectiveness of hospital management, considering triage system, hospital staff response, medical resources availability, and surgical management depending upon the nature and pattern of injuries in a mass casualty incident. Descriptive. Combined Military Hospital, Quetta, Pakistan in March 2004. All injured by gunshot or blast in a terrorist attack and reported to the hospital were included in this study. Patients were triaged by the triage team using "triage sieve" into priority I, II, III, and IV. Priority I patients were further triaged by using "trauma index" to prioritize for surgery. Phase I included life saving, Phase II limb saving surgery and Phase III for debridement. All data was recorded and analyzed. Hospital received 161 casualties among whom 20 were brought in dead, and 141 patients were admitted to the hospital. Mean age was 26.63 +/- 13.97.The cases were categorized as Priority-I 22.7%, Priority-II 14.72%, Priority-III 50.31% and Priority-IV 12.27%. Maximum casualties reached within the first 2 hours. Eighty-eight patients had pre-dominantly splinter injuries and 53 patients had dominantly gunshot wound injuries. In priority I, the trauma index was 15.55 +/- 5.74. Six patients having trauma index 20 or above could not even be resuscitated. Seventyfive percent of staff reported to the hospital within 15 minutes. Only 30% of reserve medical store was consumed. Total management cost to the hospital was Rs. 362,1856/- [British Pounds approx 32,052/-.] calculated by the hospital rates for treatment of non-entitled patients. Death rate in hospital survivors was 4%. Mass casualty management in a terrorist act requires prompt hospital response, appropriate triage, efficient surgical approach, and dedicated postoperative care. A good response can help to decrease mortality rate in salvageable injuries

Assessment of risk factors and case fatality rate of malnourished admitted children

To assess the risk factors and case fatality rate of malnutrition in children admitted in the hospital. It is a descriptive type of study. Department of Paediatrics [unit III], Dow University of Health Sciences and Civil Hospital Karachi. Study included patients admitted from July 2001 to July of 2003. Case files of 240 patients were reviewed who had been admitted in the hospital for Protein Calorie Malnutrition [PCM] and Failure to Thrive [FTT] [according to low weight for age]. Range of age was from 1 month to 12 years. Nutritional status of child was assessed with the help of anthropometric measurements. Data regarding social and medical risk factors that are responsible for malnutrition was collected. Case fatality was also calculated. Most [73.3%] of patients were 1-24 months old. Medical risk factors were present in all cases where as social risk factors were observed in 68.8% of the children. The more prominent medical risk factors recorded are inadequate feeding [100%], incomplete vaccination [65.4%], and either chronic or recurrent diarrhea [64.6%], mixed or bottle feeds [52.5%] and recurrent respiratory infections [42%]. Other medical risk factors recorded were delayed weaning [27.9%], Congenital anomalies [22%], low birth weight [15.8%], history of measles in 10.8%, history of treatment /underwent treatment TB [7.9%], twin births and otitis media were individually observed in 5.4% cases. Most prominent social risk factors included uneducated mothers [50.4%], more than 2 children under 5 in families of 36.3% and previous child death noted in 15.8% cases. Less common risk factors included unemployed fathers [5.8%], parental absence [3.8%], ill mothers [3.3%], incompetent mothers [2.9%], ill fathers [2.5%], working mothers [0.8%], and drug addiction in families [0.4%]. Case fatality rate was calculated as 16.2%. The most common medical risk factors are: Inadequate feeding, incomplete vaccinations, chronic and recurrent diarrhea, and bottle-feeding and the results are comparable to previous studies. Prominent social risk factors include uneducated mothers, more than 2 children under 5 and Previous child death. Further research needs to be carried out to establish the correct relationship between certain medical risk factors like incomplete vaccinations and respiratory infections. A prospective study should also be conducted to establish the exact association of worm infestation with PCM so that this relation could be added in the protocols of malnutrition to ensure proper documentation, treatment and cure of this menace. Case fatality rate is comparable to international standards

Skin sparing mastectomy and immediate breast reconstruction

To evaluate skin sparing mastectomy[SSM] and immediate breast reconstruction[IBR] in terms of the survival, chances of recurrence, aesthetic restoration and prevention of psychosocial problems. An interventional study. The Department of Plastic and Reconstructive Surgery, CMH, Rawalpindi from November 1998 to November 2003. Twenty-eight patients of breast cancer, included in the study, were discussed in a Multidisciplinary Breast Clinic. Detailed metastatic work-up was performed. In all patients SSM with en-bloc level II axillary clearance and IBR was done. The patients' age ranged between 25-46 years. Two patients [7%] were nullipara. Tumor size was T1 in 10 [36%] and T2 in 18 patients [64%]. In all the patients a circum-areolar incision was used. A contralateral uni-pedicled TRAM flap was used in 24 [86%] and latissimus dorsi flap in 4 patients [14%]. All the flaps survived completely. There was marginal necrosis of native skin flaps in 03 [10.5%], infection in 03 [10.5%], axillary seroma in 03 [10.5%] and abdominal seroma in 01 patient [3.5%]. As late complication 5 patients [19%] developed fat necrosis. Adjuvant chemotherapy was given in 6 [21%] and adjuvant radiotherapy in 4 patients [14%]. No recurrence encountered in maximum follow-up. We found an excellent aesthetic restoration in 23 [82%], good in 1 [3.5%] and fair in 4 patients [14%]. SSM for patients with early breast cancer is an oncologically safe procedure. IBR can greatly reduce the psychological trauma associated with breast loss including diminished feelings of feminity, decreased libido, social behavior, sense of mutilation and depression

comparison of two fasciocutaneous flaps in the reconstruction of defects of the weight-bearing heel

To compare the indications, ease of elevation, operative time, complications and durability of two fasciocutaneous flaps i.e. sensate medial plantar artery flap and distally based sural artery neurocutaneous flap, used for the coverage of weight bearing heel in young ambulant adults. Design: A comparative study. Place and duration of study: CMH Rawalpindi and PIMS Islamabad during the period from May 1995 to April 2002. Patients and All the patients fulfilling the inclusion criteria discussed later in the text were divided into two groups. Twenty patients underwent a medial plantar artery flap [MPAF] while 30 had their defects reconstructed by a sural artery neurocutaneous flap [SANF]. The mode of presentation was noted in each case with a special note of the etiology. Postoperatively the patients were followed-up to evaluate any early or long-term complications. The MPAF group consisted of 20 patients including 16 males and 4 females with a mean age of 28 years [range 22 to 37 years]. The SANF group consisted of 30 patients including 29 males and only one female with a mean age of 30 years [range 23-38 years]. In both groups a majority of patients presented with a history of road traffic accidents and was managed by delayed primary procedure. The duration of the operation was considerably less in SANF coverage i.e., 50-100 minutes compared to 120-190 minutes for the MPAF. Flap survival was 100% in both the groups. The postoperative complications were more in patients who underwent SANF. Complete weight-bearing was started at 6 weeks in medial plantar artery flap whereas the same started 6-8 weeks in sural artery neurocutaneous flap. Average time for return to work was 8 weeks in medial plantar artery flap but it was double [12 weeks] in sural artery neurocutaneous flap. The medial plantar artery flap provides sensate and the same quality skin cover to the weight-bearing heel as compared to the distally based sural artery neurocutaneous artery flap. The medial plantar artery flap procedure is longer to perform but allows early weight-bearing with less complications than the distally based sural artery neurocutaneous flap

Reconstruction of lip defects with the Karapandzic technique

To study the use and effects of Karapandzic technique of lip reconstruction by long-term assessment. Design: A descriptive study. Place and Duration of Study: CMH Rawalpindi from January 1994 to January 2002. Subjects and Thirty seven consecutive patients who underwent Karapandzic technique of lip reconstructon with a minimum follow-up period of two years have been included. The variables assessed were hemorrhage, wound infection, flap necrosis, microstomia, reconstruction time, hospital stay and dynamic lip functions. Results drawn were analyzed. A total of 37 patients were included in the study. Thirteen [35%] patients were outdoor cases while 24 [65%] were in-patients. Average time of reconstruction was 40 minutes, which was done under general anesthesia in 21[57%] patients and under local anesthesia in 16 [43%] cases. Mean hospital stay of the indoor cases was 26 hours. There was no flap loss except for marginal necrosis in 04 [11%] patients. Wound infection and wound dehiscence was observed in 03 [08%] patients. Sensations were completely intact in 29 [78%] patients and aesthetically 28 [76%] patients gave normal look at the end of two years [2Y]. Twenty-seven [74%] patients had no change in speech and only one [3%] patient had unsatisfactory speech after 2 years. Varying degree of microstomia was observed in all the cases at immediate postoperative stage of one month but 35 [95%] patients showed gradual improvement with active mouth opening and stretching by prosthetic splints over 2 years. The Karapandzic technique of lip reconstruction is strongly recommended over the other techniques as it is a single stage, quick and safe procedure which gives cosmetically and functionally excellent results. Microstomia, occuring in early postoperative stage, shows gradual improvement on long-term follow-up