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Introduction: Tattoo-associated complications are on the rise due to the popularity of decorative tattoos in recent years. The exact pathogeneses of various tattoo reaction patterns are still unclear, and their dermoscopic details are sparsely reported. Aim: We aimed to retrospectively study the clinical, dermoscopic and immunopathological details of patients with non-infectious, non-eczematous inflammatory tattoo reaction patterns in a tertiary care centre of East India. Method: The clinical, dermoscopic and pathological details of all the patients who had non-infectious, non-eczematous inflammatory tattoo reactions were collected. In all the cases, immunohistochemistry was done for CD1a, CD3, CD4, CD8, FoxP3, CD20 and CD56. Results: A total of five patients of skin phototypes IV and V and six tattoo reactions were analysed. Five lesions had reactions at the site of a black tattoo, and one at the site of red tattoo. Clinically, the patients presented with erythematous or blue-grey flat-topped to verrucous papules and plaques. Dermoscopic features were dominated by a central white to pink-white structureless area, a peripheral grey-white to bluish-white structureless area, white scales, comedo-like opening with keratotic plugging, milia-like cysts and shiny white structures. Pathologically, except for one lesion that only showed a lichenoid reaction pattern in the red tattoo, all had a combination of reaction patterns. Immunohistochemistry showed increased epidermal and dermal Langerhans cells, predominantly CD8 positive T cells in the epidermis and dermis, sparse dermal B cells and CD4 positive T cells, reduced T regulatory cells and a complete absence of CD56 positive NK cells. Limitations: Small sample size was the limitation of the study. Conclusion: The clinical morphology and dermoscopy may not differentiate between various types of non-infectious non-eczematous inflammatory tattoo reactions. The immunological profile supports a delayed hypersensitivity reaction due to contact sensitisation to tattoo pigment, and CD8 positive T cells play a central role in executing various pathological reaction patterns, both in the epidermis and dermis
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Abdominoscrotal hydrocele (ASH) is very rare in adults and difficult to suspect on clinical examination. ASH is a very unusual presentation of scrotal hydrocele with extension intra-abdominally through the inguinal canal either communicating to the peritoneal cavity or non-communicating. An ASH is a congenital pathology involving a scrotal hydrocele expanding through the inguinal canal and reaching the abdominal cavity. Here, we present the case of a 25-year-old man admitted with a complaint of pain and lump in the left lower abdomen for 2 months and swelling in the left groin for 2 years. Ultrasound and computed tomography suggest left ASH with left-sided hydroureteronephrosis. A left DJ stent was placed and on exploration, a large cystic mass was seen intraperitoneally extending into the scrotum through the inguinal canal. Excision of the abdominal part and partial excision of the scrotal part were done with eversion of the remaining tunica vaginalis sac. Although ASH is a rare entity, it should always be kept on the list of differential diagnoses during the complaint of large abdominal mass in adults.
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Background: The purpose of this study was to assess the accuracy of preoperative CT imaging for predicting pathologic nodal ECE (pECE). To estimate the accuracy of the presence of radiologic extranoda AIM: l extension (rENE) in reference to pathologic extranodal extension (pENE) in patients with oral cavity squamous cell carcinoma (OSCC) MATERIALS AND METHODS: This is a prospective study in GSVM Medical College, LLR & Associated Hospitals, Kanpur (UP). The records of 50 consecutive patients with oral cavity cancer (OCC) who underwent preoperative CT imaging before initial surgical resection and neck dissection between 2020 and 2021 were reviewed. Specimens with pECE had the extent of ECE graded on a scale from 1 to 4. Radiographic ECE was RESULTS: documented in 6 patients (12%), and pECE was observed in 11 (22%). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 45.4%, 97.4%, 83.6%, and 86.3%, respectively. The sensitivity of radio- graphic ECE increased from 40% for grade 1 to 2 ECE, to 50% for grade 3, and 50% for grade 4. Radiographic ECE criteria of adjacent structure invasion was a better predictor than irregular borders/fat stranding for pECE. Radiographic ECE has poor sensitivity, but excellent spec CONCLUSION:Radiographic ECE criteria ificity for pECE in patients who undergo initial surgical resection. PPV and NPV are reasonable for clinical decision making. The performance of preoperative CT imaging increased as pECE grade increased.
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Solitary fibrous tumors (SFTs) are an uncommon group of neoplasms. The visceral pleura is the most common site of origin of these tumors. The colonic mesentery is an unusual site of origin of SFTs. A pre-operative diagnosis of SFT is challenging as there are no pathognomonic clinical or radiological signs. Most patients reported thus far were diagnosed post-operatively with the aid of immunohistochemical markers. Complete surgical excision is the treatment of choice for SFTs. Recurrences are uncommon. However, they can occasionally show aggressive behavior. In this report, we describe two cases of rare colonic mesentery SFTs.
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Cardiovascular disease (CVD) related mortality and morbidity heavily strain society. The relationship between external risk factors and our genetics have not been well established.It is widely acknowledged that environmental influence and individual behaviours play a significant role in CVD vulnerability, leading to the development of polygenic risk scores (PRS). We employed the PRISMA search method to locate pertinent research and literature to extensively review artificial intelligence (AI)-based PRS models for CVD risk prediction.Furthermore, we analyzed and compared conventional vs. AI-based solutions for PRS. We summarized the recent advances in our understanding of the use of AI-based PRS for risk prediction of CVD. Our study proposes three hypotheses: i) Multiple genetic variations and risk factors can be incorporated into AI-based PRS to improve the accuracy of CVD risk predicting. ii) AI-based PRS for CVD circumvents the drawbacks of conventional PRS calculators by incorporating a larger variety of genetic and non-genetic components, allowing for more precise and individualised risk estimations. iii) Using AI approaches, it is possible to significantly reduce the dimensionality of huge genomic datasets, resulting in more accurate and effective disease risk prediction models. Our study highlighted that the AI-PRS model outperformed traditional PRS calculators in predicting CVD risk. Furthermore, using AI-based methods to calculate PRS may increase the precision of risk predictions for CVD and have significant ramifications for individualized prevention and treatment plans.
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Choriocarcinoma occurs mainly in the gonads, but an extragonadal origin has been reported, albeit infrequently. Primary hepatic choriocarcinoma (PHC) is a rare malignancy, with only 11 cases reported. Most cases reported were in males, with none reported in pregnant females. A 23-year-old primigravida presented with a large liver lesion involving the right lobe of the liver at 28 weeks of pregnancy. Preoperative imaging was suggestive of hepatocellular carcinoma. She underwent a non-anatomical resection of the liver lesion. Surprisingly, her postoperative histopathology revealed a diagnosis of PHC. Her blood workup showed elevated beta human chorionic gonadotrophin. She underwent a termination of her pregnancy at 32 weeks. Before initiating adjuvant chemotherapy four weeks after surgery, a whole-body PET scan revealed multiple bi-lobar liver and pelvic deposits. After a multidisciplinary team discussion, she was started on adjuvant chemotherapy. She is currently under regular follow-up, seven months post-surgery. PHC, one of the vascular lesions of the liver, poses a diagnostic and therapeutic challenge, warranting a multidisciplinary approach.
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Introduction: Zygomycetes consisting of Mucorales order is a group of fungal infections. These species cause life threatening opportunistic fungal infections mucormycosis. This infection is highly prevalent in immunocompromised. During the 2nd wave of Covid 19 pandemic corticosteroid treatment was used which has been linked to development of Mucormycosis. In our tertiary care teaching hospital we saw that patients suffering from Covid‑19 infections developed mucormycosis. We present these cases in our study. To study the clinical,demographical,and Laboratory parameters in Covid‑19 patients with Mucormycosis. Material and Methods: Retrospective Study. All biopsy proven cases of Mucormycosis (which developed after Covid‑19 infection) were included. Relevant Clinical Demographics and Laboratory data was retrieved from the available case sheets. The data was tabulated in Excel sheet and further reviewed. Results: A total of 22 patients were diagnosed as suffering from mucormycosis majority were unvaccinated. 11 patients out of 22 (50%) started manifesting mucormycosis within one week of COVID infection. All the patients who had only single comorbidity (22.72%) suffered from mild disease and patient who had more than one comorbidity suffered from moderate (27.27%) to severe (50%) COVID infection. Conclusion: It is suggested that patients with Covid‑19 infection are at risk for development of opportunistic fungal infections like Mucormycosis. Hence the physicians who are involved in treating such patients must be mindful of the fact that mucormycosis can develop in them. Histopathology helps in establishing a concrete diagnosis of Mucormycosis
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“Right to health” is a universal right inclusive of a culture of safety. This review aims to highlight how clinical microbiology laboratories can contribute to patient safety. They can bring down medical errors through clinical collaboration and quality control. Timely and accurate inputs from microbiology laboratory help in clinical correlation and aid in safe patient care. Through internet search, using keywords such as “medical errors” and “quality assurance,” global burden of medical errors has been compiled. References have been taken from guidelines and documents of standard national and international agencies, systematic reviews, observational studies, retrospective analyses, meta-analyses, health bulletins and reports, and personal views. Safety in healthcare should lay emphasis on prevention, reporting, analysis, and correction of medical errors. If not recorded, medical errors are regarded as occasional or chance events. Global data show adverse events are as high as 10% among hospitalized patients, and approximately two-thirds of these are reported from low- to middle-income countries (LMICs). This includes errors in laboratories as well. Clinical microbiology can impact patient safety when practiced properly with an aim to detect, control, and prevent infections at the earliest. It is a science that integrates a tripartite relationship between the patient, clinician, and a microbiology specialist. Through collaborative healthcare, all stakeholders benefit by understanding common errors and mitigate them through quality management. However, errors tend to happen despite standardization and streamlining all processes. The aim should be to minimize them, have fair documentation, and learn from mistakes to avoid repetition. Local targets should be set and then extended to meet national and global benchmarks.
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Introduction:Patients with COVID pneumonia, who did not respond to high‑flow oxygen by nonrebreathing mask (NRBM), needed additional support to deliver oxygen with pressure. We present our innovation to use Bain’s circuit to deliver continuous positive airway pressure (CPAP) along with 100% oxygen in patients with COVID‑19 when there was a shortage of respiratory support equipment. Materials and Methods: It is a retrospective observational study conducted at two high‑volume, government‑designated, tertiary level COVID centers of Northern India, during May and June 2021. After taking informed consent from all patients included in the study, a nonventilated noninvasive ventilation (NIV) mask was used as the interface between Bain’s circuit and the patient for making a tight seal. Vital parameters were recorded on admission, before putting the patient on Bain’s circuit, at 30 min, and 6 h after the initiation of Bain’s circuit. Results: Forty‑five patients were enrolled in this study. There was a significant reduction in the work of breathing after the application of Bain’s circuit. Vital parameters show improvement of the condition. Sensorium also showed a significant improvement after the application of Bain’s circuit. Overall, 40% of patients who received Bain’s circuit were weaned off to oxygen by NRBM, 31.1% of patients were bridged to NIV, and 28.9% of patients got intubated. Conclusion: The aim of presenting our experience is to generate interest regarding innovations in the face of crisis which may not be perfect but are practical for the situation. We do not recommend the use of Bain’s circuit to provide NIV support under normal circumstances. Further studies are needed to support the use of Bain’s circuit with modifications as a CPAP/NIV delivering device in selected patients.
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Seasonal labor migration is a vital aspect of livelihood in rural and tribal regions of India. Females are paid less than males for the same amount of work. Contractors are unwilling to hire female menstruating laborers as menstruation and pregnancy are considered as roadblocks. The worry of hefty fines for absence pushes girls to get their uterus removed as menstruation & pregnancy may require them to pass work opportunities. This review aims to summarize the prevalence of hysterectomies among these women, and tries to understand the mindset behind the same. In 2018, 36% of female sugarcane laborers in the State had undergone a hysterectomy. While the rate of hysterectomies among women aged between 15- 49 years at the all-India level is 3.2%, the hysterectomy rate in the state of Maharashtra is 2.6%. Our findings revealed several studies and newspaper articles showing the prevalence of irrational hysterectomies among the unorganized migratory farm laborers as a result of work-related pressures, a grossly unregulated private medical sector and exploitative contractors who hire them
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Purpose: To determine the effect of depth of scleral tunnel incision measured by anterior segment OCT on postoperative corneal astigmatism by comparing the change of magnitude of corneal astigmatism between superficial and deep sclerocorneal tunnel incision in manual small?incision cataract surgery (SICS). Methods: Depths of sclerocorneal incision of 72 eyes of patients undergoing uncomplicated manual SICS and attending regular follow?up schedule were assessed with anterior segment OCT at 6?week post?op follow?up. Results: The overall mean ± standard deviation (SD) change of astigmatism for superficial incision, that is, ?399 ?m, was 0.44 ± 0.30 and that for deeper, that is, ?400 ?m, was 0.13 ± 0.48 and the change was significantly higher in ?399 ?m group than in ?400 ?m group (P = 0.003). In both superior and temporal incision locations, the mean ± SD change of astigmatism for ?399 ?m incision was 0.48 ± 0.29 and 0.40 ± 0.30, respectively, and that for ?400 ?m was 0.03 ± 0.34 and 0.23 ± 0.57, respectively. The change of astigmatism was significantly higher in ?399 ?m incision group overall (P = 0.003) and also higher in both superior and temporal incision location groups (P = 0.001 and P = 0.479, respectively). Conclusion: The depth of sclerocorneal incision had a statistically significant effect on the change of astigmatism following manual SICS, with superficial incision (?399 ?m) causing a higher change than deeper incision (? 400 ?m).
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Introduction: The kidneys—the main organs of the excretory system, are supplied by a paired renal artery, originating from the Abdominal Aorta at the level of a disc between L1 and L2 and drained by a paired renal vein exiting from the hilum of the kidney to the Inferior vena cava. Aim: To evaluate the morphology of renal vessels, their variations & clinical implications during renal surgeries in the subjects of the North India population by contrast-enhanced MDCT. Materials and Method: The present study was conceptualized & carried out in the Department of Anatomy, in collaboration with the Department of Radiodiagnosis, Santosh Medical College & Hospital, Ghaziabad and from Dr. O.P Gupta Imaging Centre, Meerut. This study was performed on the 108 patients who were referred for abdominal CECT examination with suspected abdominal pathologies. Contrast-enhanced MDCT scan images of the Abdomen were reviewed for normal anatomy of renal vessels and their variants. Result: Out of 108 patients, anatomical variations of the renal vessel were found in 72 (66.66%) patients. Variations of the renal artery were found in 56 patients (51.85%). Out of these 56 patients, 47 had supplementary renal artery, 17 had early branching of the renal artery and 8 patients had both supplementary and early branching of the renal artery. Supplementary renal arteries were seen in 15 patients on the right side, 16 patients on the left side & 16 patients bilaterally. Earlier branching of the renal artery was found in 9 patients on the right side, 10 patients on the left side and in 2 patients bilaterally. Variations of the renal vein were more commonly found on the right side, late renal vein confluence was seen in 28 (25.92%) patients and supplementary renal veins in 9 (8.3%) patients. On the left side, 2 (1.85%) patients had late renal vein confluence and 2 (1.85%) patients had retroaortic vein. Conclusion: Variations of the renal artery are found frequently. Morphological evaluation of renal vessels is useful for planning and performing the endovascular, laparoscopic and urological procedure.
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Introduction: Even with the adequate use of diuretics and vasodilators, volume overload and congestion are the major causes of morbidity and mortality in patients hospitalized with acute heart failure (HF). We aim to evaluate the additive effect of tolvaptan on efficacy parameters as well as outcomes in hospitalized patients with HF. Methods: We searched PubMed, EMBASE, Cochrane library, and Web of Science databases for randomized controlled trials that studied the effects of tolvaptan versus placebo in hospitalized patients with HF. Studies were included if they had any of the following endpoints: mortality, re-hospitalization, and inhospital parameters like dyspnea relief, change in weight, sodium, and creatinine. Results: The meta-analysis analyzed data from 14 studies involving 5945 patients. The follow up duration ranged from 30 days to 2 years. Between tolvaptan and placebo groups, there was no difference in mortality and rehospitalization. HF patients had a better dyspnea relief score (Likert score) in tolvaptan group and mean reduction in weight in the first 48 h (short-term). However, at 7 days (medium-term) the mean difference in weight was not significant. Serum sodium increased significantly in tolvaptan group. There was no difference in creatinine among the two groups. Conclusions: Our meta-analysis shows that tolvaptan helps in short-term symptomatic dyspnea relief and weight reduction, but there are no long term benefits including reduction in mortality and rehospitalization.
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Background: Pelvi-ureteric junction obstruction (PUJO) is defined as anatomical or functional obstruction to the flow of urine from the pelvis to the upper ureter. This may be unilateral or bilateral. Most of the hydronephrosis cases are due to Pyelo-ureteral junction obstruction (PUJO) which can be diagnosed antenatally. The treatment protocol for antenatal diagnosed PUJO is standardized. Few children present later in life. Present study was done to evaluate clinical profile and outcome of infants and children (<12years) presenting with PUJO. Methods: A retrospective observational study conducted by the department of Paediatric Surgery, SDM hospital Dharwad. All children with age less than 12 years with PUJO from March 2017 to March 2020 were included in the study (n=51). Initial evaluation was done with Ultrasound KUB (Kidney, Ureter, Bladder). A diuretic renogram/ EC (Ethylene cysteine) was done to confirm the diagnosis. The children were managed both conservatively and surgically (Pyeloplasty), depending on the presentation. The children were followed up post-surgery. Results: Fifty one patients were included in the study. Mean age of presentation was 31±30 months. Most common presentation was pain abdomen which was seen in 9 patients (17.6%). 6 patients (11.7%) presented with Lump and 2(4%) presented with fever. Left kidney was commonly involved (66%). Males predominate (80%). The mean antero-posterior pelvic dimension (APPD) of involved kidney was 30mm with range from 12.5mm to 68mm. 4 (7.8%) children presented with poorly functioning kidney with split renal function less than 10%. PUJO was associated with Pelvic calculi, VUR, Horseshoe kidney, Mal-rotated kidney. Out of the 51 patients, 9 (17.6%) were kept in conservative management 42 (82.3%) underwent Pyeloplasty. Among 42, 1 underwent redopyeloplasty and 1 underwent nephrectomy. In rest of the operated patients (Post-pyeloplasty) diuretic renogram showed improved drainage with improved function. Conclusions: PUJO is common cause of urinary obstruction in children. Earlier the diagnosis, better the outcome. Delay in diagnosis or presentation leads to increased chances of renal damage and loss. Hence it is important to diagnose PUJ obstruction at the earliest and receive prompt treatment.
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Oral health influences general well-being and quality of life. Oral diseases can be debilitating and are amajor heath concern worldwide. Medicinal plants have been used for thousands of years for treatinghuman diseases. Considering the emergence of multi-drug resistant pathogens and financial difficultiesin developing countries, there is an urgent need for developing new antimicrobial compounds which aresafe, efficient and cost effective. Liquorice also known as yashtimadhu, sweetwood or mulhatti is onesuch herbal remedy which has shown to have immense potential in treatment of orofacial diseases.Liquorice is rich in secondary metabolites which are used in cosmetics, foods, traditional and modernmedicine. It has well known properties such as antiviral, glucocorticoid, anti-inflammatory, antioxidant,anti-ulcerative, anti-carcinogenic and many more. Liquorice extracts and liquorice bioactive ingredientssuch as glabridin, licoricidin, licorisoflavan A, licochalcone A, and glycyrrhizin have shown beneficialeffects in preventing and treating oral diseases. This paper reviews the effects of liquorice and its constituents on oral diseases such as dental caries, periodontitis, gingivitis, candidiasis, recurrent aphthousulcer and oral cancer and its use as a root canal medicament and summarizes the results of clinical trialsthat investigated the potential beneficial effects of liquorice and its constituents as a prevention andtreatment modality in oral diseases. Clinical trials, case reports and review of literature evaluating theeffect of liquorice on oral microorganisms and oral diseases are included. Literature pertaining to theeffects of liquorice on systemic diseases have been excluded from this review of literature.© 2018 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services byElsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Abstract: Today's, consumers are concerned about the meat they eat and also demandaccurate labeling. Mitochondrial Analysis of DNA was the most frequently used DNA, becauseof its highly conserved sequences in various organism species. In this study, a rapid,reproducible and simple method for simultaneous identification of multiple meat species ina single step mitochondrial DNA based test has been developed based on the designing ofspecies-specific primer. Meat samples of goat and buffalo were selected to verify theapplicability of the technique. A species specific forward and reverse primer was designedwith the help of the primer3 tool for amplification of mitochondrial D-loop region. Thespecies-specific primers were verified in silico by SnapGene software. The two pairs ofprimers amplified the expected fragment of 338bp for buffalo and 450bp for goat. The changein the size of the PCR product was due to the existence of highly polymorphic regions withinthe buffalo and goat D-loop region. The tested species gives a unique band pattern for eachspecies by using successful amplification of these polymorphic regions in the D-loop region.Overall, the simplicity of amplification of mitochondrial D-loop region could make thistechnique suitable for meat authentication in routine analysis.
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Antheraea assamensis Helfer, popularly known as Muga silkworm, the golden silk producer of Northeast India, is economically important and unique among the Saturniid silkworms. Muga silkworm is said to exhibit three semi-domesticated morphs i.e. green, blue, orange and one wild morph. In this study, the genetic diversity and phylogeny among the morphs of Muga silkworm collected from various geographical locations of Northeast India were investigated using RAPD and internal transcribed spacer DNA1 (ITS1) sequences. Thirty random primers generated 192 discrete bands; 123 of them were polymorphic (64.062%). The average amplicon per primer was found to be 6.4. In RAPD analysis, a wide range of genetic distance i.e. 0.0544-0.6228 was observed among the morphs. In the ITS1 sequence analysis, 35.35% of polymorphism and a range of genetic distance from 0.0024 to 0.2349 were observed. The phylogenetic trees based on RAPD and ITS1 sequences comprised of two major clades. The first clade comprised of the semi-domesticated morphs while the second clade included the wild morphs of different geographical origin. The information generated in this study can be used for conservation of the Muga silkworm through effective breeding programs
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Background: Extracranial head and neck schwannomas are rare tumors which are often clinically misdiagnosed. Preoperative diagnosis of these tumors is challenging but imperative for surgeons so as to avoid nerve damage during excision. Materials and Methods: Sixteen patients diagnosed with extracranial head and neck schwannomas over a period of 2 years were retrospectively analyzed. Clinical details including preoperative fine-needle aspiration cytology (FNAC) and/or computed tomography (CT)/magnetic resonance imaging (MRI) findings were retrieved. FNAC smears and formalin-fixed paraffin-embedded sections were evaluated. Results: Among these 16 tumors, 6 (37.5%) were located in the lateral aspect of neck, 4 (25%) in scalp, 2 (12.5%) in orbit, and one each (6.25%) in palate, tongue, submandibular gland and parotid gland. The mean patient age was 31.3 years. FNAC was performed in 14 cases, of which 8 cases (58.3%) showed features of benign nerve sheath tumor (BNST), two cases (14.2%) were inconclusive with possibility of mesenchymal lesion, two cases (14.2%) were inadequate, one case (8.3%) showed features suggestive of schwannoma, and a diagnosis of nerve sheath tumor inconclusive for malignancy was rendered in a single case. The sensitivity of FNAC in diagnosis of BNST was 71.4%. CT or MRI was performed in five cases, of which an accurate diagnosis was rendered only in one case of orbital schwannoma. Conclusion: Imaging has a limited role in the preoperative diagnosis of head and neck schwannomas owing to nonspecific radiological features. Cellular aspirate smears are helpful in accurate diagnosis even at unusual locations
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PURPOSE@#Defects around the distal one third of the leg and ankle are difficult to manage by conservative measures or simple split thickness skin graft. Distally based peroneus brevis muscle flap is a well described flap for such defects.@*METHODS@#This is a retrospective analysis conducted on 25 patients with soft tissue and bony defects of distal third of lower leg and ankle, which were treated using distally based peroneus brevis muscle flap from January 2013 to January 2018. Information regarding patient demographics, etiology, size and location of defects and complications were collected. All patients were followed up for at least 3 months after surgery.@*RESULTS@#There were 21 males and 4 females with the mean age of 39 (5-76) years. The most common cause of injuries was road traffic accident, followed by complicated open injury. The average size of defects was 20 (4-50) cm. The mean operating time was 75 (60-90) min for flap harvest and inset. We had no patient with complete loss of the flap. Five patients (20%) had marginal necrosis of the flap and two patients have graft loss due to underlying hematoma and required secondary split thickness skin grafting.@*CONCLUSION@#The distally based peroneus brevis muscle flap is a safe option with reliable anatomy for small to moderate sized defects following low velocity injury around the ankle. The commonest complication encountered is skin graft loss which can be reduced by primary delayed grafting.