Assessment of Panoramic Radiographic Variables as Predictors of Inferior Alveolar Nerve Injury During Third Molar Extraction

ABSTRACT Objective: To assess the role of radiological predictive markers on orthopantomogram for inferior alveolar nerve (IAN) injury related to the removal of mandibular third molar surgery and the occurrence of post-operative IAN paresthesia. Material and Methods: This prospective observational study was conducted on 60 patients (aged 17-35 years) indicated for extraction and showed one or more of the seven previously known panoramic radiographic risk signs of IAN injury. Variables such as age, sex, tooth angulation, and relationship with the inferior alveolar canal (IAC) were assessed to see their outcome on IAN injury. Data analysis is presented through tables and descriptive methods. Results: Among patients, 26 were male and 34 were female, with a mean age of 26.17 years. Out of seven radiological predictive markers, only six were found in this study, whereas one marker, viz. interruption of white line of the canal was not found. After surgical removal of the lower third molar, only two patients with radiographic signs showing the deflection of roots and darkening of roots continued with sensory deficit 5 weeks post-operatively. Conclusion: The risk of inferior alveolar nerve injury during lower third molar surgery is very low, even in patients with radiological predictive markers.

Anesthetic and surgical considerations for staged bilateral nephrectomies in a pediatric patient: A case report / Consideraciones anestésicas y quirúrgicas en nefrectomía bilateral en dos tiempos en un paciente pediátrico: Reporte de caso

Abstract We present a 9-year-old patient with end-stage renal disease, on peritoneal dialysis, who underwent a staged prone retroperitoneoscopic bilateral nephrectomy. Bilateral nephrectomy was indicated in preparation for renal transplant in the context of genetic predisposition malignancy when immunosuppressed. The two mirror-image surgeries enable the comparison of the anesthetic management and outcomes in a single patient. Features of interest to anesthesiologists include approach to a child with chronic kidney disease, different requirements for intraoperative antihypertensives; pain management strategies, including a comparison of erector spinae plane block with and without adjunct dexmedetomidine; anesthetic management of retroperitoneoscopic pediatric surgery and the first description of using a Foley bag attached to a peritoneal dialysis catheter to aid in diagnosis and repair of posterior peritoneal cavity entry.

Resumen Se presenta un paciente de 9 años de edad con enfermedad renal terminal, en diálisis peritoneal, quien se sometió a nefrectomía bilateral retroperitoneoscópica estadificada en posición prona. Se indicó la nefrectomía bilateral en preparación para trasplante renal en el contexto de predisposición genética hacia desarrollar una patología maligna al estar inmunosuprimido. Las dos cirugías en espejo permiten hacer una comparación del manejo anestésico y de los desenlaces en un mismo paciente. Las características de interés para los anestesiólogos incluyen el abordaje de un niño con enfermedad renal crónica, con requisitos diferentes de antihipertensivos intraoperatorios; estrategias para el manejo del dolor, incluyendo una comparación de bloqueo del plano del erector espinal con y sin dexmedetomidina adyuvante; manejo anestésico de cirugía pediátrica retroperitoneoscópica y la primera descripción del uso de una bolsa Foley conectada a un catéter de diálisis peritoneal para ayudar en el diagnóstico y la reparación de la entrada de la cavidad peritoneal posterior.

Clinical applications of neurolinguistics in neurosurgery / 医学前沿

The protection of language function is one of the major challenges of brain surgery. Over the past century, neurosurgeons have attempted to seek the optimal strategy for the preoperative and intraoperative identification of language-related brain regions. Neurosurgeons have investigated the neural mechanism of language, developed neurolinguistics theory, and provided unique evidence to further understand the neural basis of language functions by using intraoperative cortical and subcortical electrical stimulation. With the emergence of modern neuroscience techniques and dramatic advances in language models over the last 25 years, novel language mapping methods have been applied in the neurosurgical practice to help neurosurgeons protect the brain and reduce morbidity. The rapid advancements in brain-computer interface have provided the perfect platform for the combination of neurosurgery and neurolinguistics. In this review, the history of neurolinguistics models, advancements in modern technology, role of neurosurgery in language mapping, and modern language mapping methods (including noninvasive neuroimaging techniques and invasive cortical electroencephalogram) are presented.

Cytotoxicity, Morphology and Chemical Composition of Two Luting Cements: An in Vitro Study

Abstract Objective: To assess the cytotoxicity, surface morphology, elemental compositions and chemical characterization of two commonly used luting cement. Material and Methods: The two luting types of cement used were Elite Cement® and Hy-Bond Resiglass®. Freshly mixed (n=6) and set form (n=6) of each cement was placed in medium to obtain extracts. The extract from each sample was exposed to L929 mouse fibroblasts (1x104cells/well). Alamar Blue Assay assessed cell viability. Surface morphology and elemental composition were evaluated using scanning electron microscopy and energy dispersive spectroscopy. The chemical characterization was performed by Fourier Transform Infrared Spectroscopy. One-way ANOVA and post-hoc Tukey analysis were conducted to assess results. Results: Hy-Bond Resiglass® was the more cytotoxic of the two types of cement in both freshly mixed (68.10 +5.16; p<0.05) and set state (87.58 +4.86; p<0.05), compared to Elite Cement® both freshly mixed (77.01 +5.45; p<0.05) and set state (89.39 +5.66; p<0.05). Scanning electron microscopy revealed a more irregular and porous structure in Hy-Bond Resiglass® compared to Elite Cement®. Similarly, intense peaks of aluminium, tungsten and fluorine were observed in energy dispersive spectroscopy in Hy-Bond Resiglass. Conclusion: All these three elements (aluminium, tungsten and fluorine) have cytotoxic potential. The Fourier transform infrared spectroscopy revealed the presence of hydroxyethyl methacrylate in Hy-Bond Resiglass®, which has a cytotoxic potential.

Effectiveness of anterior middle superior alveolar injection using a computer-controlled local anesthetic delivery system for maxillary periodontal flap surgery

BACKGROUND: Profound anesthesia with adequate duration is required in periodontal flap surgery, which involves the manipulation of both hard and soft tissues. The anterior middle superior alveolar (AMSA) injection may be an alternative to multiple injections required for this purpose in the maxilla. The present study aimed to assess the effectiveness of AMSA injection using computer-controlled local anesthetic delivery (CCLAD) system to anesthetize buccal hard tissue (BHT), buccal soft tissue (BST), palatal hard tissue (PHT), and palatal soft tissue (PST) around the maxillary teeth. METHODS: Thirty-five patients who were indicated for open flap debridement in a whole maxillary quadrant were given AMSA injection using the CCLAD. The effectiveness of anesthesia was evaluated using subjective and objective parameters around each tooth. Supraperiosteal infiltrations were administered to complete the surgery wherever the AMSA injection was ineffective. RESULTS: The AMSA injection was more effective on the palatal tissues than on the buccal tissues, as 94.14% of PST and 87.89% of PHT sites were anesthetized compared to 49.22% and 43.75% of BHT and BST sites, respectively. There was no significant difference in the frequency of anesthesia around the anterior and posterior teeth. The PHT was significantly more anesthetized (P = 0.003) in males than in females. CONCLUSIONS: The AMSA injection using CCLAD is highly effective on palatal tissues and could be used as a first-line anesthesia for periodontal flap surgery. However, its effect on buccal tissues is less predictable, with supraperiosteal infiltration often required to supplement the AMSA injection.

Species richness of scavenger insects on different carcass types

@#The type and amount of resources available significantly influences the structure and dynamics of food webs. In this study, we analyzed differences in species richness of scavengers based on carcass type in Riyadh, Saudi Arabia. We collected insects from experimental carcasses of three different types, domestic dogs (Canidae, Canis lupus familiaris), Hijazi goats (Bovidae, Capra aegagrus hircus), and camels (Camelidae, Camelus dromedarius). Data collection was conducted during the decay stage in June, 2016. We used mitochondrial cytochrome c oxidase subunit I (mtCOI) barcodes as a marker for the molecular identification of the scavenger insects. The results showed that there were more insects on the camels and goats than the dogs. In total, seven species were found on all carrions. Six species were found on the camels and goats, but only five were found on the dog. Musca domestica was the most collected species of flies whereas, Necrobia rufipes was the most collected species of beetles. Overall, this study showed that carrion type had an effect on the type and number of insects attracted to the carrions. Thus, one of the significant factors that influence the associated scavenger assemblage is a carcass type.

Association of Cord Blood Telomere Biology with Mother’s Education

Background:Telomere, the biological chronometer, has been found to be influenced by different parameters which are reprogrammed during fetal life.This study was designed to find out influence of education on relative telomere length (RTL) of the maternal and new born and to detect improvement in the genetic remodeling during the fetal life between low and high educational levels of mother.Methods:Pregnant females(18-37 years) and their newborns (n=250) were recruited from Karachi hospitals. In this cross-sectional study RTL (maternal and cord) was calculated by Quantitative real-time PCR. Statistical analysis used were chi square tests and Mann Whitney U test for variables with two categories and then Kruskal Wallis for variables with more than two categories to examine mean difference between relative telomere length(RTL) and maternal education. The relationship between predictor variable(education) and RTL was done by linearregression.Results: A significant association of education and RTL revealed shorter mean maternal RTL(base pair(bp)) 6380±1128 among females with low education and longer 6553±945 in high education females respectively (p=0.071) (B= 0.009 p= >0.05). Similarly, cord RTL were shorter 6600±1218 in low and longer 7154±1585 in high educationgroup(p=0.007)(B= 0.184 p = <0.05) at 95% confidence level.It was also found that newborn among high education with upper middle Socioeconomic status (SES) have significantly longest RTL 7262±1804(p=<0.05).Conclusion: Overall longer newborn RTL than mothers were observed among different levels of education in targeted population of Karachi where higher education have a shielding effect on telomere remodeling during the fetal development

Oropharyngeal, hypopharyngeal and cervical esophageal reconstruction: an experience of pedicle flaps

Objective: To review the experience of single-stage reconstruction following pharygolaryngectomy and cervical esophageal defect with pedicle flaps in a tertiary care centre

Study Design: Retrospective study

Place and Duration of Study: Jinnah Burn and Reconstructive Surgery Centre, Lahore, from June 2007 to June 2017

Methodology: All patients who underwent oropharyngeal, hypopharyngeal and cervical esophageal reconstruction with pedicled flaps were included

Results: Thirty-two reconstructions were done, of which 16 [50.0%] were supraclavicular flaps, 12 [37.5%] were pectoralis major myocutaneous flaps [PMMF] and 4 [12.5%] platysma myocutaneous flaps [PMF]. Among these, 24 [75%] were males and 8 [25%] females. The mean hospital stay was 18.75 +5.45 days. Complications were noted in 12 [37.5%], salivary fistula being the most frequent found in 6 [18.75%]. Wound dehiscence was noted in 4 [12.5%], partial flap necrosis and wound infection present in 1 [3.1%] each

Conclusion: Oropharyngeal, hypopharyngeal and cervical esophageal reconstruction with pedicle flaps is still very useful and safe to perform, associated with minimal flap and donor site complications

Root coverage by modified coronally advanced flap with and without platelet-rich fibrin: A clinical study

Marginal gingival recession can cause major functional and esthetic problems. Advanced flaps are the simplest, yet unpredictable procedures for managing these conditions. The predictability of root coverage can be increased by combining coronally advanced flap (CAF) or its modified approach with other regenerative techniques. Objective: To ascertain the potential benefits of platelet-rich fibrin (PRF) on modified CAF for the treatment of gingival recession. Materials and Methods: Study comprised of 12 patients with Millers' class I and class II gingival recession in two non-adjacent anterior teeth having a minimum 3 mm width of attached gingiva. Following split-mouth design, one tooth with gingival recession was subjected to modified CAF, while another was treated by CAF with PRF. The clinical parameters, i.e., plaque index, modified sulcular bleeding index, vertical gingival recession depth (VGRD), gingival recession width (GRW), clinical attachment level (CAL), and gingival thickness (GT) were recorded at baseline, 1 month, 3 months, and 6 months. Results: VGRD, GRW, CAL, and GT improved significantly from baseline to 1 month in both test and control groups. However, change in these parameters from 1 month to 3 months and 3 months to 6 months were statistically nonsignificant in both groups. On intergroup comparison, only the change in GT was found to be statistically significant (P < 0.05) at all three post-treatment visits. Conclusion: Benefits of the combined technique in terms of increased GT appear to justify the use of PRF along with modified CAF for the treatment of mild to moderate gingival recessions.

Comparison of anxiety and pain perceived with conventional and computerized local anesthesia delivery systems for different stages of anesthesia delivery in maxillary and mandibular nerve blocks

BACKGROUND: Fear of local anesthesia (LA) is a significant impediment to dental care as many patients delay or avoid treatment to avert pain. Computer-controlled local anesthetic delivery system (CCLAD), with constant and controlled rate of flow, present a painless alternative. The present study aimed to compare anxiety and pain perceived with conventional and computerized systems, for different stages of anesthesia delivery when administering various nerve blocks. METHODS: One hundred patients requiring bilateral LA participated in the study. One side was anesthetized using one system and the contralateral side was anesthetized using the other, in two separate appointments. Patients assigned anxiety scores on a 5-point scale and used the visual analogue scale (VAS) for pain determination at needle insertion, during delivery of anesthetic solution, immediately after injection, and at the end of the periodontal procedure. Each patient's preference for the delivery system of future injections was also recorded. RESULTS: Patients reported significantly lower anxiety levels with CCLAD compared to the syringe. Significantly lower mean VAS scores for anesthesia deposition, pain immediately after, and at the end of the periodontal procedure were also noted. However, pain at needle insertion was comparable between the two systems, with no statistical significance. Overall, 64.4% patients preferred CCLAD for future anesthesia. CONCLUSION: Lower pain perceived with CCLAD and higher preference for the system suggest that CCLAD should replace conventional syringes to allow pain-free dental treatment.

Phenotypic and metabolic dichotomy in obesity: clinical, biochemical and immunological correlates of metabolically divergent obese phenotypes in healthy South Asian adults

<p><b>INTRODUCTION</b>Metabolic heterogeneity among obese individuals is thought to translate into variations in cardiovascular risk. Identifying obese people with an unfavourable metabolic profile may allow preventive strategies to be targeted at high-risk groups. This study aimed to identify clinical, biochemical and immunological differences between insulin-sensitive and insulin-resistant obese subgroups, to understand the population-specific pathophysiological basis of the adverse cardiovascular risk profile in the latter group.</p><p><b>METHODS</b>Cardiovascular risk indicators, including anthropometric parameters, blood pressure, acanthosis nigricans area, and related biochemical, endocrine and inflammatory markers, were determined in 255 healthy South Asian volunteers aged 18-45 years, with a 2:1 ratio of obese/overweight to normal-weight individuals. Lifetime atherosclerotic cardiovascular disease (ASCVD) risk was also calculated.</p><p><b>RESULTS</b>Body mass index (BMI) and insulin sensitivity-based tertiles independently showed incremental trends in waist-hip ratio, skinfold thickness, acanthosis nigricans area, blood pressure, serum lipids, hepatic enzymes, adipokines, inflammatory markers and ten-year ASCVD risk. The anthropometric, biochemical and inflammatory parameters of obese insulin-sensitive and obese insulin-resistant groups differed significantly. Extreme group analysis after excluding the middle tertiles of both insulin resistance and BMI also showed significant difference in anthropometric indicators of cardiovascular risk and estimated lifetime ASCVD risk between the two obese subgroups.</p><p><b>CONCLUSION</b>Obese insulin-sensitive individuals had a favourable metabolic profile compared to the obese insulin-resistant group. The most consistent discriminative factor between these phenotypic classes was anthropometric parameters, which underscores the importance of clinical parameters as cardiovascular risk indicators in obesity.</p>

Spectrum of firearm related deaths in multan city: autopsy based study

Background: Excessive use of the firearms causing severe and lethal effect to the victims and their families, delivery of health care and judicial system as well as society where they live. The easy availability of guns has increased the firearm fatalities, especially in developing countries

Objectives: To study the pattern of lethal firearm injuries, in Multan city with special reference to the regions of the body affected, seasonal variation and vulnerable age group

Study design: Retrospective study

Setting and duration: The study was carried out by examining the record of all medicolegal autopsies conducted in the department of Forensic Medicine, Nishtar Medical College Multan during calendar year 2016. Only cases of firearm related deaths were selected for detailed examination and those died of other than firearm injuries were excluded. The reports were studied in relation to Age, types of firearm used, Gender, seasonal variation and regions of the body involved

Results: During 2016, out of total 197 medicolegal autopsies, 77[39.08%] died of firearm injuries and out of those, male victim were 67[44.66%]. The most vulnerable age was 19-40 yrs [45.45%]. Male female ratio was 6.4:1, the chest being the commonest targeted area was38.96%, while during the months of July and August highest incidence of deaths due to firearm observed [15.57%]

Conclusion: The young males are the most common target and the leading cause of death was the injuries on the chest. There is need of strict implementation of law regarding possession of firearm and improvement in socioeconomic conditions of the individuals

Preference of contraceptive methods among married women of rural area of faisalabad

Objectives: To get information regarding the most preferred contraceptive method used by married women of rural area of Basic health unit [BHU] 96/GB of Faisalabad

Method: The cross-sectional study was conducted on 300 married women of rural areas with different socio-demographic factors, age groups, and family backgrounds. A structured questionnaire consisting of open ended and close ended questions was made, and pre-tested. Face to face interviews of those willing women were done at their residence with the help of a trained Lady Health Workers [LHWs] and the 100% response rate achieved. Non-probability sampling[convenient] was adopted to include willing married female. Statistical Package for the Social Sciencesp-19 was used for analysis and descriptive statistics were calculated

Results: Out of 300 participants majority of women 129[43%] are using Combined Oral Contraceptive Pills [OCP] followed by condoms 65[21.6%] and natural method [exclusive breast feeding] 40[13.6%]. Majority of women 125[41.6%] have been taking contraception for 1-2 years. Most participants 217[90.3%] were of age 27-36 years along with majority of participants were having gravidity and parity of 4-6 each. Opinion of better family well-being was given by 110[36.6%] women after taking contraception for family planning. Major side effect of nausea and vomiting noticed among 35[11.6%] user of oral contraceptive methods

Conclusion: Oral contraceptive pills are the most commonly used contraceptive method among married women. The reason of this preference is availability of combined oral contraceptive pills at basic health units. These OCP delivered through lady health workers increased the number of women taking contraception for family planning. It is also related with increased awareness about family wellbeing and health of mother

Comparison of Paramedian with Midline technique of Spinal Anaesthesia in elderly

Objective: To compare the technique of paramedian with midline approach of subarachnoid block in terms of number of attempts and frequency of success rate in elderly patients undergoing elective lower body surgeries

Study Design: Randomized controlled trial

Place and Duration of Study: This study was carried out at Anaesthesia department of Combined Military Hospital Lahore. Six months from Jan 2014 to Jun 2014

Material and Methods: One hundred and seventy elderly patients were scheduled for lower body surgery, using spinal anaesthesia. They were randomized to either Midline approach [n=85] or Paramedian approach [n=85] by lottery method. The outcome measures number of attempts and success rate were noted in both groups and analyzed using SPSS version 18

Results: The successful block in first attempt was 95.3 percent in Paramedian group and 58.8 percent in Midline group. Mean number of attempts in paramedian group was 1.24 +/- 0.52 as compared to 1.95 +/- 0.97 in midline group. A p-value <0.05 was taken significant

Conclusion: The Paramedian technique was found associated with higher success rate, lesser possibility of repeated number of attempts in elderly patients as compared to Midline approach

Role of Pancreatic Stent placement in prevention of post Endoscopic retrograde Cholangiopancreatography Pancreatitis: experience at a tertiary care hospital in Pakistan

Objective: To determine the frequency of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis [PEP] in patients who underwent prophylactic pancreatic duct stenting

Study Design: Descriptive case series

Place and Duration of Study: This descriptive case series was conducted at the department of Gastroenterology, Pak Emirates Military Hospital Rawalpindi, from Jul 2017 to Feb 2018

Material and Methods: One hundred and twenty consecutive patients were enrolled after they met inclusion and exclusion criteria. Endoscopic Retrograde Cholangiopancreatography Pancreatitis [ERCP] was performed by Olympus duodeno scope [TJF Q180V] by an endoscopist having at least 3 years experience of performingindependent ERCPs. An additional 4, 6, or 7cm long 5FrGeenen[registration sign] pancreatic plastic stent [Cook Medical] was placed in all cases where pancreatic duct was accidentally cannulated. Primary outcome variable was post ERCP pancreatitis. Data was recorded on a pre-designed proforma and analyzed by SPSS version 21.0

Results: Out of total 120 cases, PEP was found in 4 [3.3 percent] patients. All the 4 patients had mild pancreatitis

Conclusion: PEP is not an uncommon complication following ERCP. The rate of PEP appears to be lower with prophylactic pancreatic duct stenting

Comparison of effect of Olanzapine and Resperidone on Serum Prolactin levels in patients with first episode Psychosis

Objective: To compare frequency of Hyperprolactinemia with Risperidone and Olanzapine in patients with first episode psychosis

Study Design: Randomized controlled trial

Place and Duration of Study: Combined Military Hospital [CMH] Lahore, over a period of six months from Sep 2015 to Feb 2016

Subjects and Methods: Total 60 patients who had psychosis as accompanying feature in any of the various psychiatric illnesses according to ICD-10 diagnostic criteria were enrolled in this Randomized controlled Trial. Fasting venous blood samples for serum prolactin were collected between 0800 hrs and 1000 hrs at baseline [first visit]. The patients were then randomly assigned to receive risperidone or olanzapine by lottery method. Serum prolactin levels were then collected at 3 months follow-up visit. All samples were tested in labortary of Pathology department, CMH Lahore for measurement of serum prolactin levels and results were verified by a classified pathologist. Confounding variables were identified and excluded by exclusion criteria

Result: A total of 35 patients [58.33 percent] developed hyperprolactinemia. The olanzapine group showed 13 out of 30 patients [43.33 percent] and risperidone group showed 22 out of 30 patients [73.33 percent] with raised prolactin levels with p-value of 0.018 indicating that the difference was statistically significant

Conclusion: Frequency of hyperprolactinemia is high with risperidone than with olanzapine in first episode psychosis

Extended islanded reverse sural artery flap for staged reconstruction of foot defects proximal to toes

Objective: To assess the outcome of extended delayed reverse sural artery flap for reconstruction of foot defects proximal to toes in terms of flap survival, complication and extended area

Study Design: Case series

Place and Duration of Study: Jinnah Burn and Reconstructive Surgery Centre, Lahore, from February 2015 to April 2017

Methodology: Cases who underwent delayed sural artery flap were inducted. Preoperative hand-held doppler was done to confirm the location of perforator. Two suitable perforators were chosen to raise the extended flap by crossing the proximal limit in all cases. The pedicle was kept minimum 3 cm wide and perfusion was assessed. Flap was delayed for one week and vaccum-assisted closure [VAC] dressing was applied over wound. The second surgery was performed after one week. Proximal perforator was clamped and ligated after checking adequate perfusion of flap. Flap was insetted into defect

Results: Thirty-two patients were reconstructed with delayed reverse sural artery flap. The mean age of the patients was 26.5 +12.2 years. Twenty-four [75%] patients were males and 8 [25%] were females. Twenty-two [68.7%] cases were degloving wounds after road traffic accidents [RTA], 6 [18.7%] were diabetic foot wounds, 4 [12.5%] sustained injury after falling from height and 7 [21.8%] patients had fracture of metatarsals. Twenty-eight flaps were transferred after one week delay, and only in 4 cases, flap were transferred after two weeks. All flaps survived completely. Complications of infection noted in 3 [9.3%] flaps, 3 [9.3%] flaps showed tip necrosis, 2 [6.2%] flaps undergone epidermolysis and only 2 [6.2%] showed venous congestion

Conclusion: Delayed islanded reverse sural artery perforator flap is a reliable and versatile option for resurfacing soft tissue defects of lower limb proximal to the toes with lesser complications and extended coverage area

Distally based medial hemisoleus flap: reliable option for distal tibial wounds

Objective: To determine the success [flap survival as a whole without necrosis or dehiscence up to two months as judged clinically] of distally based medial hemisoleus muscle flap for the coverage of distal tibial defects

Study Design: Case series

Place and Duration of Study: Jinnah Burn and Reconstructive Surgery Centre, AIMC, Lahore, from July 2014 to July 2017

Methodology: Patients with middle and distal third tibial defects were enrolled and stratified according to the site of the wound in middle or distal third of tibia. Soft tissue coverage was provided with distally based medial hemisoleus muscle flap on which split thickness skin graft was applied. Postoperatively, patients were followed-up after one week of discharge and then fortnightly for at least 2 months. Outcome variable was taken as flap success

Results: Out of 37 cases, flap was successful in 33 patients as complete flap survived with primary wound healing. Partial flap necrosis without dehiscence was seen in 3 cases and partial necrosis of flap with dehiscence in only one case that required another surgery for the defect. Complete flap loss was not seen in any case

Conclusion: Distally based medial hemisoleus muscle flap is reliable coverage option for middle and distal third of tibial defects

Impact of depressed skull fracture surgery on outcome of head injury patients

Objective: To assess outcomes in surgically managed patients with depressed skull fractures and associated moderate to severe head injury

Methods: The study was conducted in the Department of Neurosurgery Jinnah Postgraduate Medical Centre, Karachi, from January 2016 to December 2017. We analyzed 90 patients with depressed skull fracture managed surgically from January 2015 to December 2016. The patients selected for this study belonged to all age groups with clinically palpable depressed skull fracture confirmed by CT brain with bone window. Outcome was assessed by Glasgow outcome score

Results: Total 90 patients were included in the study. Sixty [66.7%] were male and 30 [33.3%] were female with mean age of years 27.58+11.329. Among 90 patients, 38.8% were aged between 21 and 30 years. Road traffic accident was seen in 72 [80%] patients. The commonest site of fracture was frontal region in 50 patients [55.6%]. GCS improved post operatively on comparison to preoperative. Five patients expired

Conclusion: Depressed skull fracture is common neuro surgical issue. Timely surgical management gives excellent results by decreasing morbidity and mortality