Robotic-assisted free flap harvesting for diverse soft tissue reconstruction: a PRISMA scoping review of clinical outcomes over the last decade.

Introduction: The aim of our study was to assess the advantages and limitations of robotic technology in diverse reconstructive procedures. METHODS: A scoping review was conducted in Oct'23, on published studies from 2013 to 2023, focussing on robotic-assisted free flap harvesting. Three databases Ovid-MEDLINE, Scopus, and PubMed were searched. Original research studies reporting robotic-assisted free flap harvest were included. Studies on lesion excision, microvascular anastomosis, local flap harvest, roboticassisted flap inset, review articles, abstract-only studies, non-English documents, and animal studies were excluded from this review. RESULTS: Sixteen studies met the inclusion criteria out of a total of 318, searched initially. These studies included a total of 128 patients, who underwent robotic-assisted free flap harvest for the reconstruction of various defects, with 140 free flaps harvested. The most common flaps harvested by robotic technique were deep inferior epigastric artery perforator (DIEP) flap 120 (85.7%), radial forearm free (RFF) flap 11 (7.9%), latissimus dorsii flap 4 (2.9%), rectus abdominus flap 4 (2.9%), and omental flap 1 (0.7%). Breast reconstruction was the major procedure done i.e. 120 (85.7%) followed by head and neck 11 (7.9%) and limb defects 9 (6.4%) reconstruction procedures. The reported clinical outcomes were acceptable in all the studies with a 99% flap success rate and minimal complications. Variability in operating time was observed depending upon surgical steps undertaken with robotic systems. CONCLUSIONS: This scoping review highlights the role of robotic-assisted free flap harvesting in plastic surgery and its potential benefits on clinical outcomes, due to its high precision and minimal invasiveness. However, challenges like cost effectiveness, resource distribution and learning curve are there.

A prospective randomized control trial comparing outcomes of casting, pinning, and plating for distal end of radius fractures (AO type A2, A3, C1, or C2) in the elderly population.

PURPOSE: With this prospective randomized control trial (RCT), we aim to provide the outcome analyses of the three most used treatment modalities for distal end of radius (DER) fracture management in the elderly. METHODS: A prospective randomized control trial was performed. Fifty-two patients with DER fractures (AO A2, A3, C1, or C2) were randomized to the casting (n = 17), percutaneous pinning (n = 18), and the volar plating group (n = 17). Radiological measurements measured were radial inclination (RI), radial height (RH), volar tilt (VT), and ulnar variance (UV). The outcome was measured based on range-of-motion, grip strength, Patient-Related-Wrist-Evaluation (PRWE) score, and the Quick-Disabilities-of-the-Arm-Shoulder-Hand (QDASH) score. RESULTS: Immediate post-operative and 1-year-follow-up X-rays showed a significant difference measurement between the groups (p < 0.05). Pairwise comparisons of the casting and pinning groups (p < 0.05) and the casting and plating groups (p < 0.05) revealed significant differences at the 1-year follow-up, but not the pinning and plating groups (p > 0.05). The analysis found significant differences in clinical outcomes after 1 month of follow-up, with the plating group outperforming the other two (p > 0.05). However, after a year of follow-up, all groups had comparable outcomes; however, the plating group showed improved palmar flexion (p < 0.001), radial deviation (p < 0.001), and a lower PRWE score (p < 0.05), indicating better wrist function. Complications were more in casting group. CONCLUSION: The study found a radiologically significant difference between groups throughout the follow-up, but it did not affect functional results. Clinical outcomes were similar across the groups, with plating showing better palmar flexion and radial deviation. Grip strength was also better in the plating group, but statistically insignificant. The study suggests plating should be chosen over other treatments for high-demand patients.

A novel technique for prevention of anterior fistula and facilitation of alveolar cleft repair: Gingivoperiosteoplasty with palatoplasty.

Background & Objectives: The Cleft palate is one of the most commonly encountered congenital deformity in plastic surgery clinics and can be associated with cleft lip and alveolus. Though palate repair can be associated with several complications, the most frequent and troublesome is anterior fistula formation. Various technical modifications are in practice to avoid this dreaded complication. We have started combining gingivoperiosteoplasty with palate repair to avoid postoperative anterior fistula formation and to close alveolar cleft at the same time. Methods: A prospective study was performed at the department of plastic and reconstructive surgery, Liaquat National Hospital, Karachi and selected patients were enrolled in the study after informed consent. A total of 15 patients were operated on from January 2017 to December 2020. All patients had cleft palate repair along with primary gingivoperiosteoplasty (GPP) at the age of standard palatal repair. Buccal/oral and nasal layers of the alveolus were dissected as per standard gingivoperiosteoplasty and repaired in continuation with nasal and oral layers of the palate. Postoperatively, the standard cleft palate repair protocol was followed. Follow-up was done at four weeks, 12 weeks, and six months and repair integrity was checked. Future follow-up at 4-5 years of age is planned to see the effect on alveolar collapse, bone growth, and the need for secondary bone grafting. Results: All patients were followed up regularly. None had a complication of fistula. The repairs of both palate and alveolus remained intact. Patients were kept on the follow-up to assess the need for alveolar bone grafting in the future. Conclusion: Gingivoperiosteoplasty combined with the palatal repair is a novel technique for the prevention of anterior palatal fistula.

Diffuse Idiopathic Skeletal Hyperostosis Prevalence, Characteristics, and Associated Comorbidities: A Cross-Sectional Study of 1815 Whole Spine CT Scans.

STUDY DESIGN: A Retrospective Study. OBJECTIVE: To determine the prevalence and characteristics of DISH using whole spine CT scans and to evaluate the association of DISH with co-morbidities and other ossified lesions. METHOD: A retrospective study of whole-spine CT scans of polytrauma patients from 2018-2021 above the age of 20 years. The screening was done using modified Resnick criteria. Overall and age-specific prevalence, characteristics, and associations with obesity, diabetes mellitus (DM), ischemic heart disease (IHD), aortic calcification (AC), ossified posterior longitudinal ligament (OPLL), and ossified ligamentum flavum (OLF) were evaluated. RESULTS: Out of 1815 patients, 347 had DISH, with a prevalence rate of 19.1% and a mean age of 61.7 years. The highest prevalence of DISH was seen in individuals over 80 years of age (45.5%). The prevalence among males (20.2%) was higher than for females (14.9%). The most commonly involved level was T8-T9 (95.4%), followed by T9-T10 (91.9%), and the most common vertebra involved was T9 (96%). All the cases involving T9 had ossification on the right anterior aspect of the vertebral body. The presence of DM, high BMI, and IHD was found to be significantly higher in patients with DISH (P value < .001). The incidence of aortic calcification was 22.5%, OPLL was 13.3%, and OLF was 4.9% in patients with DISH. CONCLUSION: This study reports a prevalence rate of 19.1% for DISH, with the highest prevalence among individuals above 80 years of age (45.5%). DISH has a higher propensity to affect the right anterior aspect of the vertebral body in the thoracic spine and is strongly associated with obesity, DM, IHD, and AC.

An Extremely Rare Presentation of Four Coronary Anomaly Patterns Originating from the Right Coronary Sinus.

Background: "Coronary anomaly" is defined as the coronary feature or pattern seen in <1% of the population. The most common CAAs are anomalies of origin, specifically having a separate LCX and LAD origin with an incidence of 0.41%. The second most common anomaly is the LCX arising from the RCA (0.37%). Treatment options include CABG, coronary unroofing, reimplantation, or medical therapy. Case Presentation. We present the case of an 85-year-old male who presents with an acute coronary syndrome who was found to have an extremely rare combination of different coronary anomaly patterns including left main coronary artery (LMCA) atresia, small LAD arising posteriorly from the right coronary cusp, anomalous left circumflex artery arising from the RCA, and an anomalous LAD arising from the left circumflex artery which is originating from the RCA. Conclusions: To the best of our knowledge, this is the first case report to describe four coronary anomalies in a single patient. When CAAs are diagnosed, it is of utmost importance for cardiologists to do further imaging and workup that might include a stress test to be able to offer patients the best management options.

Tibialis Posterior Transfer for Foot Drop: The Difference in Outcome for Two Different Attachment Sites.

Introduction Common peroneal nerve injury leading to foot drop is of multifactorial etiology. The goal is to restore a normal toe-heel gait. Various static or dynamic surgical options are being performed. Among all, tendon transfer is the most commonly performed procedure with its different dorsal attachment sites on the foot i.e. tendon to bone or tendon to tendon transfer. The objective of our study was to evaluate the outcomes of two methods of transfer in terms of attachments sites on functional outcomes. Materials and methods In a retrospective study conducted at Liaquat National Hospital Karachi, a total of 38 patients were included. All of them were operated upon for foot drop from June 2015 to May 2018. A total of 32 patients showed up for the follow-up, 17 patients underwent tibialis posterior transfer with attachment on the second metatarsal and 15 on the tibialis anterior tendon. Functional outcome was assessed by grading of active foot dorsiflexion at six months and at the time of the study by and categorized as excellent, good, moderate, and poor. Results Most of the patients in both groups were male, and the mechanism of injury was penetrating trauma. At six months post-operatively, the majority of the patients in both groups showed excellent to good category of active dorsiflexion. At the time of the study (mean 34.4 months postoperatively) patients with insertion at second metatarsal were found to have active dorsiflexion as: excellent: 6 (35.3%), good: 8 (47.1%), moderate: 3 (17.6%), and for insertion at Tibialis Anterior tendon: excellent: 1 (6.7%), good: 6 (40.0%), moderate: 6 (40.0%) and poor: 2 (6.2%). These results were compared using the chi-square test and it was found to be statistically significant (p-value: 0.016). Conclusion Insertion at second metatarsal gives more favorable results as compared to insertion at tibialis anterior with balanced dorsiflexion.

Metacarpal Fractures, Management Techniques, and Outcomes in Our Center.

Introduction/background Metacarpal fractures comprise approximately 35.5% of cases in daily emergencies, mostly due to road traffic accidents (RTA), fall, and assault. The classification is based on the site and pattern of fracture. High-level evidence is lacking for the management of metacarpal fractures. The primary goals of treatment are to achieve acceptable alignment, stable reduction, strong bony union, and unrestricted motion. It can be managed by non-operative methods like close reduction and splintage. Operative management will be required if there is shortening, rotation, and angulation in different planes including close reduction and fixation with percutaneous intramedullary pining/k-wires and open reduction and fixation with screws, plates (compression/locking), and external fixators. This study was done to compare the efficacy of k-wire, screws, and plates in the management of metacarpal fractures and their outcomes based on their union, postoperative pain, range of movement, and grip strength in a tertiary care center, i.e., Liaquat National Hospital and Medical College. Methods It was a retrospective study conducted at the Department of Plastics and Reconstruction Surgery, of a tertiary care hospital. A total of 113 patients who were operated upon for metacarpal fracture were included in the study (open/close) without soft tissue loss or tendon injury, were divided into three groups according to the technique of fracture fixation, i.e., group 1 (k-wire), group 2 (screw), and group 3 (plates). The data like post-operative pain (visual analog scale, VAS) and radiological evidence of union were extracted from the registry. All the patients were called for follow-up in the outpatient department. Out of 113, 97 patients showed up for follow-up and were examined by a hand surgeon, and range of movement (goniometer) and grip strength (sphygmomanometer method) were assessed. Results A total of 97 patients were included in the study (male 66%, female 34%). Group 1 (K-wire) includes n = 61 (62.9%), group 2 (screw) n = 15 (15.5%), and group 3 (plate) n = 21 (21.6%). The mean follow-up time was 12 + 2 weeks after the surgery for post-operative pain and radiological evidence of union while 24 + 6 months for a range of movement and grip strength. Less post-operative pain was noted in group 1 patients while no significant difference was noted in the evidence of radiological union in all groups. Range of movement was better in group 1 patients (89.74 + 0.750) than in group 2 (80 + 0.37°) or group 3 (80.2 + 0.62°). The grip strength (compared to the normal contralateral hand) was normal in the majority of the patients in group 1, i.e., 94% while it was 80% in group 2 and 82% in group 3. Conclusion The significance of these reported findings suggests that open reduction and internal fixation with screw or plate might be a less preferable surgical technique in comparison to k-wire fixation in the treatment of a metacarpal fracture.

The Application of Buccal Fat Pad to Cover Lateral Palatal Defect Causes Early Mucolization.

Introduction Cleft lip and cleft palate are among the most common birth defects. These deformities lead to profound psychosocial and functional effects on cleft palate patients. Several surgical techniques have been described for the repair of the cleft. The defects lateral to mucoperiosteal flaps closure are sometimes covered with sterile gauze soaked with soft paraffin or tincture of benzoin or are left open for mucolization by means of secondary intention. The buccal fat pad (BFP) is used as a pedicled graft to cover the exposed bone of the lateral palatal defect, and it is associated with proposed benefits of early healing and fewer effects on transverse growth of the maxilla. Materials and methods This was a prospective study involving 42 cleft palate patients who underwent cleft palate repair; 21 patients received BFP as an additional step to cover lateral palatal defect while the rest of the patients (n=21) underwent conventional surgical cleft palate repair and the defect was covered with Surgicel (Ethicon, Inc., Bridgewater, NJ). Postoperative follow-up was conducted at first, second, and third weeks postoperatively to assess the time required for mucolization. Results Our cohort of 42 patients included an equal number of complete and incomplete cleft palate patients. Follow-up at the first postoperative week showed an equal number (n=21, 100%) patients with incomplete mucolization on both groups, while at the second postoperative follow-up, only one (4.8%) of the patients who underwent conventional cleft palate repair had complete mucolization while 20 (95.2%) among the patients who underwent BFP had complete mucolization. At the third-week postoperative follow-up, three (14.3%) patients from the conventional group had complete mucolization, while 18 (85.7%) had incomplete mucolization. Only two patients (4.8%) developed recipient area complications, and they were managed conservatively. Conclusion BFP is a good source of vascularized tissue to cover the hard palate bones after primary cleft repair. It is easy to harvest as a local tissue with a low learning curve. The epithelialization rate is faster than conventional methods with minimal complication rates.

Comparison of the Interrupted and Continuous Suture Techniques for the Closure of Oral and Nasal Mucosal Layers in Cleft Palate Surgery.

Background Cleft lip and palate are common congenital craniofacial anomalies, treated conventionally by surgery at the ages of six to 18 months. Mostly, the interrupted suture technique is used to close the nasal and oral layers of the palate. In some studies, the interrupted suture technique was compared with continuous suture techniques for the closure of oral and nasal layers and found that there was less utilization of time and suture materials in the continuous technique. This study was designed to see the outcomes of interrupted versus continuous suture techniques. Materials & methods A total of 36 patients were included in the study and were divided into two groups according to the type of suturing technique. The time utilized for the repair of the oral and nasal layers of the cleft palate, the number of suture packs utilized, and the incidence of fistula formation were noted and compared between the two groups. Out of 36 patients, 17 were included in group A (operated by interrupted techniques), and 19 were included in group B (operated by the continuous technique). Results The mean time taken to close nasal layer in Group A was 18.12 ± 1.16 minutes and in Group B was 8.37 ± 0.89 minutes (p-value < 0.001), whereas for oral layer closure, it was 14.00 ± 1.17 minutes in group A and 6.00 ± 0.57 minutes in group B (p-value < 0.001). The average usage was 2.26 ± 0.45 suture packs for repair with the continuous technique and 4.00 ± 0.35 suture packs when repaired via interrupted stitches. There was no difference noted in postoperative outcomes in both groups in terms of postoperative fistula and wound dehiscence. Conclusion A continuous suture technique for closing the oral and nasal layers in patients with cleft palate is recommended, as it is more beneficial in terms of time, cost-effectiveness, and utilization of suture material.

Raised levels of IFN-gamma and IL-13 are associated with pre-diabetes amongst newly diagnosed patients with Tuberculosis.

OBJECTIVE: To investigate pre-diabetes and diabetes in newly-diagnosed tuberculosis patients and to assess the association of serum cytokine levels with diabetes status. METHODS: The cross-sectional study was conducted at Indus Hospital and The Aga Khan University Hospital, Karachi from May to November 2015, and included patients of either gender aged 18 years or more with a confirmed diagnosis of tuberculosis who were either newly diagnosed or had received up to 1 month of anti-tuberculosis therapy were included. Patients were enrolled from among those presenting to the clinics at Indus Hospital, Karachi, and the Department of Medicine, Aga Khan University Hospital (AKUH), Karachi. The patients were tested for glycosylated haemoglobin and random blood glucose. Diabetes was defined as HbA1c >6.5%; pre-diabetes as HbA1c=5.7-6.4%; and normoglycaemic as HbA1c <5.7%. Serum cytokines were investigated using the Bio-plex 27, Bio-Rad assay. SPSS version 19.0 was used for data analysis.. RESULTS: Of the 211 subjects, 110(52%) were females and 101(48%) were males. The overall median age of the sample was 26 years, and 100(47.3%) subjects were underweight. Of the total, 24(11.4%) had diabetes and 45(21.3%) had pre-diabetes. Of the diabetics, only 7(29%) knew their status prior to screening. Interferon-gamma and interleukin-13 were significantly different among tuberculosis patients with diabetes, pre-diabetes and normoglycaemia (p<0.05). Glycosylated haemoglobin levels showed a significant correlation with interferon-gamma levels. CONCLUSIONS: Raised interleukin-13 and interferon-gamma levels in newly-diagnosed tuberculosis patients with pre-diabetes.

Solvent-dependent regio- and stereo-selective reactions of 3-formylchromones with 2-aminobenzothiazoles and transacetalization efficiency of the product 3-((benzo[d]thiazol-2-ylimino)butyl)-4H-chromen-4-one.

Using 2-propanol as the solvent, 3-formylchromones and 2-aminobenzothiaoles formed corresponding imines, while 1° and 2°-alcohols formed the corresponding 2-alkoxy-3-enamines with selectivity for the Z-isomer. Changing the substrates with similar molecules such as 3-formylchromone with quinoline-, quinolone- and indole-3-carbaldehydes sometimes resulted in the formation of the corresponding imines, whereas replacing 2-aminobenzothiazole with amides resulted in the formation of acetals. Considering the effect of the solvent, replacing alcohols with the aprotic solvents THF and CH2Cl2 resulted in the formation of imines and enamines, which are the characteristic reactions of 2-propanol and other 1° and 2°-alcohols, respectively. 2-Alkoxy-3-enamines were found to undergo transacetalization with both short and long chain alcohols. The novelty of these reactions is that they did not require an external catalyst, all the reactions were performed at the same temperature, and purification was achieved by filtration. The transacetalization we performed herein is a new concept, which has not been reported to date. In contrast, other similar reactions, such as transalkoxylation, transalkylation, and transetherification, are performed on a commercial scale using expensive catalysts such as Otera's catalyst. The highly sensitive nature of 3-formylchromones towards variations in the substrates and solvents to form different products and the reason behind the selective formation of the Z-isomer of 2-alkoxy-3-enamines and its transacetalization efficiency need further studies to understand the reaction mechanism and possibly other factors such as solvent effects.

Assessment of diabetes among tuberculosis patients presenting at a tertiary care facility in Pakistan.

OBJECTIVE/BACKGROUND: Pakistan ranks sixth among high-tuberculosis (TB)-burden countries worldwide and fifth worldwide for diabetes incidence. Although both these factors are independently known, the rate of diabetes among TB patients is not well known. We aimed to determine the prevalence of diabetes among patients with TB presenting at tertiary care health centers in Karachi, Pakistan. METHODS: A total of 216 patients with TB were recruited and their blood samples were taken for testing of glycosylated hemoglobin (HbA1c) and random blood sugar. Diabetes was defined as HbA1c>6.5% and random blood sugar>180mg/dL, pre-diabetes as HbA1c 5.7-6.4%, and normoglycemia as HbA1c<5.7%. RESULTS: Data for 211 patients were available and showed that 24 (11.4%) patients had diabetes. Of these, 17 were newly diagnosed, while seven were known diabetics. Prediabetes was identified in 45 (21.3%) cases. Of the TB patients, 165 were newly diagnosed, while 46 were retreatment cases. The majority of patients (60%) were underweight with a body mass index of <18.5. CONCLUSION: This study identified 11.4% diabetics among TB patients presenting to a tertiary care facility. Despite the high diabetes incidence in Pakistan, 71% of the diabetics in the group studied did not know their status. Given the negative impact of diabetes on treatment outcomes of TB, it is important that screening for diabetes be included as initial workup for TB patients. Identification and management of diabetes would result in improved outcomes for TB treatment.

Quantitatively evaluating the effect of social barriers: a case-control study of family members' opposition and women's intention to use contraception in Pakistan.

BACKGROUND: Uptake of family planning services in Pakistan has remained slow over the past decade despite a rapid increase in availability and awareness, indicating that social barriers may be preventing uptake. Social barriers such as opposition by family members have largely been studied qualitatively; there is a lack of quantitative evidence about the effect of different family members' opposition on women's intention to use contraceptives. The objective of this study was to quantitatively evaluate the effect of family members' opposition to family planning on intention to use contraception amongst poor women in Pakistan who have physical access to family planning services. METHODS: An unmatched case control study (nested within a larger cohort study) was conducted in two public hospitals in Karachi, Pakistan. Univariable and multivariable logistic regression analyses were conducted to compare risk factors between women that were not intending to use any contraceptive methods in the future (cases) and women that were planning to use contraceptive methods (controls). RESULTS: 248 cases and 496 controls were included in the study. Negative contraceptive intent was associated with no knowledge of contraception (AOR = 3.79 [2.43-5.90]; p < 0.001), husband's opposition (AOR = 21.87 [13.21-36.21]; p < 0.001) and mother-in-law's opposition (AOR = 4.06 [1.77-9.30]; p < 0.001). CONCLUSIONS: This study is the first to quantitatively assess the effect of opposition by different family members on women's contraceptive intent in Pakistan. Our results indicate that of all family members, husband's opposition has the strongest effect on women's intention to use contraception, even when the women have knowledge of and physical access to family planning services.

Prospective cohort study of a new vacuum delivery device to assist with complicated labour in low-resource settings.

OBJECTIVES: Currently available vacuum devices used to assist women undergoing complicated labour are unsuitable for use in low-resource settings. The objective of this study was to evaluate the safety and feasibility of a new low-cost vacuum device, named Koohi Goth Vacuum Delivery System (KGVDS), designed for use in low-resource settings. METHODS: A hospital-based, multicentre, prospective cohort study with no control group was conducted in Karachi, Pakistan. After training, KGVDS devices were made available for use by labour room staff at their discretion when instrumental delivery was indicated. Women to whom KGVDS was applied were followed from the start of labour until discharge. Feasibility was assessed in terms of successful expulsion of the foetal head following application of KGVDS and ease of use ratings. Safety was assessed by observing maternal and newborn post-delivery outcomes prior to discharge. RESULTS: Koohi Goth Vacuum Delivery System was applied to 137 women requiring instrumental delivery, of whom 111 (81%; 95% CI = 74-88%) successfully expelled the foetal head assisted by KGVDS and 103 (75%) stated that they would agree to use KGVDS again. There were no serious maternal or neonatal injuries or infections related to KGVDS use. The mean score for 'ease of use' given by doctors and midwives using the device was 8 of 10. CONCLUSIONS: Koohi Goth Vacuum Delivery System was feasible and safe to use for assisting complicated deliveries in low-resource hospitals in this initial evaluation. Our results indicate that this new device may have the potential to improve birth outcomes in settings where most mortality occurs and that further evaluations should be conducted.