Utilizing Low-cost Vacuum-assisted Closure as Adjuvant Therapy in Soft Tissue Reconstruction for a Mangled Upper Extremity.

Soft tissue reconstruction using flaps in managing mangled injuries is occasionally insufficient due to large defects and low flap viability. Conversely, delaying the closure of the defect can elevate the risk of infection. Adjuvant therapy becomes essential in the management of mangled injuries. We aim to present the use of low-cost vacuum-assisted closure (VAC) as an adjuvant therapy for mangled injuries. We reported the case of a 20-year-old man who sustained a mangled injury to his left forearm in a traffic accident 4 hours before admission. The mangled extremity severity score was 9; however, the patient declined amputation. Although the initial reconstruction was done, the flap could only cover vital structures. VAC was utilized to address the uncovered portion of the defect, to promote optimal granulation and prevent infection. The reconstruction proceeded with a skin graft and wrist arthrodesis. At 1-year follow-up, viable tissue was obtained but contracture occurred at the metacarpophalangeal and proximal interphalangeal joints. We intend to perform functional reconstruction at a later stage. Although the benefits of VAC in wound management are well established, reports regarding its advantages in mangled injury management remain relatively scarce. The high cost of VAC is a limiting factor, particularly in developing countries. This prompts the need for an affordable VAC innovation with comparable efficiency to the commercial model. Reverse Aqua Pump VAC, our innovative low-cost VAC, shows satisfactory outcomes in managing patients with mangled injuries with mangled extremity severity score indicating amputation.

Spina bifida occulta at the lumbar spine level manifested as chronic low back pain and unpredictable neurologic deficit: A case report.

INTRODUCTION: Spina bifida occulta has a variety of symptoms that may hinder the diagnosis and subsequently delay appropriate treatment, causing a decrease in the patient's quality of life. This study aims to shed light on spina bifida occulta, with chronic low back pain as the predominant symptom, and the treatment applied in this case. PRESENTATION OF CASE: A 46-year-old male was diagnosed with spina bifida occulta at the 5th lumbar spine after 2 years of having chronic low back pain that radiated to the left leg. He was initially diagnosed with chronic low back pain and was treated with epidural steroid injections which yielded a suboptimal outcome. Through an MRI examination, a spina bifida occulta at the 5th lumbar spine was identified and the patient was then referred to a tertiary hospital for further spinal decompressive treatments. The decompression level was obtained intraoperatively with the aid of intraoperative neurophysiological monitoring. Following the procedure, pain had almost completely subsided, and the patient regained full function for his daily activities without any pain or restrictions. DISCUSSION: Non-specific clinical symptoms hindered the prompt diagnose of occult spinal dysraphism. MRI examinations of the spine is required and recommended for the characterization of intraspinal and perispinal abnormalities. Using intraoperative neurophysiological monitoring, we observed an improvement of nerve function at the L3-L5 level following decompression at the L3 level. CONCLUSION: The diagnosis of spina bifida can be challenging when patients are presented with non-specific clinical symptoms, in this case as pain. We recommend spinal MRI examinations in cases of chronic lower back pain that fail to improve following expected pain management and therapy. Intraoperative neurophysiological monitoring can be used to assist in the identification of the level for decompression, as well as the resolution of pain.

Biceps Transfer to FDP-FPL Tendon Augmented with Fascia Lata to Restore Hand Function in Neglected Fracture Treated by Traditional Bone-setters.

Neglected bone fractures owing to the traditional bone-setter practices could lead to devastating complications. We aimed to describe the procedure and outcome of fascia lata augmentation for a forearm massive soft tissue loss case. Here, we report a case of a 14-year-old boy who presented to our hospital with a history of neglected right forearm fracture 4 years prior. He had been treated by a traditional bone-setter instead of seeking professional medical help, which resulted in wide-spread infection requiring debridement and, eventually, massive soft tissue loss, wrist radial deviation deformity due to epiphyseal growth arrest, and loss of all right-hand function. Intervention performed was biceps transfer to flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendon augmented with fascia lata with anterior capsulectomy, bilobed flap, and transfixing wire of wrist joint, followed by ulnar centralization with wrist arthrodesis. The patient reported satisfaction postreconstruction, owing to the enhancement of hand function and appearance. He also showed significant improvement in activities of daily living and penmanship, and was even able to continue his old hobby as a traditional puppeteer. Autologous fascia lata tendon transfer connecting biceps to FDP and FPL tendon alongside ulnar centralization with wrist arthrodesis is a novel technique that has promising results to improve hand function and appearance.

Autologous double barrel vascularized fibular bone graft for reconstruction after hemi resection of mandible due to ameloblastoma: Surgical case report.

INTRODUCTION: Mandibular abnormalities caused by ameloblastoma present significant surgical and reconstructive difficulties. This study investigates double barrel fibular bone graft to correct these abnormalities and improve mandibular function and appearance. CASE PRESENTATION: A 28-year-old male presented with a mandibular lump and facial asymmetry. The radiographic and histologic examination detected was subsequently diagnosed as ameloblastoma. After undergoing a hemi mandibulectomy procedure, a free vascularized fibular bone graft was harvested from the patient's left leg and transplanted to reconstruct the mandibular angle. The evaluation of the patient's functional outcomes was assessed utilising the University of Washington Quality of Life (UW-QOL) questionnaire. The patient UW - QOL Score has increased 62.5 pre-treatment to 93.75 post-treatment. DISCUSSION: The suggested strategy to treating aggressive ameloblastomas is radical surgery, involving the use of wide resection and following bone reconstruction. Vascularized grafts, including the double-barrel fibular bone graft, are usually preferred in relation to mandibular defect reconstruction for their ability to offer improved stability, height, and thickness, which enhances functional results. In contrast to conventional approaches, our case did not show any signs of facial deformities or bone resorption. The utilization of the vascularized fibular bone graft proved to be a valuable option for early rehabilitation in patients with mandibular continuity defects, offering promising outcomes in terms of patient well-being and quality of life. This final result provides proof supporting the potential of this technique for managing mandibular defects. CONCLUSION: Double-barrel fibular bone grafts and dental rehabilitation can restore mandibular continuity defect from ameloblastoma.

Orthopedic Surgical Management of Complicated Congenital Popliteal Pterygium Syndrome: A Case Report.

Introduction: Popliteal pterygium syndrome (PPS) is a rare autosomal-dominant condition that causes fixed flexion deformity of the knee. The popliteal webbing and shortening of the surrounding soft tissue could limit the functionality of the affected limb unless it is surgically corrected. We reported a case of PPS in a pediatric patient encountered in our hospital. Case: A 10-month-old boy came with a congenital abnormally flexed left knee with bilateral undescended testis and syndactyly of the left foot. The left popliteal pterygium extending from the buttock to the calcaneus was observed, with an associated fixed flexion contracture of the knee and equine position of the ankle. Normal vascular anatomy was seen in the angiographic CT scan; therefore, multiple Z-plasty and fibrotic band excision were performed. The sciatic trunk was exposed on the popliteal level, and the fascicular segment was excised from the distal stump and sutured to the proximal stump under the microscope to extend the sciatic nerve for approximately 7 cm. No postoperative complications were reported. Multiple tendons and soft tissue reconstruction were performed when the patient was 2-year-old to correct the adductus and equine deformity of the left foot. Discussion: Surgical correction for popliteal pterygium demands staged techniques to deal with the shortened structure. In our case, multiple Z-plasty were performed, and the fibrotic band was excised until its base with meticulous consideration of the underlying neurovascular bundle. Fascicular shifting technique for sciatic nerve lengthening can be considered in unilateral popliteal pterygium with difficulty extending the knee due to shortened sciatic nerve. The unfavorable outcome of nerve conduction disturbance resulting from the procedure may be multifactorial. Still, the existing foot deformity, including a certain degree of pes equinovarus could be treated by multiple soft tissue reconstructions and adequate rehabilitation to achieve the desired outcome. Conclusion: Multiple soft tissue procedures resulted in acceptable functional outcomes. However, the nerve grafting procedure is still a challenging task. Further study is required to explore the technique in optimizing the nerve grafting procedure for popliteal pterygium.

Pedicle morphometry analysis of main thoracic apex adolescent idiopathic scoliosis.

INTRODUCTION: Screw insertion during scoliosis surgery uses free-hand pedicle screw insertion methods. However, there is a wide variation in pedicle shapes, sizes, and morphometry, especially in scoliosis patients. CT scan pedicle measurements in main thoracic Lenke type 1 adolescent idiopathic scoliosis can help visualize this diversity. This study aimed to highlight the features of pedicle morphometry on the concave and convex sides, including pedicle diameter (width in axial and height in the sagittal plane), the depth to the anterior cortex, and Watanabe Pedicle classification in patients with main thoracic apex adolescent idiopathic scoliosis. MATERIALS AND METHODS: This study was a cross-sectional observational study of Adolescent Idiopathic Scoliosis (AIS) patients whose apex in the main thoracic patient underwent deformity correction procedures. We used a three-dimensional CT scan to evaluate pedicle morphometry on the apex vertebrae, three consecutive vertebrae above and below the apex. RESULTS: A total of 6 patients with apex main thoracic AIS with 84 pedicles consisting of 42 pedicles from each concave and convex curve were analyzed. All of the samples were female, with the mean age at the procedure being 21.2 ± 5.56. The mean cobb angle was 62° ± 23°, with the main apex between VT8-VT10. The size of the pedicle was bigger from upper to lower vertebrae. The mean pedicle depth, pedicle width, and pedicle height for the concave side were 36.06 ± 4.31 mm, 3.91 ± 0.66 mm, and 9.16 ± 1.52 mm, respectively. Meanwhile, the convex side is 37.52 ± 1.84 mm, 5.20 ± 0.55 mm, and 11.05 ± 0.70 mm, respectively. We found a significant difference between the concave and convex sides for the pedicle width and height. The concave and convex sides were mainly classified as type C (38%) and type A (50%) Watanabe pedicle. CONCLUSION: Pedicle width and pedicle height are significantly different between the concave and the convex side with convex side has better Watanabe pedicle classification. Pre-operative CT evaluation is essential for planning proper pedicle screw placement in AIS patients.

Functional outcomes following surgical treatment in patient with primary degenerative adult scoliosis.

INTRODUCTION: Primary adult degenerative scoliosis is one of the adult scoliosis group that presents in adult patient without history of scoliosis during childhood or adolescence. This condition may be asymptomatic, mild low back pain, radiculopathy symptoms, or may be causing severe low back pain and major neurological symptoms including weakness and numbness of the lower extremities which can affect the patient quality of life. CASE PRESENTATION: In this study, we presented seven cases of primary degenerative adult scoliosis that was treated either with decompression alone, decompression with short segment fusion and deformity correction, and decompression with long segment fusion and deformity correction. The parameters measured in this study were lumbar regional angle, Cobb angle, and pelvic parameters. The functional status of the patient was measured using Oswestry Disability Index (ODI). DISCUSSION: The main purpose for surgical treatment in primary degenerative adult scoliosis depends on the clinical presentation and also the patient's expectations .From the study, we found that all patient underwent surgery had improvement of functional status that measured with ODI score. The mean of pre operative ODI score was 49.70 (± 13.61 SD) (severe disability) and for post operative was 21.8 (± 13.40 SD) (moderate disability). Surgery decompressed the neural element and stabilize the spine. CONCLUSION: Surgery treatment in patients with degenerative adult scoliosis was shown to have better functional outcomes regardless of the technique used. Further study with bigger sample with corresponding statistical analytic is mandatory.