Management of Wounds with Exposed Bones or Tendons in Children by Vacuum-Assisted Closure Therapy: A Prospective Study.

Background The management of complex soft tissue defects with exposed bones/tendons is always a challenging task for the surgeon and the problem becomes more pronounced when it comes to the management of these wounds in children. Though flap procedures are considered the standard for managing the complex soft tissue defects with exposed bones/tendons yet small blood vessels for anastomosis, long operative period, increased chances of perioperative thrombosis, and difficult perioperative management in children add to the difficulty in performing flap procedures in children. The vacuum-assisted closure (VAC) therapy has emerged as a novel modality for the management of the difficult wounds with added advantages, especially in children. Objective To evaluate the efficacy of VAC in the management of wounds with exposed bones/tendons in children. Patients and Method Forty-six children of complex wounds with exposed bones/tendons were included in the study from July 2016 to June 2018. Results Out of 46 patients, 31 were male; the patients had a mean age of 8.4 years. Road traffic accident was the most common mode of injury (54%), with most of the wounds located over extremities. The mean duration of VAC therapy was 12 days. More than 90% coverage of the exposed structure was seen in 89% of patients. The wounds were definitively managed by split-thickness skin graft in 89% of patients and flap cover in 6.5% of patients. The mean cost of the VAC therapy at our government run hospital was 187 Indian rupees per day. No significant major complications were seen during the treatment. Conclusion VAC therapy is an efficient, safe, and cost-effective modality of treatment for the management of complex wounds in the pediatric population.

Role of customised negative-pressure wound therapy in the integration of split-thickness skin grafts: A randomised control study.

BACKGROUND: Split-thickness skin grafting (STSG) is a time-tested technique in wound cover, but many factors lead to suboptimal graft take. Role of custom-made negative-pressure wound therapy (NPWT) is compared with conventional dress in the integration of STSG and its cost is compared with widely used commercially available NPWT. MATERIALS AND METHODS: This is a parallel group randomised control study. Block randomisation of 100 patients into one of the two groups (NPWT vs. non-NPWT; 50 patients each) was done. Graft take/loss, length of hospital stay post-grafting, need for regrafting and cost of custom-made negative pressure wound therapy (NPWT) dressings as compared to widely used commercially available NPWT were assessed. RESULTS: Mean graft take in the NPWT group was 99.74% ± 0.73% compared to 88.52% ± 9.47% in the non-NPWT group (P = 0.004). None of the patients in the NPWT group required second coverage procedure as opposed to six cases in the non-NPWT group (P = 0.035). All the patients in the NPWT group were discharged within 4-9 days from the day of grafting. No major complication was encountered with the use of custom-made NPWT. Custom-made NPWT dressings were found to be 22 times cheaper than the widely used commercially available NPWT. CONCLUSIONS: Custom-made NPWT is a safe, simple and effective technique in the integration of STSG as compared to the conventional dressings. We have been able to reduce the financial burden on the patients as well as the hospital significantly while achieving results at par with other studies which have used commercially available NPWT.

Footboards: Indigenous and Novel Method of Screening for Diabetes Peripheral Neuropathy - A Pilot Study.

BACKGROUND: To validate the effectiveness of indigenously designed "footboard (FB)" in early diagnosis of diabetic peripheral neuropathy (PNP) by comparing it with Semmes-Weinstein monofilament (SWM) and vibration perception (VP). MATERIALS AND METHODS: Two hundred and forty-four patients with diabetes were examined for PNP using SWM and 128 Hz tuning fork. The findings were compared with indigenously designed FBs with 1, 2, and 3 mm elevations. RESULTS: Out of 108 patients who did not have protective sensation as per SWM, only 10 (9.2%) felt 1 mm board bearings, and out of 72 patients who did not feel vibration, only 8 (11.1%) felt 1 mm board bearings. Out of 136 patients who had protective sensation, 128 (94.11%) felt 2 mm elevated board bearings, and out of 172 patients who had VP, only 152 patients (88.3%) felt 2 mm board bearings. With SWM as standard, the sensitivities and specificities, respectively, were 63% and 90% (1 mm board), and 94% and 60% (2 mm board). With VP, the sensitivities and specificities, respectively, were 59% and 90% (1 mm board), and 88% and 61% (2 mm board). CONCLUSIONS: FB, which simultaneously tests touch and pressure sensation, shows a high level of performance in detecting at-risk feet. FB may be simple, time-efficient, and inexpensive test for detection of neuropathy and needs further validation in a larger study.

Contralateral lumbo-umbilical flap: A versatile technique for volar finger coverage.

BACKGROUND: While contemplating any difficult soft tissue reconstruction, patient comfort and compliance is of paramount importance. Reconstruction of the volar aspect of fingers and hand by the ipsilateral pedicled flaps (groin flap, abdominal flaps) is demanding as the flap inset is difficult for the surgeon and very uncomfortable for the patient. This often leads to flap complications. For the comfort of the patient, better compliance and ease of complete inset, we planned to manage soft tissue defects of the volar aspect of fingers and hand by a new contralateral pedicled lumbo-umbilical flap. This flap is based on the paraumbilical perforators of deep inferior epigastric artery. MATERIALS AND METHODS: The contralateral pedicled lumbo-umbilical flap was used in eight patients with high-tension electrical burn injuries involving the volar aspect of fingers and hand. The patients were closely observed for first 6 weeks for any flap or donor site complications and then followed monthly to assess donor and recipient site characteristics for 6 months to 2 years. RESULTS AND CONCLUSION: Large flaps up to 8 cm × 16 cm were raised. All but one flaps survived completely. All patients were mobilised within 48 h and five were discharged in less than a week after initial inset. The flap is reliable, easy to harvest and easy to inset on the volar aspect of fingers. The arm is positioned in a very comfortable position. The main disadvantage, however, is a conspicuous abdominal scar.

'Pheran' Induced Fourth Degree Friction Burn of the Brain.

Friction burns result from the rubbing between the skin and any other rough surface. We present a case of fourth degree friction burn of the brain, which was predisposed due to the wearing of traditional long loose clothing known as 'Pheran'. The patient was pillion riding a motor bike on a highway and was wearing a Pheran. The loose arm sleeves of the pheran were hanging by the side. The bike met with a side-on collision with a load-carrier lorry. The patient fell down and the left loose arm sleeve of the pheran was trapped in the axle of the lorry. He was dragged on the road for about half a km before the fast moving lorry stopped, the driver being oblivious of the accident. The patient developed friction injury to various parts of the body in addition to a severe fourth degree friction burn to brain and a fracture shaft of left femur.

Evaluating a conservative approach to managing liver injuries in Kashmir, India.

AIM: There has been a steep rise in incidence of liver injury in the past few years because of increase in incidence of road traffic accidents. The aim of this study was to evaluate the role of non-operative management of liver injury due to blunt abdominal trauma. MATERIALS AND METHODS: All patients with liver injury from blunt trauma abdomen were studied between January 2000 and January 2010. A total of 152 patients with liver injury were put on conservative management. Hundred and three (67.77%) patients were males and 49 (32.23%) were females with an age range of 15-60 years (32.8 years). Most of the injuries were because of road traffic accidents (81.57%). Liver injuries were graded according to Moore's classification using computed tomography. Patients with Grade V and VI were excluded from the study. Patients who were unstable hemodynamically on admission were also excluded from the study. RESULTS: There was no mortality in our series. Eight patients needed exploration because they developed hemodynamic instability. Four of the patient developed post-operative liver abscess which was treated conservatively. CONCLUSION: Non-operative management of liver injury due to blunt trauma abdomen is a safe, effective and treatment modality of choice in hemodynamically stable Moore's grade I to Grade IV injury.

Ascaris exit through the feeding jejunostomy tract: a rare case report.

A 65-year-old male was operated for esophageal carcinoma. Transhiatal esophagogastrectomy with jejunostomy feeding tube was done. Orals were started on the 12th postoperative day. The jejunostomy feeding tube was removed on the 20th postoperative day. Immediately after removal of the feeding tube, a 10-12 cm ascaris was seen emerging through the jejunostomy tract. Ascaris lumbricoides can cause a variety of complications like intestinal obstruction, perforation, biliary obstruction, pancreatitis, liver abscess, cholangiohepatitis, volvulus, and gangrene, etc. Although the above-mentioned complications have been frequently reported, ascaris exit through the feeding jejunostomy tract is very rare. This case is reported here to emphasize the importance of this complication of wandering ascariasis.

Vascular injuries after bear attacks: Incidence, surgical challenges and outcome.

BACKGROUND: Bear mauling is rarely reported in medical literature due to its rare occurrence. Present study was undertaken to describe the pattern and management of bear maul vascular injuries in Kashmir. PATIENTS AND METHODS: Study of patients with bear maul vascular injury from 1(st) Jan 2004 to 31(st) Dec. 2008. Fifteen patients with bear maul vascular injury were studied. All patients of bear maul without vascular injury were excluded from the study. RESULTS: Most of the patients were treated by reverse saphenous vein graft or end to end anastomosis. Most common complication was wound infection (20%) followed by graft occlusion (13.33%). There was no operative death. CONCLUSION: Bear attacks are very common in Kashmir. Vascular injury due to bear maul needs prompt resuscitation and revascularization. Results are very good provided timely intervention for revascularization is done.

Isolated aglossia in a six year old child presenting with impaired speech: a case report.

INTRODUCTION: The most mobile organ of the body, the tongue is associated with various congenital anomalies; most of which are in association with many other systemic abnormalities. Rarely do they occur in isolation. Isolated aglossia, that we presented, is one of the more rare presentations. CASE PRESENTATION: Our patient is a 6-year-old male child of Asiatic origin from Kashmir (India), who was physically well built and mentally sound and presented with history of impaired speech. The patient had normal velopharangeal competence but absence of tongue which was replaced by a small mucus membrane projection near the floor of oropharangeal isthmus. The patient had no difficulty in feeding or taste sensation but he was unable to pronounce lingual consonants. CONCLUSION: Isolated aglossia is very rare condition explained on the basis of growth failure of lateral lingual swellings and tubercular impar. Such patients do not usually need reconstruction of tongue; as feeding, swallowing and taste sensations are usually intact and speech cannot be improved by reconstruction. However, malocclusion of teeth needs to be taken care of.