Hand amputations: epidemiology, management and resurfacing options for soft tissue coverage.

OBJECTIVE: Agricultural hand injuries occur mainly among young adults, many affecting the dominant hand, thereby impeding patients' ability to work or cope with social obligations. This study was carried out with the aim of collecting data on the epidemiology and management of agricultural hand injuries in Indian subjects. METHOD: The study was conducted in the Department of Plastic and Reconstructive Surgery, JN Medical College, AMU, Aligarh, India, from October 2009 to December 2013. Patients with agricultural hand injuries were included. Data collected included socio-demographic details, mode and type of injury, type of reconstruction, complications, length of hospital stay and assessment of post-reconstruction status. These data were tabulated and analysed. RESULTS: The typical patient was young (mean 33.2 years), of lower socio-economic status and with a total disregard for safety regulations. There is clustering of cases during the wheat harvest season (April-June). Wheat thresher injuries were the most common cause of partial hand amputation (51%), especially during this season. This was followed by fodder cutting (kutti/chara) machine injury, especially in females and children (36%). A simple classification for these injuries has been described and Grade II injury was the commonest. Reverse radial forearm flap was the most suitable regional flap for coverage, whereas thoraco-umbilical flap was the most commonly used distant flap. Patients who had the single-stage procedure had a significantly shorter stay. CONCLUSION: Agricultural hand injuries are not totally avoidable and their incidence can be reduced by proper education, but the low economic and literacy status of the patients is a big hurdle. The forearm offers many flaps for reconstruction of hand, which can be used in defects on dorsal or palmar aspect of hand and results in early discharge from the hospital and early rehabilitation. In patients with associated injury to the forearm, abdominal flaps can be used for cover.

Superior gluteal artery perforator flap: a reliable method for sacral pressure ulcer reconstruction.

OBJECTIVE: To study the feasibility and reliability of the superior gluteal artery perforator (SGAP) flap for the reconstruction of sacral pressure ulcers. METHOD: A prospective study was conducted between 2009 and 2012 where a total of 15 patients with sacral pressure ulcers underwent reconstructive surgery with an islanded pedicled SGAP flap. Success of the flap reconstruction and primary healing were defined as a healed wound within 30 days of the procedure. Reconstructive failure was defined as those cases that resulted in a non-healed wound, thereafter. RESULTS: Of the 15 patients in the evaluation, 12 were male and 3 were female. Eleven patients were paraplegic, 3 were ambulatory and one was quadriplegic. All reconstructed flaps survived completely with no mortality or major donor site complications. Three patients had a minor infection and wound dehiscence that healed spontaneously. All wounds healed within 30 days of surgery following local wound care and culture-sensitive antibiotics. No recurrence of the pressure ulcer occurred during follow-up. The non-paraplegic patients did not develop gait disturbances following the surgery. CONCLUSION: These observations suggest that the islanded pedicled SGAP fasciocutaneous flap is a relatively easy flap to raise, with good reliability and minimal complications, and is therefore highly recommended for the reconstruction of the sacral pressure ulcer. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Management of post road traffic accident compound leg defects using fasciocutaneous flaps.

OBJECTIVE: To highlight the role of fasciocutaneous flaps in the management of leg and foot defects sustained after trauma, in rural India. METHOD: This was a prospective study conducted on patients with traumatic defects of the leg and foot, admitted between May 2001 and April 2007. Selection of flaps was done on the basis of defect size, site and condition of surrounding tissue. Ipsilateral flaps (proximally- and distally-based), contralateral-leg flaps and free flaps (anterolateral thigh and radial forearm) were raised according to standard techniques and wounds resurfaced accordingly. The outcome was considered 'excellent' when there was no flap necrosis and no donor site morbidity, 'good' when there was some infection, either at the donor or recipient site, but no necrosis, 'satisfactory' when partial flap necrosis and 'poor' when there was flap loss. RESULTS: One-hundred and ten patients (86 males and 24 females) with post-traumatic leg defects underwent reconstruction with different fasciocutaneous flaps. The ages of the patients ranged from 6 years to 58 years, with a mean age of 28.2 +/- 11.5 years. Forty cases (37%) underwent immediate reconstruction within the first 72 hours and in 70 cases (63%) delayed reconstruction was done. Hospital stay of the patients ranged from 8 days to 54 days, with a mean of 20.2 +/- 1.9 days. There were no complications recorded at donor site. The overall results were considered excellent in 92 cases (84%), good in 12 (11%), satisfactory in four (3.6%) and poor in two cases (1.8%), where flap necrosis occurred. CONCLUSION: Our results suggest fasciocutaneous flaps are convenient, simple, reliable and easy to manage. The majority of compound leg defects can be reconstructed with fasciocutaneous flaps either from the ipsilateral leg, contralateral leg or in the form of free flaps.

Role of early radical debridement and skin cover in diabetic foot ulceration.

OBJECTIVE: To assess the efficacy of radical debridement and skin grafting in treating diabetic foot ulceration, compared with conservative wound treatment. METHOD: The medical notes for 30 patients who underwent skin grafting for diabetic foot ulceration (graft group) were retrospectively analysed and matched, according to age, gender, ankle brachial pressure index (ABPI) and comorbidities, with 30 other patients, who were treated conservatively (control group). Patients in the graft group underwent early, radical debridement to prepare the wound bed for grafting. Graft take, rate of ulcer recurrence and donor-site morbidity were assessed. Healing times and the length of hospital stays were compared between the two groups. RESULTS: A 100% skin graft take was recorded in 80% of the patients on day 4, postoperatively. Ninety-three per cent of patients in the graft group completely healed, with 2 patients (6.7%) experiencing ulcer recurrence within the following 6 months. Ulcer recurrence could be due to early, non-guarded ambulation. Mean healing time and hospital stay were significantly lower in the graft group compared with the control group (4.0 ± 1.5 weeks vs 10.0 ± 1.0 weeks; p < 0.001). Mean healing time in smokers was slightly greater than non-smokers. CONCLUSION: Skin graft is an effective method of managing diabetic foot ulcers compared with dressings. It reduced healing times and hospital stay with minimum donor-site morbidity. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.