Outcomes of islanded scrotal raphe flap employment for skin shortage in complicated hypospadias repair.

BACKGROUND: Ventral skin deficiency in complicated hypospadias is a difficult problem to treat. The aim of our study is to report our technique and outcomes of vascularized islanded scrotal raphe flap for ventral skin deficiency in complicated hypospadias. METHODS: A retrospective review was conducted at Northwest General Hospital & Research Centre, Peshawar, from January 2012 to January 2019. Complicated hypospadias patients who underwent two-stage surgery employing islanded scrotal flap were identified. Patients underwent surgery in two stages: scar tissue removal, chordee correction and buccal mucosal graft in the first stage; neourethral tubularization, water proofing, and skin coverage with vascularized islanded scrotal raphe flap in the second stage. The primary outcome was 6-month flap survival rate. Secondary outcomes were 6-month complication rate (fistula, persistent chordee, distal stenosis) and end-of-follow-up patient self-reported satisfaction rate. RESULTS: A total of 1845 patients underwent hypospadias surgery, of which 380 patients had complications. Scrotal raphe flap was used in 45 patients. Mean age was 14.09 (±8.02) years. Mean follow-up was 29.78 (±12.18) months. Mean number of previous surgeries was 4.31 (±2.59). The flap survived in all cases. Nine patients (20%) developed complications. One patient (2.2%) developed distal stenosis. Eight patients (17.8%) developed fistulas, one of whom additionally had persistent chordee. Five fistulas closed spontaneously within 3 months, while the rest were repaired surgically after 6 months. All patients self-reported satisfaction with results at end-of-follow-up. CONCLUSIONS: Islanded Scrotal Raphé flap is a promising option for treating complicated hypospadias when there is significant ventral deficiency of skin, as it not only provides vascularized pliable skin but also fascia as a waterproofing layer.

Lower extremity reconstruction: utility of smartphone thermal imaging camera in planning perforator based pedicled flaps.

BACKGROUND: Presence of good size perforators are mandatory to design perforator based pedicelledflaps specially in lower limb as flap failure rate isrelativelyhigh. We have explored the use ofsmartphonebaseddynamic thermal imagingand compared it with doppler to devise a protocol forplanning and executionof pedicled perforator flaps anddescribedits use in deciding delay of flap. We have also compared the time required for detecting dominant perforators. METHODS: This prospective case series was done atJinnah burn and reconstructive surgery center Lahore from July to September 2018and included patients requiring pedicled fasciocutaneous or musculocutaneous flapfor lower extremity reconstruction. Smartphonebased dynamic thermal imaging and doppler wereused to map out suitable perforators and confirmed intraoperatively. Comparison was made regarding their ability to locatedominant perforatorsandtotal time required.Utility of thermal imaging to ascertain flap perfusion postoperatively was also assessed.Flaps were designed according to thermal mapping. Clinical judgement supplemented with thermal imaging was usedto ascertain flap survival. RESULTS: The study included 15 patientsin which22 out 23 dominant perforators as located withthermal imaging were confirmed intra-operatively (positive predictive value = 95.7%) as compared to 22 out of 32 with doppler(positive predictive value=68.8%). Mean time required with doppler was 591.27±252.48, compared to 598.47±192.94 seconds with thermal imaging. In two cases flap was delayed. Partial flap necrosis occurred in one case. CONCLUSION: Dynamic thermal imaging can be reliably usedin planning of pedicled perforator flaps for lower limb reconstruction. We have found itmore reliable than handhelddoppler in locating dominant perforators.

Medial Sural Artery Perforator Flap: A Versatile Option For Soft Tissue Reconstruction Of Head And Neck And Limbs.

BACKGROUND: To assess the outcome of Medial Sural Artery Perforator Flap (MSAP Flap) as an option for the soft tissue reconstruction of head and neck and limbs. METHODS: This descriptive case series was conducted at Jinnah Burn and Reconstructive Surgery Center, Lahore during October 2016 to August 2017. All patients in whom MSAP flap (free and pedicled) was performed for reconstruction are included. Patients were followed at one week and one month after the discharge and data was entered into the proformas. RESULTS: In total, 18 patients were operated with this flap. Free and pedicled MSAP flap were performed for reconstruction of soft tissue defects in the head and neck and the lower limb. The maximum dimensions of the flap were 14 cm length and 10 cm width. The maximum pedicle length was 16cm. All flaps survived and showed good outcome. There was necrosis of the distal margin of a pedicled flap, but no case of venous congestion and flap failure was observed. The flap donor site was closed primarily in 7 patients while split skin graft was used in the rest of the patients. CONCLUSIONS: The MSAP flap provides a thin skin paddle and has minimal donor site morbidity as compared to the other options. It is a good addition to the armamentarium of perforator flaps which are thin and pliable, can be harvested by two team approaches, under the tourniquet and has a hidden donor site.

SUCCESSFUL TREATMENT OF MULTIDRUG-RESISTANT ACINETOBACTOR BAUMANII BLISTERS ON THE KNEE.

Acinetobacter baumannii (A. baumannii), nosocomial infections, especially those due to multi-drug resistant (MDR) strains, are increasingly detected. This study reports the case of a 50-year-old man with blisters on the right knee for 8 months, first admitted through the outpatient department for incisional biopsy. Microbiological and histo-pathological examination confirmed the diagnosis of blisters extending deeply up to the knee joint caused by MDR- A. baumannii. A broad spectrum antibiotic therapy was administered and later readjusted according to the results of microbiological culture and biopsy report. Intensive hemodynamic support was required. An extensive surgical debridement was promptly performed and repeated until complete control of the infection with intravenous colistins. Blisters were excised; wounds were dressed daily with chlorhexidine dressings and polymyxine-impregnated dressing. Wounds were finally covered with split-thickness skin grafts. The infection was overcome 120 days after admission. The graft take was 40%. Postoperative rehabilitation was required because of the functional limitation of lower limb movements at the knee joint. Follow-up at 8 months showed no functional deficit and an acceptable aesthetic result. AB-MDR affecting soft tissues is a life-threatening disease, especially in patients with poor immunity and limited access to health facilities, whose clinical diagnosis may sometimes be challenging. Early recognition and treatment represent the most important factors influencing survival.

Comparison of the efficacy of single volar subcutaneous digital block and the dorsal two injections block.

BACKGROUND: Digital nerve blocks are commonly used as effective techniques of anaesthesia to allow a variety of surgical procedures performed on digits. This study was conducted to compare the efficacy of volar subcutaneous single injection block and the traditional dorsal two injections digital block. METHODS: This randomized controlled trial was conducted at Plastic and Reconstructive Surgery Department, Hayatabad Medical Complex Peshawar from December. 2009-10. A total of 126 patients with pathology distal to the first palmer digital crease divided into two equal groups. Group A received volar subcutaneous digital block while group B dorsal two injections block. Efficacy of digital block was measured in terms of time of onset of anaesthesia, which was the total time duration after administering local anaesthetic to loss of pinprick sensation and total duration of anaesthesia, which was defined as the time period from onset of block (loss of pinprick sensation) till the appearance of pain which required additional local anaesthetic or postoperative analgesia. RESULTS: A total of 126 patients were studied, 63 in each group. Of the total patients, 102 (81%) were male and 24 (19%) female with a mean age of 27 ± 4.2 years (range 17-60 years). The mean time of onset of anaesthesia from injection till the loss of pin prick sensation was 3.32 ± 0.42 minutes for volar single injection group and 4.53 minutes ± 0.57 minutes for dorsal two injections group (p = 0.049). Similarly the mean total duration of anaesthesia for the volar subcutaneous group was 271.9 ± 29.34 minutes while for the dorsal two injections group, it was 229.52 ± 28.82 minutes (p = 0.415). CONCLUSION: Single injection volar subcutaneous digital block provides faster onset of anaesthesia, produces predictable, consistent dense anaesthesia of all of the fingers with the help of single injection prick.

Pre-hospital management of spinal injuries in a natural disaster.

BACKGROUND: Spinal injuries are one of the most devastating and crippling conditions known to mankind. Natural calamities follow no rules, and all have the potential of devastating medical and public health resources, earthquakes being the deadliest. The incidence of spinal injuries increases by leaps and bounds in such calamities. Improper pre-hospital management and inadvertent manipulation of the spine during rescue and transfer can aggravate the damage. This study was conducted in order to access the level of pre-hospital care that had been provided to the patients with spinal injuries reaching Ayub Teaching Hospital, Abbottabad after the October 2005 earthquake. METHODS: This study was conducted in the department of Neurosurgery, Ayub Medical College after the earthquake of October 2005. All patients sustaining spinal injuries were included in the study. Demographic data like age, gender and time of arrival at hospital were recorded. The important aspects of pre-hospital care like spinal immobilisation, intravenous access, fluid resuscitation, catheterisation, pain killers and intravenous steroids administration were also recorded. RESULTS: Out of the 83 patients with spinal injuries, 55 (66.26%) were females and 28 (33.7%) were males. Age ranged from 12-68 years (mean 26.6 +/- 13.2 years). At the time of presentation 70 (84.3%) patients had complete spinal injury whereas 13 (15.6%) had incomplete spinal injury. Sixty-one (73.5%) patients were paraplegic and 22 (26.5%) cases were quadriplegic. Only 8 (9.6%) patients were brought to the hospital after proper spinal immobilisation on the spinal boards. Intravenous line was maintained in 24 (28.9%) patients and only 18 (21.7%) received some sort of fluid resuscitation. Thirty-eight (45.7%) were catheterised. 18 (21.6%) received some sort of parenteral analgesics and 4 (4.8%) received steroids at the time of patients. Only 10(12%) were brought in properly equipped ambulances. CONCLUSION: Poor pre-hospital management of spinal injured patients depicts the lack of emergency preparedness as well as the lack of basic knowledge rescue teams and health care providers about the common trauma management measures. There is a dire need of educating rescue workers and volunteers about spinal injury in order to save lives minimise the secondary damage to already affected spine.