Free Fibula Flap for Congenital Pseudarthrosis of the Tibia: Indications and Challenges.

Background: Congenital pseudoarthrosis of the tibia (CPT) is a rare pathological disease associated with neurofibromatosis type 1 (NF1). It presents with tibial bowing and can progress into a nonhealing fracture. Treatment options include conservative approaches such as serial bracing or various surgical options.Surgically, the aims are to achieve long-term bone union, prevent limb length discrepancies (LLDs), and avoid mechanical axis deviation, soft tissue lesions, nearby joint stiffness, and pathological fracture.The purpose of our study is to highlight our experience with both the conservative approach and the use of vascularized free fibula reconstruction of these deformities, including the challenges encountered with a long-term follow-up until skeletal maturity. Methods: We present a retrospective analysis of a total of nine (9) patients consisting of three (3) girls and six (6) boys. Six (6) children were treated with a vascularized fibula flap, and the other three (3) were treated conservatively. Outcomes measured included fractures, LLD, ankle valgus deformity, donor site morbidity, and number of surgical corrections. Results: All patients had flap survival. Three (3) of six children had a previous failed surgery with intramedullary nail and bone graft prior to performing a vascularized free fibula reconstruction. The follow-up period ranged from 8 months to 200 months. The complications included stress fractures (50%), LLD (66.6%), and ankle valgus (33.3%). During growth phases, these children required multiple corrective surgeries. Conclusions: Fibula free flap is a good treatment option for CPT even in patients with prior surgical failures with variable results.Level of Evidence - Level 4 - Case series Therapeutic Studies-Investigating the Results of Treatment.

Analysis of clinical and patient-reported outcomes in post-ELAPE perineal reconstruction with IGAP flap - A 5-year review.

BACKGROUND: Extralevator abdominoperineal excisions (ELAPE) are now the accepted treatment option for low rectal cancers, which result in large perineal defects necessitating reconstruction. The aim of our study was to assess the clinical outcomes as well as the quality-of-life parameters (QOLP) following these reconstructions. METHODS: A series of 27 patients who underwent ELAPE and immediate reconstruction with inferior gluteal artery perforator flaps (IGAP) between December 2013 to December 2018 were retrospectively analysed on patient demographics, disease and treatment, complications, and QOLP. RESULTS: With a mean age of 71.6 years, all patients had low rectal cancers and underwent ELAPE (24 open, 3 lap-assisted) and immediate IGAP flap reconstruction. The follow-up period was 1 year. The overall perineal early minor complication rate was 25.9% and the early major complication rate of 14.8%. QOLP, such as tolerance to sit, perineal pain, perineal aesthetics, showed high patient satisfaction of 77.7%, 40.74%, and 66.6%, respectively at 1 year. The perineal hernia rate was 14.8% with all patients being female (p 0.0407; significant). CONCLUSION: IGAP flaps are a reliable option for reconstructing post-ELAPE defects with good patient satisfaction and outcomes.

Therapeutic Potential of Exosomes Derived from Diabetic Adipose Stem Cells in Cutaneous Wound Healing of db/db Mice.

(1) Background: Diabetes impairs angiogenesis and wound healing. Paracrine secretion from adipose stem cells (ASCs) contains membrane-bound nano-vesicles called exosomes (ASC-Exo) but the functional role and therapeutic potential of diabetic ASC-Exo in wound healing are unknown. This study aims to investigate the in vivo mechanistic basis by which diabetic ASC-Exo enhance cutaneous wound healing in a diabetic mouse model. (2) Methods: Topically applied exosomes could efficiently target and preferentially accumulate in wound tissue, and the cellular origin, ASC or dermal fibroblast (DFb), has no influence on the biodistribution pattern of exosomes. In vivo, full-thickness wounds in diabetic mice were treated either with ASC-Exo, DFb-Exo, or phosphate-buffered saline (PBS) topically. ASC-Exo stimulated wound healing by dermal cell proliferation, keratinocyte proliferation, and angiogenesis compared with DFb-Exo and PBS-treated wounds. (3) Results: Diabetic ASC-Exo stimulated resident monocytes/macrophages to secrete more TGF-ß1 and activate the TGF-ß/Smad3 signaling pathway. Fibroblasts activated by TGF-ß1containing exosomes from ASCs initiate the production of TGF-ß1 protein in an autocrine fashion, which leads to more proliferation and activation of fibroblasts. TGF-ß1 is centrally involved in diabetic ASC-Exo mediated cellular crosstalk as an important early response to initiating wound regeneration. (4) Conclusions: The application of diabetic ASC-Exo informs the potential utility of a cell-free therapy in diabetic wound healing.

Bridging the Gap - A Traffic Light System to Ease Communication Amongst Surgeons, Hand Therapists and Patients.

Communication in the healthcare setup is essential for patient safety and for seamless delivery of services to the patient. We have adopted a novel way of communication in the form of a colour-coded visual aid in the form of a traffic light system to guide the patients through the course of their treatment. This shows the treatment plan in the form of Red, Amber, Green and Blue. The Red (Stop) denotes complete immobilisation with Splints, Amber (Proceed with caution) denotes active movements only, Green (Go forward) denotes Passive and Active movements and Blue shows when the patient can undergo guided weight bearing and strengthening exercises without a splint. The implementation of this system has created a streamlining of our protocol and improvement in the quality of the care we deliver. Level of Evidence: Level V (Therapeutic).

Anterior plagiocephaly in an atypical case of apert syndrome.

Apert syndrome is a congenital craniosynostosis syndrome comprising of bilateral coronal synostosis , symmetric syndactyly of hands and feet and midface hypoplasia. We present an atypical phenotype of this syndrome with right sided unilateral coronal synostosis. However, type I apert hand and other clinical and radiological features suggestthe diagnosis. Genetic analysis revealed an absence of the specific missense mutations in the FGFR 2 gene that is found in patients with this syndrome. We conclude that this patient represented a rare atypical variant of Apert syndrome. Further analysis is required to map the associated genotype.