Flap Monitoring using Thermal Imaging Camera: A Contactless Method.

OBJECTIVE: To determine the accuracy of the thermal imaging camera for the detection of vascular insult before the onset of permanent tissue damage. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Burn and Plastic Surgery, from July to December 2019. METHODOLOGY: The thermal image was used as an adjunct to clinical assessment in 84 flaps. Both pedicled and free flaps were performed in the study with a frequency of 68 (81%) and 16 (19%), respectively. Flap monitoring was performed regularly for five days by same team of surgeons and nurses. Flap vascularity was assessed by temperature gradient colour coding of thermal image taking the clinical assessment like colour, temperature, capillary refill, as a gold standard. Sensitivity and specificity of the thermal camera were calculated. RESULTS: The age range of patients was from 5 years to 55 years. The diagnostic accuracy of thermal imaging camera was calculated to be 96.43% with a sensitivity of 98.7%, specificity of 75%. The positive predictive value was found to be 97.4%, negative predictive value was 85.7%, the false-negative value was 14.3%, and the false-positive value was 2.6%. CONCLUSION: Thermal imaging camera is an effective and useful adjunct for clinical assessment, as it is an easy and contactless technique. Key Words: Flir one, Flap monitoring, Thermal imaging camera.

Accuracy of Thermal Imaging Camera in Identification of Perforators.

OBJECTIVE: To determine the diagnostic accuracy of thermal imaging camera in the identification of perforators using peroperative visual inspection as gold standard. STUDY DESIGN: Descriptive study. Place of Study: Jinnah Burn and Reconstructive Surgery Centre / Allama Iqbal Medical College, Lahore, from October 2017 to September 2018. METHODOLOGY: Patients undergoing pedicled or free perforator flap for reconstructive surgery of upper and lower limb, abdomen, groin, and head and neck region, where soft tissue defect was caused by trauma (road traffic accidents and electric burns), were included in this study. All patients underwent the same treatment protocol of identification of perforator location with Flir One camera preoperatively. Later, it was confirmed peroperatively by visual inspection. Diagnostic accuracy was calculated in terms of sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Diagnostic accuracy in identification of perforators in pedicled (n=154) and free flaps (n=30) by thermal imaging camera was calculated as sensitivity of 86.2%, specificity of 80.0% with the positive and negative predictive values of 98.7%, and 25.0%, respectively. CONCLUSION: Flir One, a smartphone-compatible miniature thermal imaging camera, is useful for the detection of perforators and is highly sensitive and specific. Key Words:  Flir One, Perforators, Thermal imaging, Thermal imaging camera.

Early Active Mobilization Vs Immobilization Following Modified Kessler Repair Of Extrinsic Extensor Tendons In Zone V TO VII.

BACKGROUND: The long-disputed issue of rehabilitation of extensor tendon repairs in zones V-VII has been treated with either complete immobilization or mobilization within the constraints of splint. In recent times, most authors have preferred some mobilization. Many studies have shown good results with early mobilization techniques; however, these studies have limitations. Most of these are retrospective observations. Some prospective studies are without proper controls. This study was conductive to compare the functional outcome of early active mobilization versus immobilization following repair of extensor tendons in zone V-VII. METHODS: Functional outcome was determined by total active motion, pain and complications during rehabilitation. Total active motion (TAM) was graded by scores of the American Society for Surgery of Hand as TAM=total active flexion (MCP+PIP+DIP)-total extension deficit (MCP+PIP+DIP). A randomized control trial was conducted including 50 subjects of with extensor tendon injury exclusively in zone V-VII. Patients were divided randomly in two groups. All extensor tendon repairs (zone V to VII) were performed with modified Kessler's method. The pain and TAM was assessed during all visits in both groups except TAM in group B that was assessed after four weeks. RESULTS: We found that outcome of 12% cases in Group A as excellent and no patient fell in category of fair results. While, in comparison, there was no case of excellent result in Group B. 4% cases showed fair results that were treated with immobilization. The pain score at the end of treatment, i.e., at 12 weeks were same in both the groups but, generally the score remained higher in group of EAM. There was significant difference in adhesion formation that was more in patients of immobilization group. The overall suture dehiscence was insignificant and was only 8% in each group. CONCLUSIONS: EAM has better outcome in terms of pain and range of motion.

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.

Distally Based Medial Hemisoleus Flap: Reliable Option for Distal Tibial Wounds.

OBJECTIVE: To determine the success (flap survival as a whole without necrosis or dehiscence up to two months as judged clinically) of distally based medial hemisoleus muscle flap for the coverage of distal tibial defects. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Jinnah Burn and Reconstructive Surgery Centre, AIMC, Lahore, from July 2014 to July 2017. METHODOLOGY: Patients with middle and distal third tibial defects were enrolled and stratified according to the site of the wound in middle or distal third of tibia. Soft tissue coverage was provided with distally based medial hemisoleus muscle flap on which split thickness skin graft was applied. Postoperatively, patients were followed-up after one week of discharge and then fortnightly for at least 2 months. Outcome variable was taken as flap success. RESULTS: Out of 37 cases, flap was successful in 33 patients as complete flap survived with primary wound healing. Partial flap necrosis without dehiscence was seen in 3 cases and partial necrosis of flap with dehiscence in only one case that required another surgery for the defect. Complete flap loss was not seen in any case. CONCLUSION: Distally based medial hemisoleus muscle flap is reliable coverage option for middle and distal third of tibial defects.

Quantification and Further Refinements of Dorsal Metacarpal Artery Perforator Flap for Reconstruction of Wounds of Fingers upto Distal Interphalangeal Joints.

OBJECTIVE: To assess the outcome of dorsal metacarpal artery perforator flap for coverage of finger defects extending upto distal interphalangeal joint (DIPJ). STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Jinnah Burn and Reconstructive Surgery Centre, Lahore, from March 2015 to May 2017. METHODOLOGY: Our study was carried out in two parts. 1st part of study was to measure average flap length in our population. Five hundred cases were enrolled to measure flap length, from pivot point of the flap to the distal border of extensor retinaculum. This length was traced to fingers to determine its coverage area. This was followed by clinical study in 35 cases. All patients with wounds over dorsal surface of fingers upto distal interphalangeal joint and volar surface of fingers upto mid of middle phalanx, single or multiple finger defects with exposed tendon joints or bones were included in the study. Patients with history of trauma to the dorsum of hand, metacarpal head or neck fracture and patients with history of diabetes or peripheral vascular disease were excluded. RESULTS: Flap length decreased from radial to ulnar side of hand. Average length of flap based on the second metacarpal artery was 7cm while of the third was 6.6 cm and the fourth was 6.1 cm. This flap length covered upto mid of middle phalanx in border digits while upto PIPJ in central digits. This data was confirmed in 35 patients in which 36 flaps were raised to cover finger defects. Thirty-four flaps survived completely while tip necrosis was seen in 2 cases. CONCLUSION: The dorsal metacarpal artery perforator flap is a thin, pliable flap, which has minimal donor-site morbidity. It can reliably cover soft tissue defects of dorsum of fingers upto mid of middle phalanx in border digits and upto PIPJ in central digits.