Management of a mutilated hand: the current trends

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

Outcome of standard tabularized incised plate urethroplasty repair using dartos flap and tunica vaginalis flap in of hypospadias cases

Background: Hypospadias, with prevalence of 1 per 300 live births, is a congenital malformation caused by incomplete fusion of urethral folds, in which the meatal orifice opens on the inferior surface of the penis. The commonest complication of hypospadias surgery is fistula formation which requires re-operation. Several techniques of providing vascularised soft tissue cover to neourethra have been described. They include de-epithelized skin, corpus spongiosum, dartos fascia and tunica vaginalis. The purpose of our study was to compare outcomes of standard tubularised incised plate urethroplasty (TIP) repair using dartos flap and TVF in of hypospadias cases.Methods: This study was carried out in the Department of Surgery (Paediatric Surgery Division) of Pt. JNM Medical College and associated Dr. BRAM Hospital, Raipur in patients diagnosed to had distal, mid penile and proximal penile type of hypospadias. The study was carried out during the period from February 2016 to September 2017. Total no of cases studied was 55. All admitted patients for primary Snodgrass repair were randomized into two groups by Simple Random method to avoid selection bias. Group A of 27 patients were prospectively selected for repair using TVF for soft tissue cover. Group B of 28 Patients, comparable in age and type of hypospadias, who underwent TIP repair using dartos flap as soft tissue cover. Descriptive statistics were employed to characterize the data.Results: Patients were from 1 year to 13 years of age at time of surgery for hypospadias. Mean age being 4.69+3.15. There was almost equal number of patients in both groups of flap. Both groups were comparable in terms of age and type of hypospadias. Overall, dartos flap group had significantly higher rate of urethrocutaneous fistula formation than tunica vaginalis flap. In TVF group only one patient (3.7%) developed skin necrosis while in Dartos group 5 patients (17.86%) developed skin necrosis. Both TVF group and Dartos group had one patient with residual torsion.Conclusions: In present study we have noted higher rate of fistula formation and skin necrosis in dartos flap group as compared to tunica vaginalis. Tunica vaginalis flap definitely have an edge over preputial dartos flap and we would recommend its use as waterproofing second layer in hypospadias cases.

A case series of flow-through free anterolateral thigh flap to augment the vascularity of ischaemic limbs with soft tissue defect

ABSTRACT Introduction: In a world of fast moving vehicles, heavy machinery and industries crush injury to limbs with vascular compromise and soft tissue defect is common. The traditional treatment is a 2 step one dealing with vascular repair and soft tissue cover separately, in the same operation. We report a series of single step vascular repair and soft tissue cover with flow through anterolateral thigh flap (ALT) flap for limb salvage. Materials and Methods: Ten patients with soft tissue defect and vascular injury were included in this study. A two team approach was used to minimise operative time, team one prepared the vessels and team 2 harvested the flap. Observations and Results: Of the ten patients operated (8 males), eight flaps were done for upper limb and two for lower limb salvage. Six anastomosis were done with ulnar vessels, two with radial and two with posterior tibial vessels. Nine extremities could be salvaged while one patient developed progressive thrombosis leading to amputation. Conclusion: The ALT flow-through flap is a versatile single step procedure that can be used to salvage an ischemic limb with soft tissue loss avoiding the need for interpositional vein graft.

Experience of managing open fractures of the lower limb at a major trauma centre

Introduction In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network. Methods From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC. Results Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover. Conclusions Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.