Free scapular flap for reconstruction of upper extremity defects

Objective: To determine the functional outcome of free scapular flaps performed for reconstruction of complex upper extremity defects. Design: Case series. Place and Duration of Study: The Aga Khan University Hospital, from 1998 to 2001. Subjects and Methods: All those patients in whom free scapular flap was done for reconstruction of upper extremity defects, were included. The important variables included demographic data, etiology of soft tissue defects, site and size of defect, complications, percentage of wound coverage by flap. Patient satisfaction, objective assessment of flap and range of motion of involved joints was determined. Results: There were 9 males and 2 female patients with mean age of 31.54 +/- SD11.86 years. The causes of tissue defects were road traffic accident in eight cases, bomb blast injury in 2 and industrial injury in one case. Eight scapular flaps were performed to reconstruct the defects over the hand, wrist and forearm; two flaps for defects of arm and shoulder and one for elbow coverage. Average defect size was 18 cm long and 11 cm wide. Donor site was closed primarily in all cases. Based on cosmetic appearance, coverage of required defect, performance of activities of daily living and functional range of motion of involved joints, 7 cases were graded excellent and 4 cases were good. Conclusion: Scapular flap provided good robust coverage, which helped to do an early reconstruction and rehabilitation in our cases. Scapular flap can be considered workhorse for reconstruction of upper extremity defects

An experience with free scapular flap for reconstruction of lower extremity defects at Aga Khan University Hospital Karachi

Background: Reconstruction of large composite tissue defects with exposed vital structures and weight bearing surfaces are extremely difficult for reconstructive surgeons. Coverage of such difficult defects can be achieved with free tissue transfer provided microsurgical expertise is available. This study was carried out to determine the outcome of free scapular flaps performed for lower extremity defects. Methods: Clinical records of the patients were reviewed and important variables included demographic data, etiology of soft tissue defects, site and size of defect, complications and percentage of wound coverage by flap. Patient satisfaction and objective assessment of flap coverage and motion of involved joints was made. Results: There were 13 male patients with mean age of 30.46 years. The causes of tissue defects were road traffic accident in 8 cases, industrial accidents in 2 and 3 cases had bomb blast, gunshot and gas gangrene one in each case respectively. Nine scapular flaps were performed to reconstruct the defects around the foot, ankle and lower leg; two flaps for amputation stumps and two flaps for defects around the knee and popliteal fossa. Post flap surgery, 3 cases had vascular compromise which required urgent exploration of anastomosis. Two cases were revived and one flap did not survive. With respect to cosmetic appearance, coverage of required defect, performance of activities of daily living and functional range of motion of involved joints, 6 cases were graded excellent and 7 cases were good. Conclusion: In our cases of lower extremities defects, scapular flap helped to salvage the limb. In conclusion scapular flap is a versatile flap which can be used for lower extremity defects

Bifocal metachronous giant-cell tumour of ulna and distal radius

A 36 years old gentleman had giant cell tumour (GCT) in distal ulna for which he underwent resection of distal half of ulna but developed recurrence of the tumour. Following proper evaluation (grading and staging), he underwent wide margin excision of tumour including removal of distal three-fourth of ulna and reconstruction by free vascularised osteocutaneous fibular transfer. The distal reconstructed fibula was stabilized with extensor carpi ulnaris (ECU). Two years after the surgery, he developed a metachronous GCT lesion in ipsilateral distal radius for which he had curettage and bone grafting with preservation of articular surface

Functional and radiological outcome of Intramedullary nailing vs. plate fixation for humeral shaft fractures. Does treatment method bring any difference?

Abstract BACKGROUD: Operative Management of Humeral shaft fractures may be accomplished with the help of Plate fixation or IM Nails. Controversy exists as to which modality is superior to the other in terms of fewer complications and better functional and radiologicaloutcome. OBJECTIVE: To compare the differences in radiological and functional outcome of humeral shaft fractures managed by platefixation and antegrade intramedullary nails. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised records of Patients managed surgically for uncomplicated humeral shaft fractures between 2007 and 2012. The patients were followed up for one year at clinic, and radiographs and clinical assessment were used to complete the Quick Disabilities of the Arm, Shoulder and HandQuestionnaire. SPSS 19 was used for statistical analysis. RESULTS: Of the total 61 patients, 39(64%) underwent plating and 22(36%) had intramedullary nailing. There was no significant difference in terms of mean age and mean duration of surgery in the two groups (p\u3e0.05 each). Also, no significant difference was noted in the duration of healing with either of the two methods (p\u3e0.05). Mean Questionnaire score for plating was 23.9±17.7, while for intramedullary nailing it was 21.7±19.8 (p\u3e0.05). CONCLUSIONS: There was no significant difference in the radiological and functional outcome of patients in the two groups

Short term results of ligament reconstruction and tendon interposition resection arthroplasty for basal joint arthritis

Carpometacarpal (CMC) joint of the thumb is the second most common site afflicted by osteoarthritis. Non surgical measures forms the first line of treatment with aim of preventing progression of disease, however, surgery becomes an option when symptoms are refractory to nonsurgical methods. Different procedures have been described in literature. Ligament reconstruction with tendon interposition (LRTI) is the most commonly performed procedure in North America for this problem. The Aim of study was to evaluate early results of ligament reconstruction and tendon interposition for CMC joint arthritis. This is a case series of ten patients operated in a tertiary care hospital from December 2006 to December 2008. All cases were operated by a single surgeon. All of the patients were followed up using Quick DASH questionnaire filled preoperatively and 3 and 6 months postoperatively. All of our patients were female. Mean duration of follow up was 34 weeks. Pain and residual laxity recorded at each clinical follow up visit after removal of thumb spica and Kirschner wire. Mean value for Quick DASH score is 31 in a 0-100 scale with 0 being no disability. Ligament reconstruction and tendon interposition resection arthroplasy is an effective method of controlling symptoms with preservation of motion at CMC joint axis

Osteoid osteoma of acetabulum a rare presentation

Abstract The case of a relatively frequent benign osteoblastic tumour, osteoid osteoma at an atypical site is presented. It was in a 20 year old man who attended the outpatient department of Aga Khan University Hospital, Karachi with pain in left groin since last 6 months which often occurred at night and was relieved by taking NSAIDs. X-ray failed to reveal the cause. CT scan showed central radiolucent nidus with surrounding sclerosis suggestive of osteoid osteoma in the left acetabulum. Acetabulum is a rare site for osteoid osteoma, the usual sites are diaphysis of long bones. Hence, the diagnosis is often difficult and delayed in such cases. CT scan, Bone scan and MRI, helped in diagnosing the condition. Resection of the lesion by open technique under fluoroscopic control was performed and histopathology confirmed the diagnosis

Restoration of glenohumeral motion in erb\u27s palsy by tendon transfers

Background: Children with erb\u27s palsy have significant functional disability, mainly related to the shoulder. The objective of this study was to analyze the functional outcome of tendon transfers performed for restoration of shoulder motion in patients with Erb\u27s palsy.Methods: This descriptive case series was conducted at Aga Khan University Hospital from May 1999 to December 2003. Ten patients who had functional deficit of shoulder elevation were operated by a single surgeon. The surgical procedure; modified Sever L\u27Episcopo procedure was uniform in all cases. The data was collected through patient interviewing and medical records maintained through Health Information Management System (HIMS). Mallet class was recorded preoperatively and postoperatively.Results: Ten patients; seven females (70%) and three males (30%), with average age of 75 months at operation were included in this series. Right shoulder was affected in seven cases (70%) while left in three cases (30%). Preoperative mallet class for global abduction improved from 3 to 4; for global external rotation from 2 to 4 and for ability to bring the hand to mouth and neck from 1 to 3. Post operatively mallet class improved in all aspects to 4 and 5; statistically significant on paired t-test with p value of less than 0.005. There was a significant improvement in abduction, forward flexion and external rotation as compared to -preoperative values; statistically significant on paired t-test with p value of less than 0.005.Conclusion: Tendon transfer improves the functional status of shoulder in late cases of Erb\u27s Palsy with significant improvement in mallet class, cosmesis and patient satisfaction. A motivated patient, compliance and aggressive rehabilitation are important outcome parameters

Long term follow-up of a successful lower limb replantation in a 3-year-old child

Replantation of the lower extremity has controversial indications but nevertheless it may be considered in carefully selected patients who present early and are expected to show good functional recoveries. Here we present a successful replantation in a 3-year-old boy who has made excellent recovery with no functional deficit evident at 12 years of follow-up. He sustained a traumatic amputation at the level of distal tibia when he fell of a Qing Qi (motorcycle rickshaw). Replantation was attempted at 8 hours cold ischemia time with the tibia shortened 4cm and all tendons, vessels, and nerves repaired. Patient required a second procedure during the same hospital stay for skin coverage. Patient made good recovery with ambulation without support at 6 months, less than 3cm limb length discrepancy, plantar and dorsiflexion power 4/5, and recovery of sensation over the foot. Now at 12 years of follow-up patient has a normal gait and has integrated into society with no functional deficit. Considering the functional outcome of our case, replantation should be attempted whenever possible and feasible especially in children

Delayed supramalleolar flap: An innovative technique for enhanced viability

Background: Delaying flap rotation for 48 to 72 hours leads to opening of choke anastomotic vessels linking adjacent vascular territories. This mechanism enhances flap circulation. Lateral supramalleolar flap with larger dimensions or vascular variations can potentially have survival problems. The purpose of this study is to assess the outcome of delayed lateral supramalleolar flap.Methods: This descriptive case series was conducted at Aga Khan University Hospital, Karachi from May 1999 to December 2004. Eight cases of delayed lateral supramalleolar flap were identified through medical records maintained through Health Information Management Systems (HIMS). A detailed questionnaire was developed addressing variables of interest.Results: Eight patients required flap delay for 48 hours out of 25 patients, who underwent lateral supramalleolar flap for coverage of foot and ankle soft tissue defects. There were six male (75%) and two female (25%) patients with average age of 31.25 years ranging from 5-52. The reasons for delaying lateral supramalleolar flap were larger flap dimension in four (50%), absent peroneal artery perforator in three (37.5%) and one patient (12.5%) had poor circulation in immediate postoperative period. All the patients required two stage procedure and had excellent coverage of defects. No flap failure occurred subsequent to the delay procedure.Conclusions: Flap delay enhanced survival and extended the viable dimensions of lateral supramalleolar flap. Compromised circulation in larger flaps and flaps with vascular variations can be improved by delaying flap transfer to the recipient site for 48 hours following its elevation

Intra-articular distal radius fractures: postoperative roentgenographic and functional outcomes

Abstract OBJECTIVE: To assess the outcome of volarlocking compression plate fixation for intra-articular distal radius fractures with respect to function of hand and roentgenographic parameters. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised patients who underwent locking compression plate fixation for intra-articular distal radius fractures between June 2009 and July 2012. Case notes, radiographic assessment and functional outcomes were noted. Functional outcome was determined with the help of telephone-based quick-dash score questionnaire administered atleast 6 months post-surgery. Radiological assessment of radial inclination, radial height and volar tilt was measured on immediate postoperative radiographs and then again measured at last available follow-up which ranged from 4 to 116 weeks. RESULTS: The mean age of the 43 patients in the study was 47.31±14.24 years (range: 20-95 years) at the time of injury. Mean Quick Dash score at 6-month follow-up was 17.2±8.8 (range: 4-40). The outcome was very good in 1(2.2%), good in 30(66.7%), satisfactory in 10(22.2%) and poor in 4(8.9%) patients. Mean immediate postoperative radial inclination, volar tilt and radial height were 17.26±3.23°, 7.6±3.87° and 10.2±1.95mm respectively. Corresponding values at the last follow-up were 17±3.89°, 7.67±4.28° and 9.8±1.8mm. CONCLUSIONS: Use of locking compression plate for intra-articular distal radius fracture showed good results comparable with global literature