The Versatility of Perforator-Based Propeller Flap for Reconstruction of Distal Leg and Ankle Defects

Introduction. Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this may lead to considerable donor site morbidity, is time consuming, and needs facility of microsurgery. With the introduction of perforator flap, management of small- and medium-size defects of distal leg and ankle region is convenient, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180 degree, donor site is closed primarily and increases reach of flap, thus increasing versatility. Material and Methods. From June 2008 to May 2011, 20 patients were treated with perforator-based propeller flap for distal leg and ankle defects. Flap was based on single perforator of posterior tibial and peroneal artery rotated to 180 degrees. Defect size was from 4 cm × 3.5 cm to 7 cm × 5 cm. Results. One patient developed partial flap necrosis, which was managed with skin grafting. Two patients developed venous congestion, which subsided spontaneously without complications. Small wound dehiscence was present in one patient. Donor site was closed primarily in all patients. Rest of the flaps survived well with good aesthetic results. Conclusion. The perforator-based propeller flap for distal leg and ankle defects is a good option. This flap design is safe and reliable in achieving goals of reconstruction. The technique is convenient, less time consuming, and with minimal donor site morbidity. It provides aesthetically good result

Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as markers of early sepsis and mortality in pediatric burns: a prospective evaluation

Background: Delay in the diagnosis of sepsis in pediatric burns results in advertently high mortality and morbidity. Our study aimed at evaluating the role of two upcoming biomarkers- neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR)- as predictors of early sepsis and mortality in this group of patients. Methods: This was a prospective study conducted at a tertiary care burn centre of northern India over 18 months. 90 pediatric burn cases, aged 1-16 years, presenting within 24 hours of burns, with >10% body surface area of thermal burns/scalds were included in the study. Cell counts were measured on day 1, 3, 5 and 7 of burns. Patients were followed up till discharge, 30th post burn day or death, whichever was earlier. Results: Sepsis was clinically present in 49 cases out of 90 (54.44%) with 30% median total body surface area (TBSA) of burns. Mortality was seen in 31cases out of 90 (34.44%) with 35% median TBSA burns. Higher PLR levels were seen in the sepsis group. NLR and PLR were also elevated in the survival group. Both parameters were found to be reliable markers of sepsis as well as mortality, particularly on days 5 and 7, in this cohort of patients. Conclusions: Indices like NLR and PLR, which can easily be derived from complete blood count, have potential utility as determinants of both sepsis and mortality in children afflicted with thermal injuries

Milling, Nutritional, Physical and Cooking Properties of Four Basmati Rice Varieties

Rice is one of the most popular staple foods produced contributing higher most in agriculture gross domestic production in Nepal. Thus, nutritional, physicochemical, and cooking properties of rice might interplay important roles in their production and farming practice, therefore, it is inevitable to understand these characteristic features. However, there has been only limited information available on such properties, therefore we aimed to examine nutritional, physicochemical and cooking properties of four Basmati varieties of rice namely Red Basmati, White Basmati, Black Basmati and Pokhareli Basmati. These rice varieties were purchased from different places in Nepal in paddy form. In this study various parameters associated with milling, nutritional, physical and cooking properties were evaluated. To measure protein contents in rice, Kjeldal method was implied. Among the varieties, the protein content was maximum in Red Basmati (7.74%) and minimum in Black Basmati (6.51%). The milled rice percentage and head rice recovery were maximum in Pokhareli Basmati represented by 72.02±0.10 and 67.46±0.42, respectively, while and minimum in White Basmati represented by 68.17±0.50 and 65.11±0.28, respectively. The kernel elongation ratio and volume expansion ratio was maximum in Red Basmati represented by 1.62 and 2.85 respectively. Water uptake ratio was maximum 3.11 in Black Basmati and minimum of 2.18 in Red Basmati. Gruel loss was found lowest 1.05% in Red Basmati and highest represented by 2.40% in Black Basmati. The highest starch iodine blue value of 0.21 was observed in Red Basmati and lowest of 0.12 in Black Basmati. The Red Basmati was found to have the better cooking quality among all varieties

Degree of Milling Effect on Cold Water Rice Quality

The aim of this study was to examine the effects of degree of milling on various rice parameters such as proximate composition, and cooking properties using mathematical model. The experiments were performed in the laboratory of Food Research Division, Nepal Agricultural Research Council. The three different medium type rice varieties of Nepal (Lumle-2, Chhomrong and Machhapuchre-3) were exposed to five different degrees of milling (0%, 6%, 8%, 10% and 12%). The degree of milling (DM) level significantly (P≤0.05) affected the milling recovery; head rice yield, nutrient content as well as cooking properties of the rice. Increase in DM resulted in further reduction of protein content, fat content, minerals, milled rice and head rice yield after bran layer was further removed. A positive correlation between DM used in present model, amylose content, kernel elongation and gruel solid loss was observed, however, with an increase in DM; amylose content, kernel elongation and gruel solid loss were found to be increased. Adopting 6 to 8% DM for commercial milling of rice might help to prevent quantitative, qualitative and nutritional loss along with retention of good cooking characteristics

The distally-based island ulnar artery perforator flap for wrist defects

Background: Reconstruction of soft tissue defects around the wrist with exposed tendons, joints, nerves and bone represents a challenge to plastic surgeons, and such defects necessitate flap coverage to preserve hand functions and to protect its vital structures. We evaluated the use of a distally-based island ulnar artery perforator flap in patients with volar soft tissue defects around the wrist. Materials and Methods: Between June 2004 and June 2006, seven patients of soft tissue defects on the volar aspect of the wrist underwent distally-based island ulnar artery perforator flap. Out of seven patients, five were male and two patients were female. This flap was used in the reconstruction of the post road traffic accident defects in four patients and post electric burn defects in three patients. Flap was raised on one or two perforators and was rotated to 180°. Results: All flaps survived completely. Donor sites were closed primarily without donor site morbidity. Conclusion: The distally-based island Ulnar artery perforator flap is convenient, reliable, easy to manage and is a single-stage technique for reconstructing soft tissue defects of the volar aspect of the wrist. Early use of this flap allows preservation of vital structures, decreases morbidity and allows for early rehabilitation

Modified trapezius transfer technique for restoration of shoulder abduction in brachial plexus injury

Aims and Objectives: Shoulder stability and restoration are very important in providing greater range of motion to the arm and forearm. When brachial plexus repair does not have the desired outcome and in patients with long standing denervation, the trapezius muscle is frequently used for transfer to restore the shoulder abduction and external rotation. We propose a modified simple technique for trapezius muscle transfer. Materials and Methods: From February 2004 to February 2006, eight patients with posttraumatic brachial plexus injury with insufficient shoulder abduction were treated by trapezius muscle transfer. All patients with brachial plexus palsy were posttraumatic, often resulted from motor cycle accidents. Before operation a full evaluation of muscle function in the affected arm was carried out. All patients were treated with trapezius muscle transfer performed by the modified technique. S-shaped incision from the anterior border of the trapezius just above the clavicle to the Deltoid up to its insertion was made. The accessory nerve and its branches to the trapezius were secured. The trapezius was dissected and detached from its insertion along with the periosteum and sutured to the insertion of the Deltoid muscle. Results: All patients had improved functions and were satisfied with the outcome. The average increase in active abduction of shoulder was from 13.7 degrees (0 to 35 degrees) preoperatively to 116 degrees (45 to 180 degrees) postoperatively and of shoulder flexion from 24.3 degrees (15 to 30 degrees) to 107 degrees (90 to 180 degrees). Conclusion: The modified technique proposed here for trapezius transfer is safe, convenient, simple and reliable for restoration of shoulder abduction and stability with clear subjective benefits

Modified trapezius transfer technique for restoration of shoulder abduction in brachial plexus injury

Aims and Objectives: Shoulder stability and restoration are very important in providing greater range of motion to the arm and forearm. When brachial plexus repair does not have the desired outcome and in patients with long standing denervation, the trapezius muscle is frequently used for transfer to restore the shoulder abduction and external rotation. We propose a modified simple technique for trapezius muscle transfer. Materials and Methods: From February 2004 to February 2006, eight patients with posttraumatic brachial plexus injury with insufficient shoulder abduction were treated by trapezius muscle transfer. All patients with brachial plexus palsy were posttraumatic, often resulted from motor cycle accidents. Before operation a full evaluation of muscle function in the affected arm was carried out. All patients were treated with trapezius muscle transfer performed by the modified technique. S-shaped incision from the anterior border of the trapezius just above the clavicle to the Deltoid up to its insertion was made. The accessory nerve and its branches to the trapezius were secured. The trapezius was dissected and detached from its insertion along with the periosteum and sutured to the insertion of the Deltoid muscle. Results: All patients had improved functions and were satisfied with the outcome. The average increase in active abduction of shoulder was from 13.7 degrees (0 to 35 degrees) preoperatively to 116 degrees (45 to 180 degrees) postoperatively and of shoulder flexion from 24.3 degrees (15 to 30 degrees) to 107 degrees (90 to 180 degrees). Conclusion: The modified technique proposed here for trapezius transfer is safe, convenient, simple and reliable for restoration of shoulder abduction and stability with clear subjective benefits

Subcutaneous pedicle propeller flap: An old technique revisited and modified!

Background: Post-burn axillary and elbow scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction and extension that should be achieved, respectively, while treating either of the joint. The aim of this paper is to highlight the use of subcutaneous pedicle propeller flap for the management of post-burn axillary and elbow contractures. Methodology: This is a prospective case study of axillary and elbow contractures managed at a tertiary care hospital using propeller flap based on subcutaneous pedicle from 2009 to 2014. Surgical treatment comprised of subcutaneous-based pedicle propeller flap from the normal tissue within the contracture based on central axis pedicle. The flap was rotated axially to break the contracture. The technique further encompassed a modification, a Zig-Zag incision of the flap, which was seen to prevent hypertrophy along the incision line. There was a mean period of 12 months of follow-up. Results: Thirty-eight patients consisting of 22 males and 16 females were included in this study among which 23 patients had Type II axillary contractures and 15 had moderate flexion contractures at elbow joint. The post-operative abduction achieved at shoulder joint had a mean of 168° whereas extension achieved at elbow had a mean of 175°. The functional and aesthetic results were satisfactory. Conclusion: The choice of surgical procedure for reconstruction of post-burn upper extremity contractures should be made according to the pattern of scar contracture and the state of surrounding skin. The choice of subcutaneous pedicle propeller flap should be emphasised because of the superior functional results of flap as well as ease to learn it. Moreover, the modification of propeller flap described achieves better results in terms of scar healing. There is an inter-positioning of healthy skin in between the graft, so it prevents scar band formation all around the flap