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

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

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

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

Background Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. Methods We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). Findings In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683–0·717]). Interpretation In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. Funding British Journal of Surgery Society

Long term clinical and functional outcome of lateral supramalleolar flap for soft tissue coverage of foot and ankle defects: Largest case series at a tertiary care hospital

Background: Reconstruction of defects around foot and ankle is challenging issue. We wanted to assess the clinical and functional outcome of lateral supramalleolar flap for coverage soft tissue defects around the foot and ankle. Methods: This analytic case series was conducted at Aga Khan University Hospital, Karachi. The data was collected from medical records and patient interviewing. Patients with soft tissue defects around foot and ankle and coverage with supramalleolar flaps were included. The various parameters of interest (causes, flaps dimensions, vascular variations, and outcome) were included in the prestructured proforma the data was analyzed with SPSS version 25. Results: Forty-seven patients were included in the study from May 1999 to December 2019. The male to female ratio was 35:12. The mechanism of injury was varied. Eighteen cases were pedicle island flaps whereas two were peninsular rotation flaps. The maximum flap size harvested was 20 cm × 8 cm distal flap necrosis occurred in one patient requiring split thickness skin graft. In eight patients’ flap was rotated as ‘delay flap’. In 12 cases the peroneal artery perforator was absent, the flap being based on inferolateral collateral artery from anterior tibial artery. Majority of the patients fall in excellent category based on self-designed assessment tool. Conclusion: The lateral supramalleolar flap provided coverage to almost all regions of the foot and ankle with a cosmetically acceptable donor and recipient site. There were no problems with shoe wear, only two patients requiring defattening for cosmetic reasons. Microvascular expertise was required for a predictable outcome