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BACKGROUND: Myelomeningocele is one of the most complex congenital malformations of the central nervous system. It is one of the most common types of spina bifida which involves a failure of neural tube closure. Reconstruction surgery for myelomeningocele had always been challenging for plastic and neurosurgeons. CLINICAL CASE: We report a case of a new-born with lumbosacral myelomeningocele who received treatment in the Hospital Universiti Sains Malaysia. The myelomeningocele was repaired by the neurosurgery team and subsequently, the child was left with huge lumbosacral skin defect. The large defect was successfully covered by using a combined method of bilateral bipedicle flap with lateral releasing incision and remaining lumbosacral and secondary defect resurfaced using Integra dermal regeneration template (DRT). We used ACTICOAT interfaced negative pressure wound therapy (NPWT) as our main dressing in preparing the wound bed for autologous epidermal graft. The result of our closure technique provides tension free closure. DISCUSSION: We incorporated bilateral bipedicle fasciocutaneous flap technique together with DRT for closure of the lumbosacral defect. The bilateral bipedicle flap with lateral releasing incision served to reduce tension on the skin at bilateral lumbar region. The DRT downsized the lumbosacral defect and NPWT dressing provided an optimal sterile environment in giving time for neodermis generation. The remaining secondary defect were also resurfaced utilizing DRT and autologous skin grafting. CONCLUSIONS: The outcome of surgery demonstrated that the combined use of bilateral bipedicle fasciocutaneous flap with lateral releasing incision and DRT with delayed skin grafting is safe, effective and provide long term stable and supple scar for large, exposed dura defect.

BACKGROUND: Aplasia cutis congenita is a rare newborn malformation characterized by focal absence of skin. It possesses difficulty in reconstruction surgery for neurosurgeons and plastic surgeons. We report a challenging case of aplasia cutis congenita who received treatment in our center. CLINICAL CASE: A 2-year-old boy, presented to Plastic and Reconstructive Surgery, Hospital USM, with bilateral vertex defect with encephalocele who received a series of surgical interventions since 1 month old. Unfortunately, he returned after 2 years with a chronic nonhealing scalp wound associated with dura defect and cerebral spinal fluid leakage. The wound was debrided and the swab culture result showed no organism growth. Part of the wound bed with dura defect was repaired using a small piece of transplanted fascia lata and Integra was applied. DISCUSSION: There is scarcity in the medical literature on the reconstructive technique of aplasia cutis congenita. In the case we described here, we successfully managed the wound with multiple application of dermal substitute (Integra) dressing with negative pressure wound therapy and split-thickness skin graft. CONCLUSIONS: Management of aplasia cutis congenita with skull defect remains a controversy. Its management varies depends on its pattern and underlying condition. We successfully develop a new simple method in treating scalp accutilizing Integra.

Aim Osteosarcoma is a highly malignant primary bone tumor. The study aim to evaluate the prognostic factors influencing the survival rate in our center. Methods This was a retrospective cohort study of all patients treated between January 2005 and December 2010. Results We included 163 patients with an age range of 6–59 years (median = 19). The median follow-up was 47 months (range 36–84). The overall survival in patients who completed chemotherapy and surgery (n = 117) was 72% at 2 years and 44% at 5 years. Histologically, 99 (85%) had osteoblastic, 6 (5%) had chondroblastic and 3 (2.5%) had telangiectatic osteosarcoma. Limb salvage surgery was performed in 80 (49%) and 41 (25%) underwent amputation. However, 46 patients (28%) underwent no surgical intervention and incomplete chemotherapy. In total, 38/79 patients had a good chemotherapy response. There was a significantly better survival rate for limb salvage versus amputation. Independent prognostic factors for survival are compliance to treatment and presence of lung metastasis. Conclusion The overall survival of osteosarcoma patients was influenced by the presence of pulmonary metastases and compliance to treatment. Histological subtype, different chemotherapy regimens and histological necrosis after chemotherapy did not significantly influence survival. The patients who did not complete treatment had significantly poorer survival.

A seven years retrospective study was performed in 45 consecutive vascular injuries in the extremities to investigate the pattern of injuries, managements and outcomes. Motor-vehicle accidents were the leading cause of injuries (80%), followed by industrial injuries (11.1%) and iatrogenic injuries (4.4%). Popliteal and brachial artery injuries were commonly involved (20%). Fifteen (33.3%) patients had fractures, dislocation or fracture dislocation around the knee joint and 6 (13.3%) patients had soft tissue injuries without fracture. Traumatic arterial transection accounted for 34 (75.6%) cases, followed by laceration in 7 (15.6%) and 9 (6.7%) contusions. Associated nerve injuries were seen in 8 (17.8 %) patients using intra-operative findings as the gold standard, both conventional angiogram (CA) and computerized tomography angiogram (CTA) had 100% specificity and 100% sensitivity in determining the site of arterial injuries. The mean ischemic time was 25.31 hours (4 - 278 hours). Thirty-three (73.3 %) patients were treated more than 6 hours after injury and 6 patients underwent revascularization after 24 hours; all had good collateral circulation without distal pulses or evidence of ischemic neurological deficit. The mean ischemic time in 39 patients who underwent revascularization within 24 hours was 13.2 hours. Delayed amputation was performed in 5 patients (11.1%). Of the 6 patients who underwent delayed revascularization, one patient had early amputation, one -had delayed amputation following infection and multiple flap procedures while the rest of the patients’ limbs survived. Joint stiffness was noted in 10 patients (22.2%) involving the knee joint, elbow and shoulder in two patients each. Infection was also noted in 5 patients (11.1%) with two of them were due to infected implants. Other complications encountered included nonunion (2 patients, 4.4%), delayed union (1 patient, 2.2%),limb length discrepancy (1 patient, 2.2%), hematoma (1 patient, 2.2%) and leaking anastomosis in one patient (2.2%). Volkmann’s ischemic contracture occurred in 3 (6.7%) patients. There was no complication noted in 8 (17.8%) patients Three patients (6.7%) died of whom two were not due to vascular causes. We conclude that early detection and revascularization of traumatic vascular injuries is important but delayed revascularization also produced acceptable results.

Reconstruction of massive bone defects in bone tumors with allografts has been shown to have significant complications including infection, delayed or nonunion of allograft, and allograft fracture. Resection compounded with soft tissue defects requires skin coverage. A composite osteocutaneous free fibula offers an optimal solution where the allografts can be augmented mechanically and achieve biological incorporation. Following resection, the cutaneous component of the free osteocutaneous fibula flaps covers the massive soft tissue defect. In this retrospective study, the long-term outcome of 12 patients, who underwent single-stage limb reconstruction with massive allograft and free fibula osteocutaneous flaps instead of free fibula osteal flaps only, was evaluated. This study included 12 consecutive patients who had primary bone tumors and had follow-up for a minimum of 24 months. The mean age at the time of surgery was 19.8 years. A total of eight patients had primary malignant bone tumors (five osteosarcomas, two chondrosarcomas and one synovial sarcoma), and four patients had benign bone tumors (two giant-cell tumors, one aneurysmal bone cyst, and one neurofibromatosis). The mean follow-up for the 12 patients was 63 months (range 24-124 months). Out of the 10 patients, nine underwent lower-limb reconstruction and ambulated with partial weight bearing and full weight bearing at an average of 4.2 months and 8.2 months, respectively. In conclusion, augmentation of a massive allograft with free fibula osteocutaneous flap is an excellent alternative for reducing the long-term complication of massive allograft and concurrently addresses the soft tissue coverage.

Background and Objectives. Hemipelvectomy is a major surgical procedure that associates with significant morbidity, functional impairment, and psychological and body image problem. Reconstruction of the defect is a challenged since a large amount of composite tissues are needed. We would like to share our eight-year experience with massive pelvic resection and reconstruction.Methods. A retrospective analysis of all cases of hemipelvectomy was conducted in our institution over eight-year period with particular attention given to the reconstruction choices and associated complications.Results. Thirteen patients were included with median age of 39 years (range 13–78) of which all had advanced tumour with stage IIb (54%) and Stage III (46%). External hemipelvectomy was performed in all cases, and resultant defects were reconstructed with variety type of flaps. These include fillet thigh flaps, regional pedicle flaps of different designs, and free flap.Conclusions. Massive pelvic tumour is rarely encountered in our population but can be seen across all age groups and usually due to late presentation. The defects should be reconstructed using local or regional flaps, incorporating the muscle component to enhance flap perfusion. The tissue should be harvested from the amputated limb, as it can limit the donor site morbidity.