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Introduction The medial gastrocnemius flap is an established workhorse flap to cover proximal leg defects due to its reliability and simplicity to raise. However, it has the disadvantage of being bulky, requiring a skin graft for coverage, and is associated with loss of muscle power. The pedicled medial sural artery perforator (MSAP) flap has gained popularity as a reconstructive alternative for defects of the lower extremities. We present a case series of pedicled MSAP flaps for reconstructing defects around the knee as an alternative to the medial gastrocnemius flap. Materials and Methods A consecutive series of patients with proximal leg defects following trauma, osteomyelitis, burns, and chronic wounds were included. A hand-held Doppler was used to map out the MSAPs. Defects were reconstructed using pedicled MSAP flaps, preserving the nerve supply to the gastrocnemius muscle. Patient outcomes were recorded, including their Enneking scores postreconstruction. Results A total of 10 pedicled flaps was performed to reconstruct defects around the knee joint between October 2017 and November 2018. All the patients were discharged 1 week postoperatively, and rehabilitation consisted of graduated flexion in a knee brace by means of controlled passive mobilization. Three out of the ten patients developed complications: one patient developed flap congestion, one developed epidermolysis of the tip of the flap, and the other patient had partial necrosis of the skin paddle. The average Enneking score was 29 out of 35. Conclusion The pedicled MSAP flap is a good reconstructive option for proximal leg defects as it is associated with lower donor site morbidity and provides an aesthetically pleasing reconstruction.

Introduction: The use of throat packs during oropharyngeal surgery has long been a topic of debate among cleft surgeons. The advantage of inserting an absorbent tulle within the pharynx must be weighed against the risk of unintended retention postoperatively. Despite safety check mechanisms in place, retention may occur with potentially life-threatening consequences. We present a comprehensive review of throat pack use in all cleft units within the United Kingdom and Ireland. Methods: All 20 cleft surgery units in the United Kingdom and Ireland were surveyed on their use of throat packs in children aged 6 months to 2 years undergoing elective cleft palate surgery. Results: The response rate to the survey was 100%. Seventy-five percent of units currently use throat packs; in 40%, they are used in addition to cuffed endotracheal tubes (ETTs). Inclusion of the throat pack in the surgical swab count was perceived as the safest mechanism employed to avoid retention. 26.1% of respondents were aware of at least 1 incident of pack retention in their unit. Discussion/Conclusion: The reported UK and Irish experience demonstrates that three-quarters of units routinely use packs. Notably, a quarter of respondents to the survey have experience of an incident of throat pack retention. Nevertheless, the majority of respondents considered the perceived risk of retaining a pack to be low. The growing use of microcuffed ETTs in UK cleft units paired with a low incidence of perioperative complications when a throat pack is not introduced might prompt cleft surgeons to review routine pharyngeal packing.

Supplemental Material, sj-pdf-1-cpc-10.1177_10556656211000553 for The Throat Pack Debate: A Review of Current Practice in UK and Ireland Cleft Centers by Terry-Ann Curran, Nitisha Narayan, Lynn Fenner, Guy Thornburn, Marc C. Swan and Nefer Fallico in The Cleft Palate-Craniofacial Journal

Necrotizing fasciitis is a serious life- and limb-threatening emergency that warrants early diagnosis and treatment with surgical debridement. The plastic surgeon would be involved once the debridement in complete to reconstruct the resultant defects or sometimes even in the acute stage to help with appropriate debridement. In this article we revisit the pathophysiology, microbiology, clinical features and reconstruction for defects resulting from necrotizing fasciitis and describe the management from a plastic surgeon's perspective.

INTRODUCTION The aims of this study were to assess and compare vocal cord functions before and after thyroid surgery after intra-operative identification of recurrent laryngeal nerve. PATIENTS AND METHODS Recurrent laryngeal nerve (RLN) is seen intra-operatively in all cases undergoing thyroid surgeries. Vocal cord functions including any voice change were evaluated by indirect laryngoscopy (I/L) and direct laryngoscopy (D/L) before and after surgery. RESULTS Prospective study on 100 patients over 18 months with a total of 146 nerves at risk (NAR). Majority were women (n = 86) with mean age of 37.48 years (range, 13–60 years). RLN was seen in all patients and 19 patients complained of some change in quality of their voice after surgery. Evaluation by I/L and D/L at 6 weeks showed recurrent laryngeal nerve palsy (RLNP) in nine (47.36%) and five (26%) of these 19 patients respectively. Analysed according to total NAR, the incidence of voice change and temporary RLN palsy (I/L and D/L) at 6 weeks was still less at 13.01%, 6.16% and 3.42%, respectively. Voice change improved in all cases at 3 months with no RLNP palsy by I/L or D/L. All these 19 patients had undergone difficult or extensive surgery for malignancy, large gland, extratyhroidal spread or fibrosis. CONCLUSIONS Despite identification and preservation of RLN, patients can develop postoperative voice change and RLNP although all voice change cannot be attributed to damaged RLN. Proper assessment of vocal cord functions by I/L and D/L laryngoscopy is required to rule out injuries to these nerves. Risk of damage is higher in patients undergoing more difficult surgery.

To assess the nutritional status, its change after surgery and impact of nutritional support on urinary nitrogen losses (UNL) and nitrogen balance (NB) based on changing serum albumin levels in a developing country, 89 patient (58 M) aged 39 yrs ±15 were studied. Nutritional assessment was done at admission and 2 weeks postoperatively. UNL and NB was assessed on postoperative day one (D1), two (D2), four (D4), six (D6), eight (D8) and eleven (D11) respectively. Malnutrition varied from 27 (30.3%) using body mass index to 78 (87%) by triceps skin fold thickness. Patients with falling or static serum albumin levels (Group I) showed a significant decrease (‘p’ = 0.001) in their nutritional parameters compared to those with increasing albumin (Group II). Postoperatively till D2 both groups had similar negative NB but Group II improved earlier to become positively balanced by D11 (‘p’ < 0.001). Regression analysis of nitrogen intake (Ni) on UNL on each day revealed negative association till D2 to become positively associated from D4 onwards being significant on D4 (‘p’ = 0.001) & D6 (‘p’ = 0.05*). There is a significant nutritional depletion after surgery especially in patients with falling/static serum albumin levels and NB improves earlier in patients with rising albumin levels. Increasing Ni helps in decreasing UNL.

Osgood-Schlatter disease is a common cause of anterior knee pain in adolescents. In a good proportion of cases the pain is relieved through stopping sport alone, or by doing so in conjunction with undertaking physiotherapy. However, resolution of symptoms may take several years. A proportion of teenagers are prevented from participating in sport for a prolonged period as a result of the condition, and some have persisting knee pain into adulthood. We report the use of a new surgical treatment for this disease. We describe the case of a 12-year-old boy who was unable to play rugby for a year due to this pain. Following percutaneous fixation of the tibial tuberosity his symptoms entirely resolved and he returned to competitive sport 6 weeks after surgery. A year later the screw was removed. As soon as he resumed sport his symptoms immediately returned and he requested that the screw be replaced. Following replacement his symptoms once more resolved.

Chronic wounds on the dorsum of the hand are often challenging to treat. Vacuum-assisted closure has enjoyed widespread use in recent years for many difficult chronic wounds as an alternative to surgery. Unfortunately, owing to the unique anatomy of the hand, it is usually very difficult to get a seal without significantly immobilising the hand. We report a case of a chronic wound on the dorsum of the hand as a result of osteomyelitis in a 37-year-old man, which was treated with Single Use Negative Pressure Wound Therapy, ‘PICO’ (Smith and Nephew Co, UK). We combined the PICO dressing with a rubber glove to get a good seal enabling appropriate suction without immobilising the hand. Once the wound bed was ready, the defect was covered with a reverse forearm flap.

Objective. The present study was carried out with an aim to study the nutritional status of patients undergoing emergency ileostomy using simple bedside tools in a developing country.Methods. Nutritional assessment (anthropometry, biochemical, immunological, and dietary) was done within 24–36 hours of admission and 6 weeks postoperatively. Primary endpoint was the study of the nutritional status of the patients with ileostomy.Results. , 47 males with mean age 32 years. Postoperatively 50 (86.2%) patients experienced some complications including those related to ileostomy. Malnutrition varied from 7 (12.1%) using BMI to 54 (93.1%) by triceps skinfold thickness. At 6 weeks, despite adequate nutritional intake, there was a significant decrease in almost all nutritional parameters except serum albumin which was normal in most patients. Factors contributing to weight loss in 41 (70.7%) patients were decreased length of proximal bowel left (), increased ileostomy output (), delayed surgery (), and increased disease severity score ().Conclusion. Majority of patients undergoing emergency ileostomy were malnourished and had significant nutritional depletion despite adequate nutritional support. Serial assessment helps to assess nutritional recovery in these patients.

Gluteal compartment syndrome is a rare entity but a recognised complication of prolonged immobilisation. It can present as renal failure as a result of severe rhabdomyolysis and can lead to sepsis and death. We report a case of gluteal compartment syndrome in a 25-year-old man who was found unconscious following intoxication with alcohol and cocaine of an unknown duration. He presented with tense tight left buttock swelling, right thigh swelling, cold immobile extremeties and acute renal failure. Immediate left gluteal, thigh and calf fasciotomy resulting in an improvement of lower limb and renal function.