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The anterolateral thigh (ALT) flap is a workhorse soft tissue flap. Anteromedial thigh (AMT) flap has been used as a savior flap when lateral thigh perforators are absent. ALT and AMT flaps are based on cutaneous perforators arising from the descending branch of the lateral circumflex femoral artery (LCFA), a branch of the profunda femoris artery (PFA). Here, we present a case report of a chimeric ALT and AMT flap where the perforators were directly arising from the superficial femoral artery (SFA). This case highlights an unusual origin of the vascular pedicle in the ALT and AMT flaps and promotes the freestyle perforator flap harvest theory. Level of evidence: Level V, therapeutic study.

Background There is a steep learning curve to attain a consistently good result in microvascular surgery. The venous anastomosis is a critical step in free-tissue transfer. The margin of error is less and the outcome depends on the surgeon’s skill and technique. Mechanical anastomotic coupling device (MACD) has been proven to be an effective alternative to hand-sewn (HS) technique for venous anastomosis, as it requires lesser skill. However, its feasibility of application in emerging economy countries is yet to be established. Material and Method We retrospectively analyzed the data of patients who underwent free-tissue transfer for head and neck reconstruction between July 2015 and October 2020. Based on the technique used for the venous anastomosis, the patients were divided into an HS technique and MACD group. Patient characteristics and outcomes were measured. Result A total of 1694 venous anastomoses were performed during the study period. There were 966 patients in the HS technique group and 719 in the MACD group. There was no statistically significant difference between the two groups in terms of age, sex, prior radiotherapy, prior surgery, and comorbidities. Venous thrombosis was noted in 62 (6.4%) patients in the HS technique group and 7 (0.97%) in the MACD group (p = 0.000). The mean time taken for venous anastomosis in the HS group was 17 ± 4 minutes, and in the MACD group, it was 5 ± 2 minutes (p = 0.0001). Twenty-five (2.56%) patients in the HS group and 4 (0.55%) patients in MACD group had flap loss (p = 0.001). Conclusion MACD is an effective alternative for HS technique for venous anastomosis. There is a significant reduction in anastomosis time, flap loss, and return to operation theater due to venous thrombosis. MACD reduces the surgeon’s strain, especially in a high-volume center. Prospective randomized studies including economic analysis are required to prove the cost-effectiveness of coupler devices.

Song et al. reported an anterolateral thigh (ALT) flap as a septocutaneous flap in 1984. Conventionally anterolateral thigh flap is based on the perforators arising from the descending branch of the lateral circumflex femoral artery (LCFA), accompanied by two venae comitantes, one on either side. We present an infrequent anatomical presentation of descending branch of LCFA in which two arteries accompanied a single central vein. This pattern was exactly the opposite of conventional anatomy. One of the arteries (lateral) was arising from the LCFA main trunk, and the other (medial) artery was emerging from the LCFA branch to the rectus femoris muscle. The larger artery was used for arterial anastomosis, and the lone vein was used for venous anastomosis. The patient had an uneventful recovery. To the best of our knowledge, the unusual pattern described above is not reported before. Level of Evidence: Level V, risk / prognostic study

Background: Spaghetti wrist injuries involve a complete transection of three or more structures at the wrist level (including tendons, nerves, or arteries). Few studies on spaghetti wrist trauma have been reported in the literature, and most of them have focused on functional recovery rather than the prognostic factors which affect the outcome. We attempted to address some of the lacunae in current knowledge. Methods: Patients who were operated between January 2017 to January 2019 for spaghetti wrist injuries at a level 1 trauma center were included in the study. Several variables such as age, gender, smoking, education level, mechanism of injury, time gap between the injury to surgery, number of damaged structures and pattern of neurovascular structure were selected as potential prognostic factors to be included in the analysis. Motor recovery, sensory recovery & QuickDash score were used for the outcome assessment. A Multivariate analysis was done to identify the prognostic factor(s). Results: Thirty patients were included in the study. The mean age was 30.5 years (range: 7–57 years). Male population was predominantly affected (93.33%). The dominant limb was injured in 73.33%. The most common mechanism of injury was accidental glass cut (n = 19,63.33%), the most frequently affected structure was flexor digitorum superficialis of the middle finger (n = 23, 76.6%). Combined nerve injury was present in 23.33%. Intrinsic muscle recovery was affected significantly by presence of crush injury (e = 7.189, std error = 2.425, p = 0.003), education significantly affected power grip recovery (p < 0.0001), age was associated with pinch grip recovery (e = 0.083, std error = 0.039, p = 0.034). Conclusions: Increasing age, low education level, and presence of crush injury were identified as negative prognostic factors in the study. These findings may be used for counselling of patients affected by spaghetti wrist injuries.

Purpose The purpose of the study was to share our indications, technique, outcome, and complications associated with the pedicled latissimus dorsi myocutaneous flap (LDMF) for reconstructing various upper limb and trunk soft tissue defects. Patients and Methods We reviewed the prospectively collected data of the patients who underwent reconstruction of upper limb/trunk soft tissue defects with pedicled LDMF between January 2016 and March 2019. By analyzing the clinical scenarios, the location of flap inset, the arc of rotation, reach of the flap, and associated complications, we put forward few significant findings from our experience. Results Thirty-four patients were included in the study: 13 of them underwent LDMF for coverage of upper limb defects, 12 of them for postradical mastectomy soft tissue defects, 8 for posterior trunk reconstruction, and 1 for sternal wound infection. LDMF was successfully used to cover the scapula, anterior and posterior arms, axilla, cubital fossa, mid-forearm, breast, sternum, and midline dorsal wounds. When used reversely, the flap could cover the exposed spine in the midline dorsum. Three patients (9%) had major complications (two patients had partial flap necrosis which required additional debridement and skin grafting, and one patient required an additional transpositional flap). Three patients had minor complications (managed nonoperatively). Conclusion Pedicled LDMF is a straightforward and versatile option for reconstruction of the varied upper limb and trunk soft tissue defects with minimal complications. Level of Evidence This is a level IV, therapeutic, retrospective study.

Purpose Microvascular reconstruction is the standard of care for salvage of soft tissue defects in complex upper extremity due to their distinct advantages over the pedicled flaps. However, in the era of microsurgery, pedicled flaps have an acceptable significant role for reconstruction of complex soft tissue defects. The authors aim to demonstrate the versatility of pedicled thoracoumbilical flap (TUF) in selected clinical scenarios. Patients and Methods Retrospective analysis of patients who underwent TUF for upper limb posttraumatic reconstruction was performed between January 2016 and October 2017. The demographic details, etiology, wound parameters, clinical circumstances, and complications were recorded. Results Ten patients were included in the retrospective case series. Out of them, nine of the patients had critical issues, which justified a pedicled TUF over free flap. The critical issues were severe comorbid illnesses (n = 3), the paucity of recipient vessels (n = 1), salvage of hand replant and revascularization (n = 2), circumferential degloving injury to the multiple fingers and palm (n = 1), coverage for metacarpal hand (n = 1), and extensive scarring at the surgical site (n = 1). Mean age was 34.4 years (range: 11–70 years), six of them were males, and four were females. Two patients had infections resulting in wound gaping. One of the patients had flap tip necrosis. Conclusion Pedicled flaps have a significant acceptable role in this era of microsurgery, and a pedicled TUF is a versatile option for coverage of complex soft tissue defects of the forearm, wrist, hand, and fingers. Level of Evidence This is a level IV, therapeutic, and retrospective study.

The authors demonstrated the utility of hemi-intravascular stenting technique in a pediatric thumb replant.

The authors present a retrospective review of 7 patients who underwent wide excision of the malignant tumors around the clavicle. Patient demographics, clinical details, the arc of rotation, outcome, and complications were analyzed.

A 20-year-old woman presented to us with a crush avulsion amputation of the right upper limb at the level of forearm following a sideswipe injury. She was a right-handed person. The warm ischaemia time was 6 hours. She had a comminuted fracture of both bones of the forearm and severely crushed upper

A 45-year-old man was referred to us for the management of an infected groin wound following femoral artery repair. One week earlier he sustained fall from a rooftop and was diagnosed with pelvic diastasis, right acetabular fracture, femoral artery and vein injury. He underwent femoral artery repair

Introduction Reconstruction of complex soft tissue defects around the cervico-occipital and thoracic spine regions is a challenging task. We want to share our experience with trapezius flap for the reconstruction of these complex cases. Materials and Methods A retrospective analysis of patients who underwent reconstruction using trapezius flaps from January 2016 to June 2019 was performed. The indications, technique, complications, and outcomes were analyzed and presented. Results Six patients (three males and three females, >10 years of age) underwent seven reconstructions using trapezius flaps (one of the patients underwent reconstruction using a bilateral trapezius flap). Trapezius flap was used to resurface the parieto-occipital (n = 2), cervico-occipital (n = 2), cervicothoracic (n = 1), and thoracic (n = 1) regions. All flaps showed successful outcomes; one patient had wound dehiscence, and one patient had partial skin graft loss. Conclusion Trapezius flap is a reliable and good alternative to free flaps for the coverage of complex cervical-occipital and upper thoracic soft tissue defects.

Pedicled anterolateral thigh flap is a versatile option for reconstruction of complex soft tissue defects in varied anatomical regions. Its wide arc of rotation and less donor site morbidity are its added advantages.

A 18-year-old man presented to us following a sideswipe injury leading to crush avulsion amputation of the right upper limb at the level of the upper 1/3 of the humerus shaft. The injury occurred 7 hours earlier, and he was haemodynamically stable at the time of presentation. On examination of the

A 60-year-old man presented with painless progressively enlarging multiple cutaneous nodules for the past 6 months. On examination, multiple nodular cutaneous lesions were noted over the anterior abdominal wall, right popliteal region, right arm, nape of neck and left loin area (figures 1⇓⇓⇓–5). Plaque-like lesions were noted over the left arm (figure 4). Nasopharyngeal and ophthalmological evaluations were normal. Routine haematological and biochemical parameters were within normal limits. Incisional biopsy was performed. Histopathological examination showed multiple sporangia in different stages of development and, in the inset, spores within sporangia can be seen (figure …

Skin avulsion injuries are one of the most common soft tissue injuries encountered by the trauma surgeons and reconstructive surgeons. Harvesting skin graft from the avulsed skin either avoids or reduces the requirement of subsequent skin grafting. A 12-year-old child presented to us with an avulsion injury left lower limb 6 hours following road traffic accident. On examination, the patient had avulsion of skin from the anterolateral surface of the thigh and circumferential skin avulsion extending from knee joint to the foot (figure 1). The non-viable avulsed skin was debrided till the fresh bleeding edges were obtained. The avulsed skin was cleaned, and gross defatting was performed with a surgical blade and curved Metzenbaum scissors in a turnover fashion (dermal side facing above and epidermis side facing below). Once …

A 50-year-old man with a history of hypertension was diagnosed with a left capsuloganglionic haemorrhage and he underwent right frontal burr hole and external ventricular drainage for ongoing hydrocephalus. He was referred to our tertiary care hospital for further management after 6 days of treatment. His Glasgow Coma Scale (GCS) at first visit to the referring hospital was E1, M3, V1. His GCS at admission to our hospital was E1, M1, VT, and he had a healing abrasion over the presternal area measuring 7 cm …

Carcinoid tumours are uncommon well-differentiated neuroendocrine tumours. Primary duodenal carcinoids account for less than 2% of all gastrointestinal carcinoids. Duodenal carcinoids are seldom associated with carcinoid syndrome. We report a rare case of duodenal carcinoid presenting as a carcinoid syndrome in a middle-aged man with upper abdominal pain, hot flushes, diarrhoea and dry cough. Endoscopy-guided biopsy and 24 h urine 5-hydroxyindoleacetic acid (5-HIAA) proved the diagnosis. He was further evaluated and managed with definitive surgical treatment.

A 30-year-old woman presented with left upper abdominal pain for 6 months and recurrent vomiting for the past 1 week. There was no history of trauma. Abdominal examination did not reveal any significant findings. Ultrasound scan of the abdomen revealed cystic lesion in the spleen. Contrast-enhanced CT of the abdomen showed a large, well-capsulated cystic mass measuring 10.6×9.6 cm in the upper pole of the spleen (figure 1). The patient was immunised against Streptococcus pneumoniae , Haemophilus influenzae type B and Neisseria meningitidis 2 weeks before surgery. She underwent a splenectomy (figure 2) and histopathological …

A 23-year-old man presented to us with reports of right-sided lower abdominal pain for 1 day associated with anorexia and nausea. Abdominal ultrasound scan showed inflammed appendix. His routine blood investigations revealed mild neutrophilic leucocytosis and eosinophilia. He was taken up for emergency laparoscopic appendicectomy. Intraoperatively, after dividing the appendix between the endoloop ligatures three pinworms (Entrobious vermicularis) fell into the abdomen. One of them reached the abdominal wall (figure 1), and its movement can be seen (video 1). All three of them were extracted using blunt grasper. Appendix specimen was cut open and we found one more …

A 35-year-old man presented with complete rectal prolapse which was irreducible for 2 days. He was diagnosed to have a rectal prolapse 6 years ago when he noticed a mass protruding through the anus. Initially, the mass protruded from the anus only after a bowel movement and retracted spontaneously. As the disease progressed, the mass protruded more often, especially with straining and sneezing or coughing and he had to manually replace it. The patient never came for follow-up in 6 years. He does not have bleeding per rectum or pain in the abdomen. He does not have faecal incontinence. On examination the patient was anxious and dehydrated. His pulse rate was 100/min and his blood pressure was 90/60 mm Hg. He had a full thickness rectal procidentia with mucosal congestion …