Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.

/pdf/flap-decisions-and-options-in-soft-tissue-coverage-of-the-2pcv98ufv6.pdf

Flap Decisions and Options in Soft Tissue Coverage of the Upper Limb

Background In 1986, Marko Godina published his seminal work regarding the timing of free-flap reconstruction for traumatic extremity defects Early reconstruction, compared with delayed and late reconstruction resulted in significant decreases in free-flap failure rate, post-operative infections, hospitalization time, bone healing time, and number of additional anesthesias The objective of this manuscript was to evaluate whether these principles continue to apply Methods A meta-analysis was performed analyzing articles from Medline, Embase, and Pubmed Four hundred and ninety-two articles were screened, and 134 articles were assessed for eligibility Following full-text review, 43 articles were included in this study Results The exact timing for free-flap reconstruction, free-flap failure rate, infection rate, and follow-up was defined in all 43 articles Early free-flap reconstruction was found to have significantly lower rates of free-flap failure and infection in comparison to delayed reconstruction (p = 0008; p = 00004) Compared with late reconstruction, early reconstruction was found to have significantly lower infection rates only (p = 001) with no difference in free-flap failures rates Early reconstruction was found to lead to fewer additional procedures (p = 003) No statistical significance was found for bone healing time or hospitalization time Conclusion Early free-flap reconstruction performed within the first 72 hours resulted in a decreased rate of free-flap failures, infection, and additional procedures with no difference in other parameters The largest majority of free flaps continue to be performed in a delayed time frame

/pdf/meta-analysis-of-timing-for-microsurgical-free-flap-292c1yqc7y.pdf

Meta-analysis of Timing for Microsurgical Free-Flap Reconstruction for Lower Limb Injury: Evaluation of the Godina Principles.

Viral hepatitis is a major cause of morbidity and mortality worldwide and a rising cause for concern in Asian countries. Weather it is blood borne or water/food borne hepatotropic virus, increasing burden is alarming for Asian countries. In this review we have evaluated the existing data to estimate the burden of viral hepatitis in populations of all age groups nationwide, along with an assessment of the risk factors and preventive and management strategies currently employed in Pakistan. The aim of our work is to consolidate and supplement the present knowledge regarding viral hepatitis in light of past and present trends and to provide future direction to the existing health policies. How to cite this article Butt AS, Sharif F. Viral Hepatitis in Pakistan: Past, Present, and Future. Euroasian J Hepato-Gastroenterol 2016;6(1):70-81.

/pdf/viral-hepatitis-in-pakistan-past-present-and-future-3gkygqjz9c.pdf

Viral Hepatitis in Pakistan: Past, Present, and Future.

Background: Global prevalence of Hepatitis B varies from high (>8%) in Africa, Asia and Western Pacific to low (<2%) in Western Europe, North America and Australia. An estimated 180 million people worldwide including 4 million people in USA are infected with HCV. This cross-sectional observational study was carried out at Department of Pathology, Pakistan Rangers (Punjab) Central Hospital, Lahore from March to June 2010 to determine prevalence of HBV and HCV infection among serving asymptomatic healthy adult males of paramilitary force. Methods: The healthy adult males from province Punjab serving in Pakistan Rangers Punjab without previous history of known positivity for HBV or HCV infection were included in the study. Demographic data including the district of origin were noted. HBsAg and anti-HCV antibodies were tested by rapid immuno-chromatographic method while positive tests were reconfirmed by enzyme immuno-assay (EIA). Results: Out of total 15,793 adults screened for Hepatitis B & C viral infections, 14,027 adults belonged to the province of Punjab. There were 396 (2.82%) adults who were found positive for HBsAg and 511 (3.64%) positive for anti-HCV on screening. Retesting of the positive tests by EIA showed 396 (2.82%) positive for HBsAg, and 440 (3.13%) for anti-HCV respectively. Specificity of immune chromatographic method for HBsAg and anti-HCV calculated taking EIA as gold standard was 100% for HBsAg and 99.5% for anti-HCV while positive predictive value of the immuno-chromatographic methods was 100% for HBsAg and 86.1% for anti-HCV. Highest of prevalence of HBsAg was seen in Rahimyar Khan (7.58%) while high prevalence of anti-HCV was seen in Chiniot (8.9%), Faisalabad (7.2%), Vehari (7.03%), Muzaffargarh (5.95%) and Sheikhupura (5.83%). Conclusion: Overall prevalence of HBsAg and anti-HCV is on the decline. The isolated pockets of very high prevalence of HCV infection in the districts of Chiniot, Faisalabad, Vehari, Sheikhupura, Rahimyar Khan, Muzaffargarh, and Okara pose a community health problem with a dire need to adopt strict preventive measures in the medical and social practices with effective public awareness campaigns. Keywords: HBsAg, Anti-HCV, Hepatitis

/pdf/prevalence-of-hepatitis-b-and-c-in-healthy-adult-males-of-2tcuwnmtod.pdf

Prevalence of hepatitis B and C in healthy adult males of paramilitary personnel in Punjab.

Background Hepatitis B is considered the most dangerous among the five types of Hepatitis, as it is clinically asymptomatic. It can silently damage the liver over many years without being diagnosed. Hepatitis B is one of the top risks of liver complications in Khyber Pakhtunkhwa (KP), a province of Pakistan, with an average prevalence rate of 2.70%. Aims We aimed to carefully review the previously published data on prevalence of Hepatitis B Virus (HBV) in KP-Pakistan and use the statistical approach to obtain more precise estimate of the prevalence of HBV in KP-Pakistan. This study on one hand will provide a more reliable and consolidated estimate (pooled estimate) of HBV in the stated region, on the other hand, it enabled us to judge the heterogeneity among the estimates found from these studies. The study is intended to provide more authentic prevalence record and help government/ non-government organizations and health professionals, which plan to initiate HBV prevention programs in KP-Pakistan. Methods A meta-analysis was performed based on studies found in literature search from electronic databases and bibliography on the prevalence of HBV in KP-Pakistan from 2007 to 2017. Abstracts and results of twenty papers were thoroughly studied and the data were extracted. The findings from these studies were distributed in two groups (general and population at high risk) constituting 15 and 5 studies respectively. Results The combined prevalence by considering random model for the general population of KP-Pakistan was observed to be 2.71%, while population at high risk was reasonably high i.e. 5.64%. By comparing this prevalence rate to the highest global prevalence of HBV in the adult population of Western Pacific Region (6.2%), significant (p-value= 0.000) heterogeneity was observed among the estimates in each group. However, the funnel plot provides a symmetric look, eliminating the effect of publication bias. We can say that HBV has an alarming prevalence rate in KP-Pakistan. However, HBV is thrice more prevalent in male population of KP-Pakistan than the female population. Conclusion The above results lead that HBV infection has reached an alarming state in KP-Pakistan, though projects like Prime Minister's Program for Prevention & Control of Hepatitis which are contributing in improving the health of the people of KP by trying to prevent and control the incidence of HBV. More massive vaccination and awareness programs should be initiated to prevent the spread of HBV on urgent basis. Provision of diagnostics and treatment facilities against HBV in healthcare units of KP-Pakistan should be assured.

/pdf/determining-the-actual-prevalence-of-hepatitis-b-in-khyber-5866k1eu8f.pdf

Determining the Actual Prevalence of Hepatitis B in Khyber Pakhtunkhwa-Pakistan: A Meta-Analysis.

HBV and HCV are common health problems in developing countries like Pakistan, sharing the same mode of transmission. The purpose is to determine the prevalence of HBV and HCV, and its risk factors in Bannu. A cross sectional descriptive study was conducted in medical units of DHQTH, Bannu, from January, 2004 till December, 2008. A total of 25944 patients comprising 13953 males (53.7%) and 11991 females (46.3%) all above the age of 15 years, were screened for HBV and HCV by rapid method and confirmed by ELISA technique. Out of those, 1352 (5.2%) patients were found positive either for HBV or HCV, 502 (1.93%) patients for HBV, whereas 850 (3.27%) patients for HCV. Non of the patients were found positive for both HBV and HCV. Nine hundred and five (67.0%) were males and 447, (33.0%) were females. Average age was 35-55 years. Keeping in mind the above mentioned results, the most important goal to be achieved is to increase the literacy rate and awareness among people about HBV and HCV so that it endeminity could be controlled.

/pdf/rising-prevalence-of-hepatitis-b-and-c-and-risk-factors-at-2otzbpowx1.pdf

Rising prevalence of Hepatitis B and C and risk factors at District Headquarter Teaching Hospital Bannu, Khyber-Pakhtunkhwa.

Background: Thoracodorsal artery perforator flap (TAP) is a feasible option to reconstruct defects in upper limb where only skin and subcutaneous tissue is required. Methods: This case series was carried out at department of Plastic and Reconstructive Surgery Combined Military Hospital Rawalpindi. A total of 5 patients with upper limb defects were reconstructed with thoracodorsal artery musculocutaneous perforator flaps. Among them, 3 were pedicled and two free TAP flaps. All flaps except one pedicled flap were raised on a single perforator pedicle. Recipient sites were one axilla, two shoulder regions and two hands. The soft tissue defects in the patients had resulted from burns, trauma, wide local excision of synovial sarcoma and surgery for hidradenitis suppurativa. Preoperative hand held Doppler ultrasound was used to locate and mark the perforator. Results: All flaps survived without significant complications. All flaps were hyperemic in the immediate postoperative period. We designed and raised all the five flaps on eccentrically placed perforators. All the raised perforators originated from the descending branch of the thoracodorsal artery. The donor sites were closed primarily with linear scars in all cases except one, in which partial closure was accomplished with split thickness skin grafting (STSG). Conclusion: The thoracodorsal artery perforator flap has great potential for reconstructing large, relatively shallow, defects of upper limb because of its suitable skin quality, texture and appropriate thickness, as well as hidden donor site, a reliable pedicle and sparing of muscle unit. Keywords: Thoracodorsal artery perforator flap, Upper limb reconstruction, Hidradenitis suppurativa, Synovial sarcoma

Thoracodorsal artery perforator flap for upper limb reconstruction

The case series was conducted at the Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, from June 2009 to May 2011, and comprised 19 patients in whom free fibula flap was performed for upper and lower limb reconstruction, using SPSS 16. Results showed that flap survival was 100%. One (5.2%) flap was re-explored for venous congestion and was salvaged. One (5.2%) patient of congenital pseudoarthrosis of tibia had a fracture of the fibula and was treated with external fixation. Average follow up was 8 months. Mean union time and full weight-bearing was 6.5 +/- 1.34 months (range 3-8 months) and 9 months, respectively. No recurrence of pseudoathrosis was observed until the last follow up, with only a 1.5 cm length discrepancy in one patient. The results proved that a microvascular free fibular flap heals rapidly, causes early functional recovery and it can be raised as an osteocutaneous flap.

/pdf/use-of-vascularised-free-fibula-in-limb-reconstruction-for-4txtwz2yyt.pdf

Use of vascularised free fibula in limb reconstruction (for non-malignant defects).

The anterolateral thigh flap (ALTF) has been in wide clinical use for the last two decades, its major disadvantage has been its variable anatomy. We are presenting a case in which no substantial perforators were found to be arising from either the lateral septum of thigh or Vastus Laterlis muscle. In this case, instead of raising another flap, we used the same skin paddle raised on the musculocutaneous perforators of rectus femoris muscle.

/pdf/free-anterolateral-thigh-flap-raised-on-musculocutaneous-h50k1kymo7.pdf

Free Anterolateral Thigh Flap Raised on Musculocutaneous Perforators of Rectus Femoris Muscle

Primary intrathoracic goiter is a rare presentation of thyroid disease. Its removal usually necessitates thoracotomy or sternotomy. This patient having a primary intrathoracic goiter presented with posterior mediastinal mass that was removed through a right lateral thoracotomy.

Primary intrathoracic goiter -a rare mediastinal tumor.

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