Selective Fasciectomy in Dupuytren’s Contracture: An Experience of A Specialized Tertiary Hospital in Bangladesh

Background: Dupuytren’s disease is a benign yet disabling, irreversible, progressive fibroproliferative condition affecting the palm and fingers, leading to flection contracture of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints.Objective: To evaluate results of selective fasciectomy to correct the deformity of MCP and PIP joints and observe the complications.Methods: This crosssectional study was done on 30 patients of Dupuytren’s contracture treated by selective fasciectomy, between January 2015 and December 2018, in Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Selective fasciectomy was done under brachial plexus block, tourniquet control and loupe magnification. Brunner zigzag incision was used. Indications for surgery was MCP flection contracture more than 30⁰ and any degree of PIP flection contracture. Postoperatively hand was immobilised in extension of MCP and PIP joints for 2 weeks and then active and passive movements were encouraged and intermittent splinting for 10 weeks (only at night in last 6 weeks).Results: Among 30 patients, 24 (80%) patients were male, 6 (20%) were female; mean age was 62 years (56-74 years). 12 (40%) cases were bilateral, ring and little fingers involvement were seen in most cases (92%). Mean MCP correction was 53⁰ and mean PIP correction was 34⁰ (p<0.001). There were 3 digital nerve injuries peroperatively which were repaired/reconstructed and protective sensation regained in repaired nerve area at 1 year and 3 (10%) marginal skin loss postoperatively which healed secondarily. Superficial wound infection developed in 3 (10%) patients which healed on dressing and antibiotics. Complex regional pain syndrome developed in 2 (6.66%) patients which were mild and resolved on conservative management. 3 (10%) patients developed scar sequilae which were mild and resolved on conservative treatment. Radial digital artery injury was observed in 1 (3.33%); however, no ischaemic insult was observed postoperatively. 2 (6.66%) patients developed recurrence of the disease who were more than 70 years old; however, they declined further intervention.Conclusion: Selective fasciectomy is an easy and effective procedure with less complication to correct the deformities and improve the gripstrength significantly in Dupuytren’s contracture patients.International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page: 41-46

Case Report: Non-microscopic surgical management of incomplete penile amputation

Background: Penile amputation is an emergency urologic condition requiring immediate attention in order to maximize functional outcomes. Unfortunately, there is limited experience and publication of case reports describing the successful replantation of penis after incomplete amputation, especially in facilities without adequate microsurgical tools and means. We hereby present a case of penile amputation caused by a mechanical grass cutter and a discussion of its surgical management. Case description: A 33-year-old Indonesian male presented to the emergency department with incomplete penile amputation six hours post injury. The patient has no prior medical history and presented with penile amputation due to a mechanical grass cutter trauma. He underwent immediate non-microsurgery reconstructive replantation of the penis, reattaching all visible vascular, corporal, and fascia layers. After replantation, the patient recovered well and showed preserved normal appearance and sensitivity of the penis. Subsequent Doppler ultrasound investigation revealed adequate arterial flow at the distal end of the anastomosis. The patient was discharged five days after surgery. Conclusion: In the absence of microsurgical tools and means, the use of non-microsurgical replantation with an at least 2.5x loupe magnification should be the choice of treatment in the case of incomplete penile amputation. The technique showed good outcomes involving adequate functional and cosmetic restoration.

Morton Neuroma Surgery: Relation Clinical Results to Excised Sample Length

Background:Morton’s neuroma (MN) is mechanical neuropathy of plantar interdigital nerve. It is one of the most common causes of forefoot pain. One of the most undesirable complications of MN surgery is recurrent neuroma. Excision level of MN is important to prevent recurrence. In this study, we aimed to find the relation resection lenght of MN to clinical results of MN surgery cases. Methods:76 samples sent with the diagnosis of Morton neuroma to the pathology department of our hospital between years 2010-2019. 66 patients whose clinical results were available were included in the study. Mean age was 41,5 (between 21 to 70). All of 66 patients were primary diagnosed 22 of them was left foot and the other 170 were right foot. 50 of them were female, and 16 were male. Recurrent neuromas, pathological sample more than one piece from one surgical site were excluded from the study. 72 of them were evaluated as a clinically and compare the sample lenght.Results:76 pathological specimens were prepared and examined by the same pathologist. Gross pathological appearance and histopathology findings were recorded. Mean sample length was 2,05 cm (between 0,7cm and 3,5 cm). 68 samples was smaller (89.5%) than 3 cm and only 8 sample (10.5%) was bigger than 3 cm. Average interdigital neuroma score improved from 20 to 62 points following the surgery (p<0.05).Conclusion:We recommend that, the common digital nerve should be cut from the proximal as much as possible to bury the proximal stump into the lumbrical muscles regardless of the sample size and using loupe magnification, careful and sharp dissection can be prevent injury to the PDNB.Level of Evidence: 2

Microsurgery: A 10-Year Experience with Loupe Magnification

Background Microsurgical procedures are still rare in many countries especially in resource-constrained countries. Among reasons for this is the unavailability of operating microscopes that are costly. Operating loupes are considered inferior to the microscope and are most discouraged for many microsurgical procedures. We audit patients operated under loupes for the past 10 years and present our findings. Patients and Methods This was a prospective audit of patients who underwent microsurgical reconstructive procedures in the plastic surgery unit at Kenyatta National Hospital between January 2009 and December 2019. Results A total of 352 patients with 360 procedures were done over a 10-year period. The age range for the patients was 5 to 90 years. Free flaps accounted for 78% of the surgical procedures (n = 298) followed by nerve repairs 8.8% (n = 32) and reimplantation surgeries 8.5% (n = 30). The overall success rate for free flaps was 93.3% with reimplantations of 77%. Conclusion Microsurgical reconstructive procedures as demonstrated in this study can safely be done with loupes. Loupes provide an alternative means of magnification that is cost effective and cheaper. In good hands, good surgical outcomes can be achieved that are comparable to the operating microscopes.

How to Dissect Lymphatics under Loupes for Line Production System for Multiple Lymphaticovenular Anastomosis

Background A surgical line production system using loupes to dissect lymphatics and veins is a cost-effective way of performing multiple lymphaticovenular anastomoses. There is an art to successful dissection of lymphatics under loupes, and selection of the correct loupe magnification is important. Therefore, the aim of this study was to provide a detailed description of how to dissect lymphatics under loupes. Patients and Methods Dissection of lymphatics under loupes was performed for a series of 13 patients. Lymphatics are transparent threadlike structures that are arranged longitudinally and may be oriented with feeding capillary vessels. At the start of dissection, it is helpful to have a reference scale in the field of vision when operating to appreciate the size of the structures seen under loupes. It is also helpful to be able to separate lymphatics from fat tissue in the background. Results Mean time for exploration under loupes was 25 ± 7 minutes; lymphatics were successfully found in 27 sites (90%) of the 30 attempted with failure to identify lymphatics in three sites (10%) and failure to identify veins in three sites (10%); the average size of the lymphatics was found to be 0.5 ± 0.2 mm. No lymphatics could be found by the microscopes after loupes exploration in two sites. Discussion Even a novice surgeon can identify lymphatics based on knowledge of the visual characteristics of these structures. However, a higher magnification is likely necessary for accurate discrimination.

Reverse Posterior Interosseous Artery Flap: A Reliable, Comfortable and Versatile Flap for Coverage of Soft Tissue Defects of Hand

Background: Soft tissue defects of the hands require coverage with soft, pliable full-thickness skin. The posterior interosseous artery (PIA) flap fulfils all these requirements and also has significant advantages over other flaps; it is a single-stage procedure that does not sacrifice major vascular axis of the hand. However, the dissection can be challenging and requires meticulous skill. The objective of the study was to evaluate the reverse PIA flap for coverage of hand soft tissue defects in terms of its safety, reliability, comfort, function and aesthetic appearance.Methods: Over a period of 3 years, patients with soft tissue defects over the dorsum of the hand and first web space were observed. A standard PIA flap was raised using loupe magnification under general or brachial anesthesia. The size and location of the defect were noted along with the size and success of the flap.Results: Twelve patients, including nine males and three females, were taken up for this procedure. All the flaps survived completely except one with marginal necrosis not requiring a secondary procedure. All patients were quite satisfied with the procedure and went on to resume their work within a month or two.Conclusion: PIA flap is a safe, reliable option with great versatility for coverage of hand defects, especially over the dorsum. A well-planned flap surgery done under loupe magnification affords excellent results. The entire treatment also requires a shorter hospital stay and allows the patient to return to work quickly.