2-stage Technique Research Articles

A population-based estimation of maternal mortality in Lagos State, Nigeria using the indirect sisterhood method

BackgroundPregnancy and delivery deaths represent a risk to women, particularly those living in low- and middle-income countries (LMICs). This population-based survey was conducted to provide estimates of the maternal mortality ratio (MMR) in Lagos Nigeria.MethodsA community-based, cross-sectional study was conducted in mapped Wards and Enumeration Areas (EA) of all Local Government Areas (LGAs) in Lagos, among 9,986 women of reproductive age (15–49 years) from April to August 2022 using a 2-stage cluster sampling technique. A semi-structured, pre-tested questionnaire adapted from nationally representative surveys was administered using REDCap by trained field assistants for data collection on socio-demographics, reproductive health, fertility, and maternal mortality. Data were analysed using SPSS and MMR was estimated using the indirect sisterhood method. Ethical approval was obtained from the Lagos State University Teaching Hospital Health Research and Ethics Committee.ResultsMost of the respondents (28.7%) were aged 25–29 years. Out of 546 deceased sisters reported, 120 (22%) died from maternal causes. Sisters of the deceased aged 20–24 reported almost half of the deaths (46.7%) as due to maternal causes, while those aged 45–49 reported the highest number of deceased sisters who died from other causes (90.2%). The total fertility rate (TFR) was calculated as 3.807, the Lifetime Risk (LTR) of maternal death was 0.0196 or 1-in-51, and the MMR was 430 per 100,000 [95% CI: 360–510].ConclusionOur findings show that the maternal mortality rate for Lagos remains unacceptable and has not changed significantly over time in actual terms. There is need to develop and intensify community-based intervention strategies, programs for private hospitals, monitor MMR trends, identify and contextually address barriers at all levels of maternal care.

Use of Banked Fibula for Improved Nasal Reconstruction Following Free Fibula Midface Reconstruction.

Anterior maxillary deficiency caused by trauma or oncologic resection presents a complex reconstructive challenge. The authors present a technique for 2-stage midface reconstruction utilizing a vascularized free fibula flap for maxillary reconstruction, followed by nasal reconstruction at a second stage utilizing a banked fibula graft. This case series utilizes a 2-stage technique for midface reconstruction. In the first stage, a fibula-free flap was used to reconstruct the maxilla with the excess banked in the abdomen. In the second stage, this bone graft was used to restore the nasal dorsum. Two patients were included in this series. Patient 1 was a 28-year-old man who presented after a remote gunshot wound to his face, resulting in complete loss of his anterior maxilla and nasal support with midface collapse. Patient 2 was a 65-year-old man who presented with squamous cell carcinoma of the hard palate with extension into the maxilla and nasal septum. In both cases, the flaps healed without complication, providing midface restoration. Placement of the banked fibula graft in a second stage resulted in restoration of dorsal nasal projection. The authors describe the use of "spare" fibula parts for nasal reconstruction after loss of the maxilla and cartilaginous septum. The use of the fibula bone as a graft to restore the nasal dorsum in a delayed manner allows for a better assessment of the esthetic needs after the massive swelling from the initial surgery has abated. Further, this approach eliminates the need for a second donor site for nasal reconstruction.

Routine diversion following delayed IPAA construction does not reduce the incidence of pouch-related sepsis or failure in patients with ulcerative colitis.

The aim of this study was to compare modified 2-stage and 3-stage IPAA construction techniques to evaluate the effect of diverting loop ileostomy following completion proctectomy and IPAA for ulcerative colitis. In addition, our overall institutional experience was reviewed to describe long-term outcomes and changes in staging trends over time. Our institutional database was searched to identify all cases of IPAA for ulcerative colitis between 1981 and 2018. Patient, pouch and outcome characteristics were abstracted. Primary study outcomes were the incidence of primary pouch failure and pouch-related sepsis. Failure was evaluated by Kaplan-Meier estimates of survival over time. The adjusted effect of pouch stage was evaluated using multivariable Cox and logistic regression models. Exploratory analysis evaluated the effect of stage on failure in the pouch related sepsis subgroup. A total of 2105 patients underwent primary IPAA over the study period. The 5, 10 and 20-year pouch survival probabilities were 95.2%, 92.7% and 86.6%. The incidence of pouch related sepsis was 12.3%. Adjusted analysis demonstrated no difference in pouch failure (HR = 0.64: 95% 0.39-1.07, p = 0.09) or post-operative sepsis (aOR = 0.79: 95% CI 0.53-1.17, p = 0.24) by stage of construction. Among patients experiencing pouch sepsis, there was no difference in Kaplan-Meier estimates of pouch survival by stage (p = 0.90). Pouch related sepsis and IPAA failure did not differ between modified 2-stage and 3-stage construction techniques. Among the sub-group of patients experiencing pouch related sepsis, there was no difference in failure between groups. The results suggest diverting ileostomy may be safely avoided following delayed pouch reconstruction in appropriately selected patients.

Simultaneous Tunnel Grafting and Anterior Cruciate Ligament Reconstructions Revision Using Double Suspensory Fixation: A Single-Stage Solution

The anterior cruciate ligament (ACL) is often vulnerable to sports-related injuries, leading to numerous ACL reconstructions (ACLRs) annually in the United States. Although largely successful, these procedures face the risk of recurrent instability due to graft failure. ACLR failures are typically attributed to technical errors and patient-related factors, with improper positioning of the tibial and femoral tunnels as the most common technical mistake. Current 2-stage revision techniques involve primary bone grafting followed by secondary tendon graft placement, resulting in increased costs and extended rehabilitation times. This article proposes a single-stage revision strategy involving simultaneous tunnel grafting and ACLR revision. The method employs double suspensory fixation by adjustable loop buttons, thereby eliminating the dependence on metaphyseal bone stock for stable graft fixation. This new procedure may offer a more efficient and cost-effective approach, reducing the need for a second surgery and potentially allowing patients to return to normal activities more quickly.

Vascularized Bone Grafting Versus the 2-Stage Masquelet Technique for Upper-Extremity Bone Reconstruction: A Meta-Analysis

Vascularized bone grafting (VBG) has been described as the technique of choice for larger bone defects in bone reconstruction, yielding excellent results at the traditional threshold of 6 cm as described in the literature. However, we hypothesize that the 2-stage Masquelet technique provides equivalent union rates for upper-extremity bone defects regardless of size, while having no increase in the rate of patient complications. A systematic literature review was conducted using PubMed and Scopus for outcomes after VBG and the Masquelet technique for upper-extremity bone defects of the humerus, radius, ulna, metacarpal, or phalanx (carpal defects were excluded). A meta-analysis was performed to compare outcomes following VBG and the Masquelet technique at varying defect sizes. There were 77 VBG (295 patients) and 25 Masquelet (119 patients) studies that met inclusion criteria. Patients undergoing the Masquelet technique had defect sizes ranging from 0-15 cm (average 4.5 cm), while patients undergoing VBG had defect sizes ranging from 0-24 cm (average 5.9 cm). The union rate for Masquelet patients was 94.1% with an average time to union of 5.8 months, compared to 94.9% and 4.4 months, respectively, for VBG patients. We did not identify a defect size threshold at which VBG demonstrated a significantly higher union rate. No statistically significant difference was found in union rates between techniques when using multivariable logistic regression analysis. There was no statistically significant difference in union rates between VBG and the Masquelet technique in upper-extremity bone defects regardless of defect size. Surgeons may consider the Masquelet technique as an alternative to VBG in large bone defects of the upper extremity. Therapeutic IV.

Autonomous dental robotic surgery for zygomatic implants: A two-stage technique

Zygomatic implants (ZIs) can be a treatment option for patients with severe atrophy in the maxilla, but deviation during ZI placement could lead to serious complications. Surgical guides and dynamic navigation have been used to improve the accuracy of ZI placement, but both techniques are subject to human error. A 2-stage technique is described that enabled an autonomous dental robot to overcome mouth-opening restrictions for ZI placement. The technique enables the complete digitalization of ZI placement, further improving the accuracy of the drilling process.

A modified induced membrane 2-stage technique using a thoracodorsal artery perforator free flap followed by vascularized or non-vascularized free fibular transfer for the treatment of complex bone infection with concomitant severe soft tissue lesion–A case series of 9 cases

Treatment of post-traumatic complex bone infection is very challenging. The two principal bone reconstruction approaches are the single-stage vascularized bone graft technique and the two-stage induced membrane technique (IMT). Here we introduce a modified 2-stage induced membrane technique (MIMT) for complex long bone infection with a major bone defect and a concomitant severe soft tissue lesion. The 2-stage procedure consists of bone debridement, placement of a PMMA spacer and soft tissue reconstruction with a thoracodorsal artery perforator free flap (“Tdap”) at stage 1. At stage 2, the thoracodorsal artery perforator flap is elevated and a fibular strut graft (either vascularized of non-vascularized) is placed for bone reconstruction.We retrospectively analyzed the extents of lower extremity, long bone, post-traumatic bone infection treated via MIMT from 2008 to 2020. There were nine such cases (eight males) of mean age 59.8 (range 31 to 79) years. The osteomyelitis durations ranged from 3 to 360 months (mean 53 months). The cortical bone defect sizes was ranged from 9 to 14 cm (mean10.7 cm). All skin resurfacing employed Tdap. Vascularized fibular grafts were placed in six patients and non-vascularized grafts were placed in three. The fibular graft size ranged from 12.5 to 19 cm (mean 16.2 cm). Non-vascularized iliac bone grafts served as the fibula docking sites.Unfortunately, all patients suffered complications before bone union was achieved. One case of plate stress fracture and one case of screw fracture required plate and screw change. In three cases of cellulitis, one resolved by use of intravenous antibiotics, others required plate and screw removal. Wound disruption required re-suture and distal skin flap partial necrosis was covered by perforator-based island flap. One case of fibular stress fracture needed cast for 4 weeks. A peroneal nerve palsy patient recovered spontaneously. Bone union was achieved after 6 months in five patients and after 8 months in three (mean 6.9 months). All patients were able to walk unaided. The follow-up period ranged from 2 to 14 years (mean 6.2 years).MIMT saves the limbs in cases with difficult post-traumatic bone infection. It is valid treatment option for complex bone infections with severe soft tissue lesions. However, even with this technique potential complication must be considered.

The alternative irregularity reduction algorithm built on 2-stage identification with AMF on FMIO

Built on neighborhood correlation, a 2-stage identification technique was offered to incorporate on the irregularity reduction algorithm for random magnitude impulse outlier (RMIO). As a result, this algorithm has an ultimate efficacy thereby a 2-stage identification technique becomes to be one of the high efficacy identification technique. Accordingly, this paper attempts to propose an alternative irregularity reduction algorithm built on a 2-stage identification and adaptive median filter (AMF) with under fix magnitude impulsive outlier (FMIO) at little, mild and immense massiveness. First, by examining great number of depictions, the optimized window dimension for 2-stage scheme from computation and performance is disposed. Second, comprehensive examinations represent that the 2-stage identification technique is disposed to identify between regular and irregular pixels at all massiveness, especially little and mild massiveness. Third, the identification efficacy on great depictions at all massiveness is examined on regular, irregular, regular-irregular efficacy perspective to estimate the optimal window size and optimal 2-stage constant value. Finally, the overall outlier reduction efficacy of an outlier reduction built on 2-stage technique and AMF is examined on great depictions at all massiveness related with other up-to-the-minute outlier reductions. From these results, the outlier reduction has remarkable efficacy than other up-to-the-minute outlier reductions.

Revision Anterior Cruciate Ligament Reconstruction Using Bone Dowels

Background: Revision anterior cruciate ligament (ACL) reconstruction is technically challenging and may require the use of bone dowels in either 1 or 2 stages. Indications: The indications for bone dowels include tibial or femoral tunnel malposition or widening of the tunnels. In the patient case, the tibial tunnel aperture was positioned far medial to the native ACL insertion with a horizontal tunnel trajectory and the femoral tunnel was vertical. In addition, there was tunnel widening to 12 mm of both tibial and femoral tunnels. Technique Description: A bone-patellar tendon-bone autograft was harvested and diagnostic arthroscopy was performed. The previous tibial tunnel was sequentially reamed from 8 to 12 mm to adequately overdrill the previous widened tunnel. Next, the femoral tunnel was reamed to 12 mm in similar fashion. Using a tamp and guide pin, a 12 × 30-mm allograft bone dowel was then malleted into the femoral tunnel until it was flush with the medial aspect of the lateral femoral condyle. Another 12 × 30-mm bone dowel was then advanced into the tibial tunnel until it was just below the native articular margin. With the bone dowels securely in place, the ACL reconstruction using the harvested bone-patellar tendon-bone autograft was performed. Results: Werner et al reported a study of 12 patients who had excellent incorporation of femoral tunnel allograft bone dowels and comparable objective and subjective scoring to 2-stage techniques. Dragoo et al reported a study of 18 patients with tibial tunnel allograft bone dowels that demonstrated significant increases in patient-reported outcome measures and a significant decrease in tunnel widening. Discussion/Conclusion: Revision ACL reconstruction may require bone dowels if there are malpositioned tunnels or if there is tunnel widening. Overall, the literature demonstrates that 1-stage revision outcomes have been comparable to reported 2-stage revision outcomes, both of which are satisfactory.

Pectin Production from Biowaste (Fruits & Vegetables) by Crosscurrent Solid-Liquid Extraction Technique

The impact of fruit and vegetable waste is becoming a significant concern for the environment. The biomaterial waste generated from fruit processing industries is very high. When discharged as processed waste, it also increases water pollution. 45% of the total industrial organic pollution originates from food processing industries. These generated wastes are suitable for the production of biochemicals. Pectin is one such biochemical that plays a vital role in reducing the burden on the environment. Pectin helps in the manufacturing of confectionaries. Vegetable waste like beetroot, carrot, beans can also act as a source for pectin production. This study depicts extracting Pectin from mixed fruit pomace waste. Mixed fruit (Orange, Pomegranate, Banana & grapes) pomace waste reacts with 0.1N HCl. This reaction uses a 2-stage crosscurrent solid-liquid extraction technique. For its nature, obtained pectin was tested as calcium pectate using methylated spirit. The filtrate from 2-stage crosscurrent leaching was further dried in an oven. RSM technique helps in optimizing parameters like drying time, temperature, pH, and concentration. The experimental setup generated Pectin gave an efficiency of 11.52% for 22.4g of dried mixed fruit pomace waste.

Malnutrition and Associated Risk Factors among Children 6–59 Months Old in the Landslide-Prone Bududa District, Eastern Uganda: A Cohort Study

ABSTRACTBackgroundThe United Nations Sustainable Development Goal 2.2 calls for an end to all forms of malnutrition. This might be derailed due to persistent landslide disasters in low-income countries like Uganda.ObjectivesThe prevalence of malnutrition and the impact of seasonal variations and associated factors were assessed among children aged 6–59 mo in the landslide-affected households in Bududa District, eastern Uganda.MethodsA prospective cohort study using a 2-stage simple random technique was applied to select 422 households including 392 children during May–August (food-plenty season) 2019. After 6 mo, in January–March (food-poor season) 2020, 388 households and 366 children were assessed. Socioeconomic and demographic data were collected using structured questionnaires. Child malnutrition outcomes were defined according to WHO criteria. Factors associated with malnutrition outcomes were identified by bivariate and multivariate logistic regression.ResultsStunting, underweight, wasting, and overweight prevalences were 37.7%, 13.3%, 3.6%, and 4.3%, respectively, in the food-plenty season and 42.6%, 14.2%, 2.1%, and 2.7%, respectively, in the food-poor season. Residing in the landslide-affected sub-county increased the odds for stunting [adjusted OR (aOR): 1.68; 95% CI: 1.08, 2.59; P = 0.025] and underweight (aOR = 4.25; 95% CI: 1.10, 15.36; P = 0.032) for children in the food-plenty season. Child age, sex, breastfeeding status, a nonimproved drinking water source, migration of any household member, and parents’ education were significant risk factors in the food-plenty season. In the food-poor season, parents’ education status, loss of any household member, child sex, and child age were significant risk factors.ConclusionsStunting and underweight were more prevalent in the food-poor season while wasting and overweight were more prevalent in the food-plenty season. With the exception of child age, child sex, and parents’ education, child malnutrition risk factors differed between food-plenty and food-poor seasons. There is a need to address seasonality factors in program interventions targeting children <5 y in landslide-prone areas.

Assessment of Consumers' Perception of Chicken Eggs Consumption and Associated Health Implications in the Volta Region of Ghana.

Background:Rather erroneously, eggs consumption is linked to increase in plasma cholesterol content and incidents of cardiovascular diseases, cancer, stroke, or diabetes. This misconception which is more pervasive particularly in sub-Saharan Africa, has led to very low patronage of eggs intake. In this study, egg consumption patterns, desired egg characteristics, and the extent to which the perception of eggs consumption as a health risk is entrenched among consumers in the Volta Region of Ghana, were examined.Methods:The study used primary data for the analysis and the 2-stage sampling technique was employed. First, 5 districts (Keta, Ho, Krachi East, Nkwanta South and North Tongu) were selected and afterward, a sample was randomly selected from each of the district. A well designed and pretested questionnaires were administered to the respondents.Results:It was found that cheaper price and deep yellow yolk were the most persuasive parameters that motivate consumer purchase. The relationship between educational level and awareness on cholesterol types was significant. More than half of the respondents held the view that egg intake results in an increase in serum cholesterol and leads to the incidence of serious health problems.Recommendation:This study proves the urgent need for a concerted national public education effort to raise awareness about the nutritional and health benefits of eggs intake. Success in such awareness creation will go a long way to greatly minimize acute malnutrition in the Ghana.

Induced Membrane Technique for the Treatment of Infected Forearm Nonunion: A Retrospective Study

Infected forearm nonunion remains a challenge for the hand surgeon. Autologous bone grafting within an induced membrane following implantation of a cement spacer, also known as the Masquelet technique, is a procedure used for addressing segmental bone defects. This report summarized our experience using this technique to treat the infected forearm nonunion. We retrospectively reviewed a series of 32 patients treated for infected forearm nonunion by the 2-stage Masquelet technique between 2009 and 2018. There was an infected nonunion of the ulna in 28 patients and an infected nonunion of the radius in 4 patients. All patients had undergone an average of 2.7 procedures before presenting at our institution. Treatment involved a staged procedure in which an antibiotic-impregnated cement spacer was implanted into the bone defect following debridement without internal fixation. It was left in place for 4-6 weeks, during which time a membrane formed around the cement spacer. In the second stage, the induced membrane was incised, and the cement spacer was removed. The defect was then filled with cancellous autograft with the addition of internal fixation. Postoperative radiographs were taken for the evaluation of bone healing. The functional results of the affected forearm were evaluated for motion loss of elbow or wrist and rotation loss of forearm. All nonunions healed without recurrent infection or loosening of internal fixation at the time of final follow-up. All the patients showed substantial functional improvement, with excellent results in 14 patients, satisfactory results in 13, and unsatisfactory results in 5. The induced membrane technique is an effective solution for infected forearm nonunion. Therapeutic IV.

Household welfare status and crop insurance uptake by cocoa farmers in Ondo State, Nigeria

This study examined the effect of welfare status on insurance uptake. The reason for the study is that formal insurance is still underutilized amongst farmers in Nigeria despite the incessant risk and uncertainties faced in agriculture. For this study, 200 households were randomly drawn from four local government areas of Ondo state through a 2-stage sampling technique. The analytical tools used were descriptive statistics and the Heckman selection model. The result obtained from the study showed that the risk coping strategies adopted by cocoa farmers in the study area included the use of pesticides, herbicides and manual weeding of their farms. Insurance awareness was low among cocoa farmers in the study area. Also, factors that influenced farmers’ decision to take insurance were years of formal education, distance of household from insurance company, access to extension agent and total land cultivated. Household size which was used as instrumental variable for welfare status was also significant in the model influenced farmers’ decision to take crop insurance. Key words: Heckman selection model, cocoa, risk, welfare, crop insurance.

Porcine-Derived Collagen-Augmented Chondrogenesis Technique for Treating Knee Cartilage Defects.

Porcine-derived C-ACT is initiated by creating a mixture of atelocollagen, thrombin, and fibrinogen. First, thrombin is mixed with atelocollagen and placed in one arm of an assembled Y-shaped syringe, and fibrinogen is placed in the other arm. The articular cartilage defect site is confirmed in a routine arthroscopic procedure. The articular margin is debrided, and the calcified lesion is cleanly removed. Then, microfractures are created. After creating a more extended incision at the anteromedial portal, the microfracture site is prepared by removing moisture. The prepared atelocollagen mixture is applied to the defect site as a single layer, although a second layer can be formed 1 to 2 minutes later. After 5 minutes, the stability is verified by range of motion of the knee.Indications for this procedure include (1) cartilage defects in the knee, including knee osteoarthritis and knee traumatic arthritis; (2) knee osteoarthritis with a Kellgren-Lawrence grade of 3 or less; (3) hip-knee-ankle malalignment of <5° or a deformity that is able to be surgically corrected; and (4) knee stability, or instability that is able to be surgically corrected.Contraindications for this procedure include (1) patient or family history of autoimmune disease, (2) history of anaphylactic reaction, (3) history of hypersensitivity to an implant, (4) history of allergy to porcine or bovine protein, and (5) inflammatory arthritis such as rheumatoid and gouty arthritis.C-ACT is a procedure for cartilage repair, and the effects of this procedure can be limited in cases with a deep subchondral bone defect; however, there is no limit to the size of the cartilage defect in terms of patient selection for C-ACT. There are several alternatives to C-ACT, ranging from the simple microfracture technique to autologous chondrocyte implantation5, matrix-induced autologous chondrocyte implantation6, autologous matrix-induced chondrogenesis7, osteochondral autograft transplantation8, and stem cell therapy. There are various ways to recover from an articular cartilage defect, but C-ACT does not require a 2-stage technique, as is necessary with both autologous chondrocyte implantation procedures. Therefore, C-ACT has the advantages of ease of operation and being a single-stage procedure3,9. C-ACT can be classified as an upgraded version of microfracture, which is the most common treatment method for articular cartilage defects. With the microfracture technique, repaired cartilage is limited to fibrous cartilage and does not include hyaline cartilage3,4. However, a recent study reported that C-ACT exhibited a superior quality of repaired cartilage compared with microfracture3,4. Previous studies have reported favorable results with the use of C-ACT3,4. Kim et al.4 compared atelocollagen augmentation with microfracture alone in patients undergoing medial opening wedge high tibial osteotomy for the treatment of medial compartment osteoarthritis. Although there was no clinical difference between the 2 groups, the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and the International Cartilage Repair Society II score were superior in the atelocollagen augmentation group. In addition, the microfracture group formed fibrous-like cartilage compared with the hyaline-like cartilage created in the atelocollagen augmentation group. A recent multicenter randomized study compared the use of C-ACT and microfracture and found that C-ACT exhibited significantly better results in several MOCART subscores and quantitative T2 mapping, indicating a histologically superior form of repaired cartilage compared with microfracture3. According to recent research, microfracture is superior to autologous chondrocyte implantation in terms of cost-effectiveness10. Similar results appear to be applicable to C-ACT. C-ACT requires an additional $1,300 for material costs; however, C-ACT showed better cartilage regeneration on magnetic resonance imagining and histology3,4, and higher rate of patients meeting the 20%-improvement rate in visual analogue scale pain scores at 24 months postoperatively compared with microfracture3. Long-term studies will be needed to assess whether histological superiority of C-ACT is reflected in meaningful improvements to clinical outcomes. Debride all of the damaged cartilage to subchondral bone and remove the calcified layer without interfering with tissue repairTake special care when creating the atelocollagen mixture to ensure that it is accurately manufacturedDry the defect site with use of suction or gauze to aid in atelocollagen adhesion when applying atelocollagen.

Lower Lip Reanimation: Experience Using the Anterior Belly of Digastric Muscle in 2-stage Procedure.

Retrospective analysis of 2-stage lower lip reanimations between 2010 and 2018 was performed. Demographics, etiology, and operative details were recorded. Videos were graded pre/postoperatively using a 5-point Likert scale by 21 independent observers. Objective changes of symmetry were analyzed using Photogrammetry (Emotrics). Twenty-seven patients were identified (median age 34.9 years, range 6-64). The mean duration between the 2 stages was 15.1 months. Follow-up ranged from 18-72 months. There were minor complications in 4 patients, and 1 case was abandoned due to insufficient length of anterior belly of digastric muscle. Average peer-reviewed scores improved from 2.1 to 3.2 (P < 0.05). Emotrics did not show improvement in static symmetry (P > 0.05). However, during open-lip smiling, lower lip height improved significantly (P < 0.05) whilst dental show improvements approached significance (P < 0.08). Lower lip symmetry was also improved during lower lip depression, as shown by improvements in lower lip height (P < 0.05), smile angle, and dental show (both P < 0.05). These results show the safety and efficacy of 2-stage lower lip reanimation using anterior belly of digastric muscle transposition. This procedure is our choice for longstanding lower lip paralysis and provides coordinated spontaneous lower lip depression, thus enhancing the overall perioral animation and smile.

Prelamination of Vascularized Tensor Fascia Lata for Complex Abdominal Wall Reconstruction.

There are 2 to 5 million laparotomies performed in the United States annually. Of these, 250,000 to 350,000 will undergo a ventral hernia repair. Repairs are often complicated by recurrence and infection. These risks are significantly increased in previously infected repairs, with reported recurrence rates varying from 17% to 28% after repair of infected ventral hernias, double the rates reported for first-time uninfected repairs. We describe here a novel treatment strategy involving the creation then use of bilateral prelaminated permanent mesh-reinforced tensor fascia latae flaps for abdominal wall reconstruction in patients who have recurrent ventral hernias and had undergone previous repairs complicated by infection. Previous repairs included anterior components separation, thereby making subsequent fascial release techniques and achievement of a reinforced repair extremely unlikely. Three patients were treated by a single surgeon using this 2-stage technique. There have been no incidences of recurrence and no infections after 2 to 10 years. In these patients, the only conventional option would have been a bridged repair with absorbable mesh. Combining the advantages of permanent mesh and well-vascularized autologous tissue optimizes the repair's tensile strength while mitigating the chance of recurrent infection associated with the use of permanent mesh. We propose that this strategy may be an appropriate treatment option for patients with recurrent ventral hernias that have not responded to other conventional modalities of treatment.

Surgical Strategies: Cement Spacer for Staged First Metatarsophalangeal Arthrodesis After Failed Arthroplasty

Revision arthrodesis following surgery for first metatarsophalangeal arthritis (hallux rigidus) is a complex problem. Failed implants, arthroplasty, primary fusion, or infection may result in bone loss with abnormal soft tissue tensions. This requires technically challenging revision surgery necessitating debridement of nonviable bone, culture, and bone grafting of resultant defects. We describe a 2-stage technique for first metatarsophalangeal arthrodesis in the setting of osteolysis, infection, or bone loss. This staged technique allows for the restoration of appropriate soft tissue tension through the use of a temporary cement spacer before structural grafting.

Effect of malaria preventive education on the use of long-lasting insecticidal nets among pregnant females in a Teaching Hospital in Osun state, south-west Nigeria

Background: Malaria in pregnancy is a major public health problem in Nigeria. Long-Lasting Insecticidal Nets (LLINs) have been advocated as an effective tool against malaria transmission. However, success of this intervention largely depends on the knowledge and practices regarding malaria and its prevention. Unfortunately, few studies have been done on effect of malaria preventive education on use of LLIN in pregnancy.Objective: To assess the knowledge of malaria and determine the effect of malaria preventive education on the use of LLINs among pregnant females in a Teaching Hospital in Osun state.Method: It was a one group pre-test post-test quasi - experimental hospital based study involving pregnant females attending Ante-Natal Clinic (ANC) of the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). A total of 200 respondents were recruited for this study by 2-stage sampling technique. Data was collected using a pretested questionnaire to elicit information on socio-demographic characteristics, use of LLIN in pregnancy, knowledge of malaria and its preventive measures. The data collected was analysed using descriptive and inferential statistics. The descriptive statistics comprised frequency, percentage, means and standard deviations. Bivariate analysis comprised Chi-square test on knowledge of malaria before and after intervention while correlation test assessed strength of relationship between knowledge of malaria preventive education and use of LLINs before and after intervention. Multivariate analysis determined the predictors of LLINs use. Analytical statistics of cross tabulation was conducted considering a p < 0.05 to be statistically significant.Results: There was an increase in the scores of knowledge on malaria transmission after the intervention and this was statistically significant (χ2 = 8.862, p < 0.01). Similarly, the scores of knowledge on malaria prevention increased after the intervention and this was statistically significant (χ2 = 10.023, p < 0.01). Respondents' age, marital status and gravidity were predictors of LLINs use. Biserial correlation showed a statistically positive relationship between knowledge of malaria preventive education and use of LLINs after intervention (r = 0.036, p < 0.01).Conclusion: The use of malaria preventive education was found to be effective in increasing the use of LLIN in this study. These findings highlight a need for educational intervention in implementation of LLINs. There is therefore a need to strengthen the policy of malaria prevention education as an integral component with distribution of free LLIN in health care setting to enhance its utilization.

Use of Pericranial Flaps with Dermal Substitute for Scalp Reconstruction: A Case Series.

Background:Skin cancer incidence has been rapidly increasing over the past 2 decades, and the resulting defects from excision have significant aesthetic and functional implications. In particular, wound coverage for large scalp and forehead defects with calvarial exposure can lead to hairline distortion, contour irregularities, and alopecia. We describe a 2-stage technique for scalp reconstruction, which preserves the normal hairline, covers exposed bone with vascularized tissue, and restores an aesthetic soft-tissue contour.Methods:This is a retrospective case series of 13 adults with ages ranging from 50 to 89 years. All patients underwent Mohs surgery on the forehead or scalp between July 2014 and April 2017. Patients underwent a 2-staged reconstruction with an initial pericranial flap and dermal substitute placement followed by the placement of a split-thickness skin graft within 4–6 weeks.Results:Over a 3-year period, 13 patients had successful reconstruction of the scalp defect without alteration of the hairline or contour irregularity. Two patients had minor complications after the first-stage procedure with successful aesthetic reconstruction.Conclusions:Full-thickness defects of the scalp and forehead with bone exposure provide a reconstructive challenge for plastic surgeons. Reconstructive algorithms continue to evolve and should be tailored to best suit patients’ needs and medial comorbidities. Two-staged reconstruction with local pericranial flap provides a safe and efficacious reconstruction that minimizes hairline distortion, contour irregularity, and donor site morbidity.