Extensive Defects Research Articles

SCUBE3 promotes osteogenic differentiation and mitophagy in human bone marrow mesenchymal stem cells through the BMP2/TGF-β signaling pathway.

In clinical settings, addressing large bone defects remains a significant challenge for orthopedic surgeons. The use of genetically modified bone marrow mesenchymal stem cells (BMSCs) has emerged as a highly promising approach for these treatments. Signal peptide-CUB-EGF domain-containing protein 3 (SCUBE3) is a multifunctional secreted glycoprotein, the role of which remains unclear in human hBMSCs. This study used various experimental methods to elucidate the potential mechanism by which SCUBE3 influences osteogenic differentiation of hBMSCs invitro. Additionally, the therapeutic efficacy of SCUBE3, in conjunction with porous GeLMA microspheres, was evaluated invivo using a mouse bone defect model. Our findings indicate that SCUBE3 levels increase significantly during early osteogenic differentiation of hBMSCs, and that reducing SCUBE3 levels can hinder this differentiation. Overexpressing SCUBE3 elevated osteogenesis gene and protein levels and enhanced calcium deposition. Furthermore, treatment with recombinant human SCUBE3 (rhSCUBE3) protein boosted BMP2 and TGF-β expression, activated mitophagy in hBMSCs, ameliorated oxidative stress, and restored osteogenic function through SMAD phosphorylation. Invivo, GELMA/OE treatment effectively accelerated bone healing in mice. In conclusion, SCUBE3 fosters osteogenic differentiation and mitophagy in hBMSCs by activating the BMP2/TGF-β signaling pathway. When combined with engineered hydrogel cell therapy, it could offer valuable guidance for the clinical management of extensive bone defects.

Repair of an Extensive Defect of the Scalp.

Repair of an Extensive Defect of the Scalp.

Medially Based “Abdominal Rotation Advancement Flap”: A Promising Technique for Mastectomy Defect Reconstruction in “High-Risk Patients” Awaiting Adjuvant Radiotherapy

Abstract Background Extensive postmastectomy defects and soft-tissue defects often require some additional flap cover of reconstruction after excision. The reconstruction aim in this group should be a diligent and easy closure with a quality skin cover, early recovery, and brief stay in hospital so that the patients can receive early postoperative radiotherapy/chemotherapy. Medially based abdominal transposition flap is a type C fasciocutaneous flap based on medial perforating vessels. We present our experience in significant postmastectomy defects, especially in high-risk morbid patients. Materials and Methods This is a retrospective study conducted by the department of plastic surgery, from an analysis of the breast cancer database maintained by our hospital from 2019 to 2023. A total of 826 breast cancer patients underwent surgery, of which 547 were locally advanced breast cancer (LABC) patients and 138 (32.5%) LABC patients needed flap cover for mastectomy defect. Medially based abdominal transposition flap was used in 56 of 138 (40.5%) LABC patients for defect closure, and 42 of the 56 patients were stage IIIB patients. Upfront surgery was primarily done in 20 patients and 36 patients underwent surgery after neoadjuvant chemotherapy. This analysis aimed to assess the operative duration, postoperative morbidity, hospital stay, and time taken to start adjuvant treatment by analyzing the medical records of patients who underwent this procedure. Results Fifty-six patients with breast cancer underwent surgical intervention, whereby 8 patients presented with tip and edge necrosis, and 3 patients were infected. The mean duration of operation was 58.852 minutes, and the average length of hospital stay was 5.39 days. It took 24.57 days for the patients to stabilize sufficiently for adjuvant therapy. The average age of the patients in the study was 48.73 years. Conclusion Our clinical experience has demonstrated that the medial abdominal transposition fasciocutaneous (MATF) flap represents a straightforward, reliable, and cost-effective method for managing extensive postmastectomy soft-tissue defects in a subset of patients with LABC. This group typically consists of high-risk and comorbid patients. The procedure holds considerable promise for developing countries with limited infrastructure and expertise, owing to its ease of execution and short learning curve. By its simplicity and affordability, the MATF flap offers a viable and sustainable solution for treating LABC-associated soft-tissue defects.

The Mcgregor Pedicled Groin Flap for Hand Skin Defects

The groin flap is a surgical method used to cover soft tissue defects in the hand and forearm, such as wounds, traumatic amputations, degloving injuries, burns, burn scar release, and tumor excision. It is effective in covering extensive and intricate defects, such as wounds, traumatic amputations, degloving injuries, burns, burn scar release, and tumor excision. The procedure involves a remote autoplasty supported by the vascular territory of the superficial iliac circumflex artery. The flap's boundaries are defined using the "2 fingers width" criterion, and the flap is raised from lateral to medial, transferring subcutaneous tissue while keeping it above the fascia. The flap is closed using drain suction, and the patient is allowed to walk on the 5th day after surgery. Effective preoperative planning is essential for preventing the creation of too big or too tiny flaps and ensuring the fabrication of appropriate tubing to avoid complications. The McGregor groin flap is a commonly used technique for hand deformity reconstruction due to its extended pedicle and quick execution. It is adaptable, repeatable, and can be performed by less-experienced surgeons without microsurgery expertise. The flap covers significant tissue loss with pliable tissue, making it suitable for joints. It can cover abnormalities on the back or palm, and can be used for early wrist and hand rehabilitation. However, it has drawbacks, such as shoulder stiffness in older patients, discomfort during the upper limb positioning, and the need for multiple phases. Despite these, the groin flap remains relevant in the age of microsurgery and can be improved with technical modifications.

Reconstruction for extensive sacrococcygeal defects in complex tumor patients with personalized customized gluteus maximus myocutaneous flaps

AimTo evaluate the clinical effects of personalized customized gluteus maximus myocutaneous flaps (GMMF) for reconstruction of extensive sacrococcygeal soft tissue defects in complex tumor patients. MethodsA retrospective chart review was conducted on 8 patients who underwent personalized customized GMMF reconstruction for large sacrococcygeal defect from December 2021 to August 2023. The personalized customized GMMF were designed based on the variations of tissue defect in location, shape and volume of different dead spaces. The principle of the personalized GMMF is to ensure that the rotation point of the flap can reach the farthest end of the defect. Patient demographics, operative characteristics, and perioperative risk factors were analyzed. Clinical outcomes were assessed, focusing on complications such as flap necrosis, wound dehiscence, infection, seroma, and hematoma. ResultsSix patients with rectal cancer and two with sacral tumors underwent personalized customized GMMF reconstruction for extensive sacrococcygeal defects. The average volume of the wound cavity was 104 mL, with a mean vertical depth was 10.8 cm. Six patients had low serum albumin (<35 g/L). After a mean follow-up of 15.5 months, no major complications occurred, except for one seroma that resolved within 2 weeks. ConclusionThe personalized customized GMMF described in this study is an effective method for reconstructing large sacrococcygeal wounds with significant depth in complex tumor patients. It allows for greater rotation of the muscle flap into the sacrococcygeal wound defect and provides adequate blood supply by utilizing the bulk of muscle tissue to obliterate dead space.

Role of Local Flaps in the Reconstruction of Extensive Anterolateral Noma Defect: A Case Report

Abstract The scarring stage of noma disease often presents with composite tissue loss involving hard and soft tissues with resultant fibrosis making reconstruction a challenge. Microvascular reconstruction option is associated with good outcomes when the expertise is available. Trismus, which is caused by either soft tissue fibrosis or the union of the coronoid to the zygomatic complex, is also a common presentation. Effective treatment necessitates the involvement of a diverse team of specialists and the establishment of clear treatment objectives. This report presents a case of an extensive composite noma defect with trismus in a 9-year-old female managed using local flaps.

Algorithm of surgical treatment for diaphyseal defects of the forearm bones due to gunshot injuries

Introduction In the current system of providing medical aid to wounded servicemen, along with the conservative primary surgical treatment and minimally invasive extrafocal fixation, high-tech surgical interventions of considerable complexity with the use of additive and tissue-engineering technologies have been coming to the forefront. It is necessary to determine their place in the current algorithm of limb bone defect management, which was the substantiation of our study.The purpose of the study was to improve the algorithm for selecting a treatment method for patients with associated gunshot defects of the forearm based on the literature and clinical observations.Materials and Methods We analyzed scientific articles in PubMed and Scientific Electronic Library (eLIBRARY.ru) platforms, published from 2004 to 2024, on the basis of which we could refine the algorithm of treatment method selection for patients with associated gunshot defects of the forearm. The developed algorithm was used to treat 178 patients with gunshot fractures of the forearm.Results The review of the literature established the main provisions and principles that are applied in the reconstruction of the forearm with an associated defect. When choosing the method of bone defect management, a great number of authors tend to build a “reconstructive ladder”, moving from less severe (one bone) and extended defects (small defect up to 2 cm) to more complex (both bones) and massive defect (more than 10 cm). Upon having considered the revealed regularities, we improved the algorithm of surgical treatment of the latter, which is based on two classification principles: defect extention and location. Reconstruction of the forearm as a dynamic system after diaphyseal fractures requires consider the state of the radioulnar joint. The function of the latter depends on the length ratio of the radius and ulna bones. Therefore, we substantiated small (up to 2 cm) forearm bone defects that can be managed by simple surgical methods. Another fundamental addition to the algorithm was the allocation of a patients’ group with a defect of one forearm bone and a fracture of the other bone (defect-fracture); this combination allows avoiding complex surgical methods for reconstruction and use segment shortening.Discussion The treatment of associated forearm defects is challenging, the choice of reconstruction technique remains uncertain, and the required consensus is lacking. Several forearm reconstruction techniques are available, yet there is no reliable evidence of their effectiveness in terms of treatment time, complications, reoperations, and functional recovery.Conclusion The algorithm proposed for the treatment of extensive gunshot-associated defects of the forearm allows us to consider the change in the anatomy, make a surgical plan based on the reconstruction vector, and select optimal surgical techniques.

Enhancing automated fiber placement process monitoring and quality inspection: A hybrid thermal vision based framework

Automated Fiber Placement (AFP) has revolutionized composite manufacturing, yet quality assurance remains challenging due to the significant impact of emerging defects on part quality and the current reliance on time-consuming manual inspection protocols. This paper presents a comprehensive hybrid framework that enhances AFP process monitoring and quality inspection by integrating thermal vision with innovative methodologies. Our framework combines model-based and data-driven algorithms across three modules to address key AFP inspection tasks, including in-situ monitoring, dynamic tow identification, defect detection, segmentation, localization, and quantitative lay-up quality evaluation. The setup-independent spatial–temporal analysis algorithm estimates tow boundaries with sub-pixel accuracy. An optimized SVM classifier, trained on an extensive AFP defect database, achieves a defect detection accuracy of 96.4% and an F1-score of 96.43%, meeting industry standards. The active contours-based segmentation and localization module provides critical qualitative traits such as defect shape, size, and location. Moreover, the novel Defect Area Percentage (DAP) metric enables precise quantitative defect impact evaluation at both the course and tow levels. By consolidating qualitative and quantitative outcomes, the system offers real-time high-level feedback for informed decision-making, significantly improving process performance and reducing machine downtimes. This proactive approach advances AFP process monitoring and quality inspection and positions our framework as a promising solution for next-generation composite manufacturing.

Scalp Reconstruction With Free Tissue Transfer Using Descending Branch of Lateral Circumflex Femoral Vessels as Interposition Graft.

Despite the rich blood supply to the scalp, postoperative skin necrosis at the surgical site sometimes occurs, and unresolved defects often present a significant challenge for the surgeon. When planning a free flap for scalp reconstruction, distant anastomoses may be necessary if local recipient vessels are unavailable due to previous surgery. This study presents the authors' treatment strategy, which includes extending the pedicle length with arteriovenous bundle interposition grafts. Two patients who experienced surgical wound necrosis after bypass surgery for moyamoya disease underwent reconstruction for skin and soft tissue coverage. To evaluate the altered anatomical structures after the previous surgery, three-dimensional computed tomography angiography was performed, and preoperative photos were taken to accurately measure the expected defect. The surgical strategy was designed to accommodate their unique conditions, utilizing an arteriovenous interposition graft, which included 2 stages of microvascular anastomoses, for pedicle lengthening. The procedure successfully bridged the gap between distant recipient vessels and the extensive defect, and the wounds healed without major complications such as venous congestion or total flap loss. Both patients were satisfied with the surgical outcomes. Arteriovenous bundle interposition grafts can be a useful option for patients with complex scalp defects who lack local recipient vessels. The use of an anterolateral thigh flap with artery-to-artery anastomosis, utilizing the lateral circumflex femoral artery from the opposite side in this study, offers many advantages compared with traditional pedicle lengthening tools utilizing vein-to-artery anastomosis.

Polyetheretherketone split post and core for restoration of multirooted molar with insufficient dental tissue remnants by digital techniques: a case report and 3-year follow up

BackgroundMulti-rooted teeth with extensive dental defects often face challenges in stability and biomechanical failure. High-performance polymer PEEK materials, with properties closer to dentin, show promise in reducing stress concentration and preserving tooth structure. This report aimed to explore the use of a highly retentive polyetheretherketone (PEEK) for manufacturing custom-made split post and core for the restoration of grossly destroyed endodontically treated molars.Clinical considerationsA 40-year-old female patient presented with complaints of loss of tooth substance in the posterior mandibular tooth. This case involved the digital design and fabrication of PEEK split post and core to restore multirooted molar with insufficient dental tissue remnants. The restorations were evaluated over a 3-year follow-up using the World Federation criteria (FDI). The restoration was clinically evaluated through intraoral examination, radiographic assessment, and subjective patient satisfaction, and was deemed clinically good according to FDI criteria.ConclusionThe outstanding mechanical properties of PEEK, coupled with the structure of the split post, provide an effective treatment option for weakened multirooted teeth. Simultaneously, the restoration configuration effectively addressed the challenge of varying postinsertion directions, and the interlocking mechanism between the primary and auxiliary posts enhanced the stability of the post and core.

Identification of a Novel SCN5A gene variant in a young female with atrioventricular canal defect in the absence of classical Brugada syndrome phenotype.

Brugada syndrome is generally considered a cardiac channelopathy disorder characterized by syncope or sudden cardiac death. The sodium voltage-gated channel alpha subunit 5 (SCN5A) gene is the most commonly mutated gene associated with Brugada syndrome. Recent discoveries of new variants of this gene, along with current guidance of family screening, have identified several asymptomatic carriers with potentially causative mutations. We present the case of a 25-year-old female patient without any family history of Brugada syndrome nor related congenital cardiovascular disorders, with an extensive atrioventricular canal defect, who tested positive for a novel heterozygous variant NM_198056.3: c.3169G>C (p. Asp1057 His) in the SCN5A gene. She had no history of syncope or aborted sudden cardiac death except for recurrent chest infections since her early childhood. Intriguingly, she did not show a type I Brugada electrocardiogram pattern. This report provides a novel heterozygous variant NM_198056.3: c.3169G>C (p. Asp1057 His) in the SCN5A gene, which may have a potential detrimental effect.

Femoral head decentration on hip MRI: comparison between imaging planes, methods of contrast administration, and hip deformities

ObjectivesTo compare the prevalence of femoral head decentration (FHD) on different MR imaging planes in patients undergoing direct/indirect hip MR arthrography (MRA) with asymptomatic controls and to evaluate its association with osseous deformities.MethodsIRB-approved retrospective single-center study of symptomatic hips undergoing direct or indirect hip MRA at 3 T. Asymptomatic participants underwent non-contrast hip MRI at 3 T. FHD was defined as a continuous fluid layer between the acetabulum and femoral head and assessed on axial, sagittal and radial images. The association of intra-articular/intra-venous contrast agents and the prevalence of FHD was evaluated. The association of FHD with osseous deformities and joint damage was assessed using multiple logistic regression analysis.ResultsThree-hundred ninety-four patients (447 hips, mean age 31 ± 9 years, 247 females) were included and compared to 43 asymptomatic controls (43 hips, mean age 31 ± 6 years, 26 females). FHD was most prevalent on radial images and more frequent in symptomatic hips (30% versus 2%, p < 0.001). FHD prevalence was not associated with the presence/absence of intra-articular contrast agents (30% versus 22%, OR = 1.5 (95% CI 0.9–2.5), p = 0.125). FHD was associated with hip dysplasia (OR = 6.1 (3.3–11.1), p < 0.001), excessive femoral torsion (OR = 3.0 (1.3–6.8), p = 0.010), and severe cartilage damage (OR = 3.6 (2.0–6.7), p < 0.001).ConclusionWhile rare in asymptomatic patients, femoral head decentration in symptomatic patients is associated with osseous deformities predisposing to hip instability, as well as with extensive cartilage damage.Critical relevance statementDecentration of the femoral head on radial MRA may be interpreted as a sign of hip instability in symptomatic hips without extensive cartilage defects. Its presence could unmask hip instability and yield promise in surgical decision-making.Key PointsThe best method of identifying femoral head decentration is radial MRI.The presence/absence of intra-articular contrast is not associated with femoral head decentration.Femoral head decentration is associated with hip deformities predisposing to hip instability.Graphical

Vascularized Bone Graft in Mangled Hand Reconstruction

Extensive bone defects especially in conjunction with associated coverage involvement in mangled hands, pose significant challenges to hand and upper extremity surgeons. Vascularized bone grafts often play a vital role for effective treatment now-a-days. It not only bypasses the drawbacks of conventional grafts but also allows for simultaneous one stage reconstruction of its coverage as well as repairs other injured structures.Preoperative evaluation of mangled hand is crucial, the injury extent, including circulation, patient expectations and clinical reality should be all taken into consideration before finalizing the reconstruction plan. The fibula bone and other vascularized bone flaps such as iliac crest bone and medial femoral condyle and some others as well as corresponding spare part can provide effective solutions. Especially important considerations about surgeons’ experience and expertise , donor site morbidity , postoperative care and rehabilitation are essential for optimal outcomes. In this article , we would like to share our current practicing vascularized bone flaps in mangled hand reconstructions.

EFFECT OF STEM CELL THERAPY ON BONE REPAIR OF THE MAXILLA AND MANDIBLE

Maxillary and mandibular defects can result from a number of issues, such as periodontal disease, tumors, trauma and congenital anomalies, and can affect not only speech and mastication, but also aesthetics and self-esteem. In this sense, stem cell therapy is a promising, effective and safe option in the growing search for new forms of treatment for these dysfunctions. In this context, the aim of this study is to evaluate, through a literature review, the use of stem cells in bone regeneration of the maxillary and mandibular bones. The information was obtained through a bibliographic search carried out in February and March 2024 on the Scielo, Pubmed, Medline and Google Scholar platforms using the descriptors "Stem Cells", "Bone Repair", "Mandible", "Maxilla" and their Portuguese versions. Only papers published in English and Portuguese that dealt with the use of stem cells to regenerate defects in the mandible and maxilla were selected. During the search, x papers were initially selected, which 18 were included after consulting the abstracts and then reading them in full. Mesenchymal stem cells have been shown to improve and accelerate healing processes and increase bone density in the long term, thus promoting a faster and more complete recovery for patients, reducing the need for autologous grafts or synthetic materials. However, they have been shown to have a limited effect in cases of extensive bone defects. It can be concluded that stem cell therapy is an effective and safe alternative for promoting bone regeneration in cases of maxillary and mandibular defects, but further controlled studies are still needed to improve its performance by developing more efficient application strategies.

A single-center retrospective comparison of muscle versus cutaneous free flaps for posterior elbow defect reconstruction

IntroductionComparative data regarding free flap outcomes for elbow defect reconstruction is still lacking. This study aims to compare complication rates of free muscle (MFs) versus cutaneous flaps (CFs) for posterior elbow reconstruction. MethodsIn a single-center retrospective analysis, patients with free MFs and CFs for posterior elbow reconstruction from 2000 until 2021 were analyzed. Retrospective chart review included patient demographics, operative details, and postoperative complications. Compared outcomes of interest were microvascular complications, partial or total flap necroses, wound dehiscence, hematoma or flap infection, and donor-site complications. ResultsSixty-six free flaps (CFs: n=42; MFs: n=24) were included, with a trend over time towards using CFs (64%). MFs were used for larger defects (CF: 175 ± 82 vs MF: 212 ± 146 cm2; p=0.13). Outcome analysis revealed an equal distribution of microvascular complications (10% vs 13%; p=0.7), partial flap necrosis (7% vs 8%; p>0.9), wound dehiscence (7% vs 4%; p>0.9), evacuation of hematoma (10% vs 4%; p = 0.7), and infection (0% vs 4%; p = 0.4). Total flap necrosis requiring additional flap surgery was necessary in one CF (2%) and in no MF (0%) (p>0.9). ConclusionSurgical outcomes, flap necrosis rates, and microsurgical complications did not differ between CFs and MFs. Both flap types are safe and effective options. The free anterolateral thigh and latissimus dorsi flaps represent indispensable workhorses for the reconstruction of extensive elbow defects.

Surgical treatment of a teenager with an extensive wound defect of soft tissues against the background of severe combined injury

Extensive posttraumatic wounds, affecting functionally active areas and complicated by a purulent–necrotic process, are a serious problem in the acute period of injury due to a critical condition and in reconstructive surgical treatment. This study presents the case of a 16-year-old victim of a transport accident on a ferry who underwent a surgical treatment. Due to a truck collision, the girl was crushed against the metal structure of the ship and received a severe combined injury: closed craniocerebral injury, moderate brain contusion, linear fracture of the occipital bone on the right, closed chest injury, fracture of 9–11 ribs on the right, closed abdominal injury, rupture of the right kidney, damage to the bladder, retroperitoneal hematoma on the right, closed spinal injury, fracture of the spinous processes of the L4–L5 vertebrae, open fractures of the pelvic bones, and extensive posttraumatic wounds of the right half of the pelvic girdle and hip joints. During the initial hospitalization, the following were performed within 2 days: laparotomy, nephrectomy of a crushed kidney on the right, suturing of the bladder, primary surgical treatment of the wound in the sacrogluteofemoral region on the right and the wound of the left thigh with their primary suturing, and external osteosynthesis of the pelvic bones with a rod-based external fixation device. The early postoperative period was complicated by necrosis of injured soft tissues and a new surgical infection (polyantibiotic-resistant strains of microorganisms), which led to an increase in the size of the wound defect and loss of soft tissues due to their purulent melting. Complex surgical treatment aimed at eliminating surgical infection and transferring the wound process to the regeneration phase included repeated surgical treatments and the use of modern dressings and negative pressure therapy. An extensive wound defect of soft tissues caused by and injury or surgical treatment for purulent–necrotic complication was found in the functionally active zone of the hip joint and in the sacral region, which required the restoration of the skin of these areas. A strategy for surgical repair of a soft tissue wound defect is presented. Nonfree (rotated) blood-supply flaps were used: fasciocutaneous muscle flap based on the musculus tensor fascia lata from the right thigh and gluteal fasciocutaneous flap from the left gluteal region. After multistage surgical treatment, it was possible to replace an extensive wound defect of soft tissues and restore full skin in the hip joint and sacrogluteal region, which enabled avoiding trophic disorders and joint contractures and ensured a satisfactory cosmetic and functional result during 5-year followup.

A Systematic Review of Clinical Outcomes of Pedicled Flap Repairs of the Knee Extensor Mechanism.

Rupture of the extensor mechanism of the knee has severe functional morbidity, and repair can be complicated by infection, allograft degeneration, and recurrent rupture. Techniques of autologous tissue repair utilizing pedicled flaps such as the gastrocnemius offer vascularized methods of reconstruction, with potentially diminished complication rates. The goal of this study was to evaluate the functional outcomes and complications associated with pedicled flap repair of the knee extensor mechanism. A systematic review was conducted following the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Publications that focused on local myocutaneous flaps as a means for reconstruction were included. Causes for knee extensor mechanism deficit, flap characteristics, ambulation rate, changes in range of motion pre- and postoperation, and postoperative complications were analyzed. Technique reports including primary suture repairs, synthetic mesh, and allograft use were excluded. An initial 119 studies were identified, with final review of 22 observational studies encompassing 128 cases of pedicled flap reconstructions. The gastrocnemius (88.2%, n = 113), quadriceps (6.3%, n = 8), and a combination of the vastus and gastrocnemius flaps (5.5%, n = 7), were the most frequently utilized flaps. Functional outcomes were favorable with 87.2% of patients achieving ambulation without external support. Variability in range of motion outcomes across different flap may be secondary to the patient characteristics as well as extent of initial injury. Autologous pedicle flap reconstruction of the knee extensor mechanism emerges as a viable option for cases characterized by extensive defects and insufficient soft tissue coverage, which are not amenable to direct suture repairs or allografts. Postoperative assessments revealed that the majority of patients experienced improved ambulation status, with no instances of deterioration noted among the patients.

Primary Posterior Uterine Rupture in Labor: Case Report and Literature Review

Purpose: To report a rare case of primary posterior uterine rupture in a healthy term multigravida. Methods: Case report. Results: We present the case of an otherwise healthy 35-year-old gravida 4 para 3 with no reported medical or surgical history and three prior uncomplicated term vaginal deliveries who presented in labor at 39 weeks gestation. After four hours of oxytocin augmentation, the fetus was noted to have recurrent late decelerations and then became bradycardic with a baseline of 60 bpm. The patient’s cervix was found to be 7 cm dilated, 90% effaced, and -1 station. Standard resuscitative measures were undertaken at which point the patient’s cervix was rechecked and found to be 9 cm dilated, 90% effaced, and -1 station. Attempts at manually reducing the cervix while the patient pushed were unsuccessful. With the fetus still bradycardic with a baseline of 60 bpm, the patient was taken for an emergency Cesarean delivery. Within seven minutes of calling the emergency Cesarean delivery, surgery had started. However, there was difficulty with delivering the fetus, who had flipped to transverse back down. The fetus was rotated to breech before being delivered through a “T” incision made on the uterus to facilitate delivery of the head. Three tight nuchal cords were reduced at time of delivery. Examination of the uterus after delivery of the fetus revealed a full thickness, cruciate-shaped laceration in the posterior lower uterine segment extending ~9 cm in the vertical plane, involving the vagina, and ~5 cm in the transverse plane. The rupture was repaired, and the remainder of the surgery proceeded without further complication. Blood loss was estimated at 2500 mL, and she required transfusion of 4 units of packed red cells, 2 units cryoprecipitate, 1 unit fresh frozen plasma, and 1 unit of platelets. The infant was atonic upon delivery with a weight of 3785g and APGARs of 1/5/7. Umbilical artery blood gas analysis was normal with a pH of 7.19 and a base deficit of 7.9 mmol/L. The infant initially required intubation, but quickly improved and was extubated to room air at 1 hour of life. Imaging and neurological exams indicated possible moderate encephalopathy, and the infant underwent therapeutic hypothermia for four days at which point cooling was discontinued after improvement was noted. The remainder of his NICU stay was unremarkable and he was discharged on day nine of life. The mother required 2 additional units of packed red cells during the remainder of her postpartum course, but otherwise did well and she was discharged on post-op day five. Conclusion(s): Uterine rupture is the complete separation of all three layers of the uterus. It is a life-threatening event for both the fetus and the mother. Most uterine ruptures occur in a previously scarred uterus. Uterine rupture in a previously unscarred uterus (primary uterine rupture) is rare and estimated to occur in ~1:20,000 pregnancies. Over 90% of primary uterine ruptures occur in the anterior lower uterine segment. Although this patient did not have any reported medical or surgical history, her status as a multipara and being of advanced maternal age did pose a higher risk of primary rupture. This patient also underwent 3 ½ hours of oxytocin infusion at the time the Cesarean was called. Although she was not on oxytocin for long, its use is associated with primary uterine rupture more so than secondary rupture. Normal indicators of uterine rupture include non-reassuring fetal heart rate tracing, sudden unexplained abdominal pain, unexplained vaginal bleeding, and loss of fetal station. In this patient, fetal bradycardia was the only sign that her uterus was compromised. Although the uterine arteries were not involved in this patient’s rupture, blood loss was still profound due to the extensive uterine defect. This case highlights that, while rare, uterine rupture can occur in any patient, regardless of uterine surgical history and physicians must be prepared to intervene quickly.

Bilateral Superior Gluteal Artery Perforator (SGAP) Flap: Modified Concept in Perineal Reconstruction.

Background/Objectives: Perineal reconstruction after abdominoperineal excision often requires complex closures and is fraught with wound healing complications. Flap-based approaches introduce non-irradiated vascularized tissue to the area of resection to fill a large soft-tissue defect and dead space, reduce the risk of infection, and facilitate wound healing. Employing perforator flaps with their beneficial donor site properties, the authors have developed a concept of bilateral superior gluteal artery perforator (SGAP) flaps to restore extensive perineal defects. Methods: This retrospective case series was conducted between September 2015 and December 2019. We included three patients who received bilateral SGAP flap reconstruction after oncological resection. One deepithelialized SGAP flap was used for obliteration of dead space, combined with the contralateral SGAP flap for superficial defect reconstruction and wound closure. Results: Within this patient population, two male and one female patient, with a median age of 62 years (range, 52-76 years), were included. Six pedicled SGAP flaps were performed with average flap dimensions of 9 × 20 cm (range 7-9 × 19 × 21). No flap loss or no local recurrence were documented. In one case, partial tip necrosis with prolonged serous drainage was observed, which was managed by surgical debridement. No further complications were detected. Conclusions: The combination of two SGAP flaps provides maximal soft tissue for defect reconstruction and obliteration of dead space, while maintaining a very inconspicuous donor site, even with bilateral harvesting. Given these advantages, the authors recommend this promising approach for successful reconstruction of perineal defects.

Features of the neutrophil granulocyte system in patients with common scalp defects

Objective. To identify the dynamics of changes in the structure of the neutrophil granulocyte system in patients with extensive scalp defects before and after their surgical closure. Materials and methods. A computer morphometric analysis of the quantitative and qualitative characteristics of neutrophilic granulocytes of patients with common scalp defects who were treated at the Department of Microvascular Plastic and Reconstructive Surgery of the Shalimov National Scientific Centre of Surgery and Transplantation from 2017 to 2023. The main group included 15 patients with widespread defects of the soft tissues of the scalp in the I – II stage of the wound process (10) and arteriovenous angiodysplasias in the III stage according to Schobinger (5). The control group consisted of 15 volunteers without pathology. The structure features (optical cytoplasmic density in units, which indicates the presence of bactericidal potential, and cell area in μm², which indicates the level of activation) of peripheral blood neutrophil granulocytes before and after surgical closure of the defect were studied. Results. Before the surgical intervention, a pronounced polymorphism was detected, which meant a functional failure of the neutrophil granulocyte system. After surgery and healing of the defect, excessive polymorphism of the neutrophil granulocyte system was not detected in patients. Conclusions. The assessment of the degree of cellular polymorphism of neutrophil granulocytes determines the diagnostic efficiency of the study and makes it possible to identify and predict the development of local inflammation and infectious complications in patients with scalp defects.