Limb Defects Research Articles

Oromandibular Limb Hypogenesis Syndrome: Overlap of Moebius and Ankyloglossia Superior With Severe Limb Defects.

The oromandibular limb hypogenesis syndromes (OLHS) represent a group of rare conditions characterized by congenital malformations involving the tongue, mandible, and limbs. In this report, we describe a newborn girl with paralysis of abducens and facial nerves, transverse agenesis of the distal segments of the limbs, micrognathia, cleft lip and palate, and ankyloglossia superior. This observation confirms an overlap between Moebius syndrome and ankyloglossia superior syndrome with severe limb defects. The etiology of the OLHS is not clearly understood. The intriguing link between facial and limb anomalies can result from their simultaneous development from the fourth to eighth week of gestation, making both areas susceptible to the same teratogenic stimuli. There is an overlap between OLHS conditions, supporting a clustering, rather than a divided nosology and requiring an appropriate classification of these conditions. Patients with OLHS can be successfully managed using a multidisciplinary approach.

Splinting Technique for Venous Anastomosis in Lower Limb Free Flap Reconstruction.

Summary:Lower limb reconstruction of the distal third following tumor extirpation or trauma is a complex procedure. The use of free flaps to cover lower limb defects is a common practice in our department. Vascular kinking or compression resulting in thrombosis is the leading cause of venous congestion and free flap failure in lower limb reconstruction. We describe a simple and inexpensive technique to avoid venous kinking during microvascular anastomosis in free flap reconstructions in the lower leg, which has proved safe in a cohort of patients.

In ovo hyperglycemia causes congenital limb defects in chicken embryos via disruption of cell proliferation and apoptosis

While the correlation between diabetes during pregnancy and birth defects is well-established, how hyperglycemia causes developmental abnormalities remains unclear. In this study, we developed a novel “hyperglycemic” chicken embryonic model by administrating various doses of glucose to fertilized eggs at embryonic stages HH16 or HH24. When the embryos were collected at HH35, the LD50 was 1.57 g/Kg under HH16 treatment and 0.93 g/Kg under HH24 treatment, indicating that “hyperglycemic” environments can be lethal for the embryos. When exposed to a dose equal to or higher than 1 g/Kg glucose at HH16 or HH24, more than 40% of the surviving chicken embryos displayed heart defects and/or limb defects. The limb defects were associated with proliferation defects of both the wing and leg buds indicated by reduced numbers of p-H3S10 labeled cells. These limb defects were also associated with ectopic apoptosis in the leg bud and expression changes of key apoptotic genes. Furthermore, glucose treatment induced decreased expression of genes involved in Shh-signaling, chondrogenesis, and digit patterning in the limb bud. In summary, our data demonstrated that a high-glucose environment induces congenital heart and limb defects associated with disrupted cell proliferation and apoptosis, possibly through depressed Shh-signaling.

The Efficacy of a Protocol of Iliac Artery and Limb Treatment During EVAR in Minimising Early and Late Iliac Occlusion

Iliac limb occlusion (ILO) is a complication of endovascular aortic repair (EVAR) and requires re-intervention in most cases. Attention to any intra-operative defect of iliac limbs and arteries may prevent ILO. The study aimed to analyse the long term effect of an intra-operative protocol of iliac limb treatment during EVAR on ILO. Patients treated from 2012 to 2017 for abdominal aortic aneurysm (AAA) with standard EVAR were collected prospectively. Pre-operative computed tomography angiography anatomical characteristics were evaluated. The protocol for intra-operative iliac limb management was: a. pre-EVAR angioplasty of common/external iliac artery stenosis; b. precise contralateral iliac limb deployment at the same level of the flow divider; c. iliac limb kissing ballooning with high pressure non-compliant balloons; d. iliac limb stenting for residual tortuosity/kink and adjunctive external iliac stenting for residual stenosis/dissection after EVAR. ILO was evaluated at 30 days and at follow up, which was performed by duplex ultrasonography before discharge, at three, six, and 12 months and yearly thereafter. Kaplan-Meier and Cox linear regression were used. Four hundred and forty-two patients and 884 iliac limbs were included in the study. Severe iliac tortuosity and calcification were present in 15% (132/884) and 8% (70/884), respectively. External iliac angioplasty and stenting of iliac limb were performed in 2% (18/884) and 9.5% (84/884) of limbs. The thirty day mortality was 1.6%, with no ILO. At a mean follow up of 33±12 months, ILO occurred in 7/884 (0.8%) limbs of six patients. Five ILO were treated by endovascular relining, two surgically: one by femorofemoral bypass and one by surgical explant. On univariable analysis, sac shrinkage was significantly associated with ILO (HR 1, 95% CI 0.8-2.5, p=.043). A protocol of aggressive iliac limb treatment in EVAR leads to a very low rate of late ILO. The role of sac shrinkage in ILO should be investigated further.

Novel variant in NSDHL gene associated with CHILD syndrome and syndactyly- a case report

BackgroundCongenital hemidysplasia with ichthyosiform erythroderma and limb defects also known as CHILD syndrome is an X-linked dominant, male lethal genodermatosis with a prevalence of 1 in 100,000 live births. Mutations in NSDHL gene located at Xq28 potentially impair the function of NAD(P) H steroid dehydrogenase-like protein and is responsible for its pathogenesis.Case presentationThe proband was a 9-month-old twin (T2) girl with a healthy twin sister (T1) of Sri Lankan origin born to non-consanguineous parents. She presented with right sided continuous icthyosiform erythroderma and ipsilateral limb defects and congenital hemidysplasia since birth. Notably the child had ipsilateral hand hypoplasia and syndactyly. There were other visceral abnormalities. We performed whole exome sequencing and found a novel heterozygous variant (NSDHL, c.713C > A, p.Thr238Asn).ConclusionWe report a novel missense variant in the NSDHL gene that resides in a highly-conserved region. This variant affects the NAD(P) H steroid dehydrogenase-like protein function via reduction in the number of active sites resulting in the CHILD syndrome phenotype and syndactyly.

Prevalence of congenital limb defects in Uttarakhand state in India – A hospital-based retrospective cross-sectional study

BackgroundCongenital limb defects (CLD) occur when normal development of limbs is hampered during the intrauterine period. There is a paucity of literature regarding the prevalence and pattern of various congenital limb defects in India. The aim of this study is to assess the prevalence and pattern of various CLD using Swanson classification in the state of Uttarakhand, India. MethodsRetrospective study over a 6-year period was done. The prevalence of CLD was calculated by determining the live births from birth rate and total population from the 2011 census of the Government of India. ResultsA total of 316 cases with a mean age of 3.2 ± 2.3 years (1 day–12 years) were included. Radial clubhand (n = 9, prevalence = 0.4 per 10,000 live births) was the most common CLD in upper limb. Idiopathic clubfoot (CTEV) (n = 158, prevalence = 7 per 10,000 live births) was the most common CLD in lower limb. Failure of formation (n = 12) was the most common defect in the lower limb whereas failure of differentiation (n = 16) was common in the upper limb. DiscussionThis is the first study from any part of India depicting the prevalence of CLD, which can be used to formulate public health policies for early diagnosis and management of the same. ConclusionThe prevalence of CLD is 14 per 10,000 live births in Uttarakhand, India, which are comparable to various studies published from different parts of the world. Males are commonly involved with radial clubhand being common in the upper limb and CTEV being common in the lower limb.

Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction.

Reconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

Use of Free Anterolateral Thigh Flap in Reconstruction of Soft Tissue Defects in Orthopedic Oncology: What are the Outcomes?

Soft tissue defects due to trauma with crush injuries and post-tumor excision are large in size. Free anterolateral flap provides a stable and durable coverage of soft tissue defects and leads to good functional outcomes. Between January 2017 and January 2019, eight males and six female patients with soft tissue defects were operated upon using a free anterolateral thigh flaps. The defects in ten patients were due to post-tumor extirpation and in four patients due to wound breakdown following post-tumor extirpation. The average flap dimension was 14cm × 12cm. The mean follow-up was 11months (4-28months). All the flaps survived well except in one patient who with an upper limb defect, had flap necrosis owing to which patient needed to undergo abdominal flap coverage. Two patients with sarcoma developed local recurrence and had to undergo above‑knee amputation. The method of reconstruction depends on the size of defect and area to be covered and need of post-surgery mobilization and need for radiotherapy. The free anterolateral thigh flap has varied uses in orthopedics with very good extent of coverage and provides very potent coverage of neurovascular structures, bones, tendons, and implants.

Association of Radial Longitudinal Deficiency and Thumb Hypoplasia: An Update Using the CoULD Registry.

Deficiency of the radial aspect of the forearm and hand is the most common congenital longitudinal deficiency of the upper limb. Radial longitudinal deficiency is associated with several named syndromes. The purpose of the present study was to explore patterns of radial longitudinal deficiency and thumb hypoplasia in syndromes and to examine the severity of these differences across various syndromes. Data were collected from the Congenital Upper Limb Differences (CoULD) registry. Congenital differences are classified in the registry with use of the Oberg-Manske-Tonkin (OMT) classification system. Diagnosis of a syndrome by a physician as noted in the CoULD registry was recorded. Thumb deficiency and radial deficiency were classified according to the modified versions of the Blauth criteria and the Bayne and Klug criteria, respectively. We identified 259 patients with 383 affected limbs with radial deficiency. Eighty-three of these patients had a diagnosed syndrome. The severity of radial deficiency was correlated with the severity of thumb deficiency. The Kendall tau coefficient indicated significant correlation between radial severity and thumb severity (tau = 0.49 [95% confidence interval = 0.40 to 0.57]; p < 0.05). Subjects with a syndrome were twice as likely to have bilateral deficiency and 2.5 times more likely to have both radial and thumb deficiency compared with subjects without a syndrome. Subjects with VACTERL syndrome (vertebral defects, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal anomalies, and limb defects) had patterns of thumb and radial deficiency similar to the general cohort, whereas subjects with Holt-Oram syndrome, TAR (thrombocytopenia absent radius) syndrome, and Fanconi anemia demonstrated varied presentations of thumb and radial deficiency. The present study investigated the characteristics of patients with radial longitudinal deficiency and thumb hypoplasia. Our results support the findings of previous research correlating the severity of radial deficiency with the severity of thumb deficiency. Furthermore, we identified characteristic features of patients with radial longitudinal deficiency and associated syndromes.

Seed skin grafts for reconstruction ofdistal limb defects in 15 dogs.

To report the surgical technique of seed skin grafting and clinical application for reconstruction of wounds on the distal limb of client-owned dogs. Medical records from The Animal Hospital at Murdoch University were retrospectively reviewed for dogs requiring reconstruction using seed grafting for distal limb skin defects between January 2009 and May 2020. Fifteen dogs were included. Grafting was performed on distal limb wounds at or below the carpus or tarsus, following trauma (n=12) or neoplasia excision (n=3). Complete epithelialisation with minimal contracture was recorded at a median of 4 weeks (range 3 to 8 weeks) after implantation. Median follow-up was 37 months (range 3 to 55 months) after grafting. Postoperative complications included epidermal inclusion cyst in two dogs. Good functional outcome with acceptable cosmesis despite sparse hair growth was achieved in all cases. Seed grafting is a simple technique that can be used reliably to reconstruct wounds on the distal limb in dogs where other reconstructive techniques are not suitable. Complete epithelialisation with sparse hair growth, good long-term functional outcome and minimal complications can be expected.

Sirenomelia with vertebral, anal, cardiac defect, tracheo-esophageal fistula, renal anomalies, limb abnormalities association: a case report

Sirenomelia is a rare congenital malformation, characterised by abnormal development of caudal part of body with variable degree of fusion of lower limbs. VACTERL is an acronym used for a group of sporadic non-random birth defects involving multiple organ systems, namely vertebral (V), anal (A), cardiac (C), tracheoesophageal (TE), renal (R) and limb (L) defects. Combination of both the anomalies is very rarely reported in literature. Survival is extremely rare and early prenatal diagnosis may allow for termination of pregnancy. Here we present a case of sirenomelia phenotype, with a complete spectrum of autopsy findings, suggestive of VACTERL association.

User-relevant factors determining prosthesis choice in persons with major unilateral upper limb defects: A meta-synthesis of qualitative literature and focus group results.

ObjectiveConsidering the high rejection rates of upper limb prostheses, it is important to determine which prosthesis fits best the needs of each user. The introduction of the multi-grip prostheses hands (MHP), which have functional advantages but are also more expensive, has made prosthesis selection even harder. Therefore, we aimed to identify user opinions on factors determining prosthesis choice of persons with major unilateral upper limb defects in order to facilitate a more optimal fit between user and prosthesis.MethodsA qualitative meta-synthesis using a ‘best-fit framework’ approach was performed by searching five databases (PROSPERO registration number: CRD42019126973). Studies were considered eligible if they contained qualitative content about adults with major unilateral upper limb defects experienced in using commercially available upper limb prostheses and focused on upper limb prosthesis users’ opinions. Results of the meta-synthesis were validated with end-users (n = 11) in a focus group.ResultsOut of 6247 articles, 19 studies were included. An overview of six main themes (‘physical’, ‘activities and participation’, ‘mental’, ‘social’, ‘rehabilitation, cost and prosthetist services’ and ‘prosthesis related factors’) containing 86 subthemes that could affect prosthesis choice was created. Of these subthemes, 19 were added by the focus group. Important subthemes were ‘work/school’, ‘functionality’ and ‘reactions from public’. Opinions of MHP-users were scarce. MHPs were experienced as more dexterous and life-like but also as less robust and difficult to control.ConclusionThe huge number of factors that could determine upper limb prosthesis choice explains that preferences vary greatly. The created overview can be of great value to identify preferences and facilitate user-involvement in the selection process. Ultimately, this may contribute to a more successful match between user and prosthesis, resulting in a decrease of abandonment and increase of cost-effectiveness.

Sensory interventions on motor function, activities of daily living, and spasticity of the upper limb in people with stroke: A randomized clinical trial

Study DesignThis is a single-blinded clinical trial study. Clinical Trial Number registry: IRCT201610223551N4. IntroductionStroke is the second cause of death around the world. Motor and sensory problems are common complications of the stroke. These defects in the upper limb cause reduced use of the affected limb and consequently a decrease in the quality of life. Purpose of the StudyThe purpose of this study was to examine the effect of exteroceptive and proprioceptive stimulations on motor function, spasticity of the upper limb, and activities of daily living in people who have had stroke. MethodsSixty people with chronic stroke selected by convenience sampling. Before the intervention, Modified Ashworth Scale, Fugl-Meyer assessment of Motor Recovery after Stroke, and Barthel Index were measured and then the intervention phase was started. Exteroceptive and proprioceptive sensory stimulations were performed for 6 weeks. Independent t-test was used to compare groups. ResultsThe intervention group made improvement in motor function (P = .0001, Cohen's d = 2.14), activities of daily living of upper limb (P = .0001, Cohen's d = 1.32), and spasticity (P = .002, Cohen's d = −0.94). DiscussionMotor function and activities of daily living and spasticity of the upper limb can be improved through exteroceptive and proprioceptive stimulations. In this study, this type of intervention had the most impact on motor function compared with the rest. ConclusionExteroceptive and proprioceptive stimulations in upper limb can be used in chronic phase of stroke. Improvement in motor function and activities of daily living and reducing spasticity are the results of these stimulations.

Keystone Flap as a Reconstructive Option for selected areas; A Prospective Study

ObjectiveA very few flaps would be described as versatile as the Keystone Flap. There is an increasing demand for coverage of defects in lower limb due to traumatic defects as well as other parts of the body. Keystone flap is one of its kind, which is simple and easy to perform. It is a safe option for conditions where microsurgery may not be a viable option. The relative simplicity of this flap makes it a to go option at many places. MethodsA prospective study was developed from October 2017 to December 2019 at SMS Hospital, Jaipur. We assessed the size of the flap, operation time, average hospital stay and the complications. Perforators over the leg were Doppler marked preoperatively over which the flap was raised. Results50 patients were taken into the study. 30 key stone flaps were done to cover lower limb defects, 10 flaps were done for upper limb defects and the remaining 10 were for trunk defects. The average intraoperative time from skin incision to final suture was 50 min (range 20–90 min). The largest defect covered by keystone flap in our series measured 50 × 20 cm and the smallest defect covered was 8 × 4 cm. The average hospital stay was 3 days. We observed partial flap necrosis in 2 cases which required skin grafting. 3 other cases had wound infection leading to wound dehiscence, which required secondary suturing. The overall success rate was 95%. ConclusionThe Keystone flap being a versatile flap with its qualities of replacing “like with like”, easy to perform, use of local tissue, good vascularity and a low complication rate makes it an excellent flap for a variety of defects. The KeyStone flap allows reconstruction in a single stage and is a relatively easy and fast technique for the beginner as well as the experienced surgeon. We believe it should be incorporated more into a surgeons practice.

Complications of bone transport technique using the Ilizarov method in the lower extremity: a retrospective analysis of 282 consecutive cases over 10\u2009years

BackgroundThe treatment of large bone defects in lower limbs is a serious challenge for orthopedic surgeons and patients. The bone transport technique using the Ilizarov method has become the main treatment option for the reconstruction of bone defect. However, inevitable difficulties and complications related to bone transport technique have been reported by many studies. The purpose of this study was to evaluate the effectiveness and complications of bone transport technique using Ilizarov method in the treatment of bone defect of lower extremity.MethodsThe study was conducted on 282 patients who underwent bone transport procedures using Ilizarov method at our institution from January 2007 to June 2017. Patient’s demographic data, complications and clinical outcomes at minimum of 2 years follow-up were collected and retrospectively analyzed. All difficulties that related to bone transport were documented according to Paley’s classification. The clinical outcomes were evaluated using Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) at last clinical visit.ResultsThere were 243 male and 39 females with a mean age of 40 years (range 18–65 years). The mean defect was 6.56 ± 2.15 cm, whereas single level transport in 221 cases and double level transport in 61 cases. There were 189 problems, 166 obstacles and 406 complications (257 minor and 149 major complications), and the average complication rate per patients consists of 0.91 minor and 0.53 major complications. The top five complications were pin-site infection (65.96%), axial deviation (40.78%), joint stiffness (23.76%), soft tissue incarceration (22.34%) and delayed union of the docking site (13.48%).The ASAMI bony result was excellent in 233 patients, good in 32, fair in 5 and poor in 12. The ASAMI functional result was excellent in 136 patients, good in 88, fair in 47, poor in 11.ConclusionBone transport is a reliable method for reconstruction of bone defects in the femur and tibia. Awareness of predictable complications is beneficial to prevent or early detection of the expected complication which can improve the risk-benefit balance.

Ранняя протезно-ортопедическая помощь как основа медицинской реабилитации детей с врождёнными и ампутационными дефектами нижних конечностей

Introduction The quality of medical rehabilitation and habilitation of children with lower limb defects depends on early prosthetic and orthopedic care. Purpose Analysis of the provision of prosthetic and orthopedic care for children with orthopedic pathology of the lower extremities at the Federal Scientific Center of Rehabilitation of the Disabled named after G.A. Albrecht. Methods The results of rehabilitation and habilitation of 261 children with orthopedic pathology of the lower extremities were studied. Methods of clinical examination, radiography, physiological and biomechanical study were applied. Statistical analysis was carried out. Results In 261 cases studied, the causes of defects were congenital anomalies (82 %) and amputation defects (18 %). Surgical preparation for prosthesis application was performed in 85 cases (33 %). More than half of the patients who sustained interventions had a defect at the hip level. The anatomical and functional features of stumps in children with abnormal development of the lower extremities were studied and the principles of prosthesis and orthosis application were developed. Discussion Delay in prosthesis application leads to negative effects on the child's body. The supply of children with technical means of rehabilitation is not regulated in due manner by the current legislation, which leads to the complexity of the purpose of the product and the delay in the timing of prosthesis and orthosis fitting. Early prosthetic and orthopedic care for children with orthopedic pathology of the lower limb is a prerequisite for normal development of their growing body. Due to subjectivity of child's assessment of the results of prosthetic fitting, there is high risk of secondary deformities of the child's musculoskeletal system; for children using limb prostheses and orthoses, it is necessary to use an objective instrumental assessment of the results of prosthesis application; dispensary observation; monitoring of motor loads and the technical condition of the prosthesis. Early prosthetic and orthopaedic assistance to children should be conducted not only according to the rules of registration of the individual program for rehabilitation and habilitation (IPRH), but also followed to disability with the aim of preventing the development of complications, injuries, diseases of the musculoskeletal system, and impairment of functional disorders.

Spliceosomopathies and neurocristopathies: Two sides of the same coin?

Mutations in core components of the spliceosome are responsible for a group of syndromes collectively known as spliceosomopathies. Patients exhibit microcephaly, micrognathia, malar hypoplasia, external ear anomalies, eye anomalies, psychomotor delay, intellectual disability, limb, and heart defects. Craniofacial malformations in these patients are predominantly found in neural crest cells-derived structures of the face and head. Mutations in eight genes SNRPB, RNU4ATAC, SF3B4, PUF60, EFTUD2, TXNL4, EIF4A3, and CWC27 are associated with craniofacial spliceosomopathies. In this review, we provide a brief description of the normal development of the head and the face and an overview of mutations identified in genes associated with craniofacial spliceosomopathies. We also describe a model to explain how and when these mutations are most likely to impact neural crest cells. We speculate that mutations in a subset of core splicing factors lead to disrupted splicing in neural crest cells because these cells have increased sensitivity to inefficient splicing. Hence, disruption in splicing likely activates a cellular stress response that includes increased skipping of regulatory exons in genes such as MDM2 and MDM4, key regulators of P53. This would result in P53-associated death of neural crest cells and consequently craniofacial malformations associated with spliceosomopathies.

TAp63γ influences mouse cartilage development.

Depletion of tumor protein p63 results in severe epithelial as well as limb defects in mice, suggesting that p63 is also required for endochondral ossification during long bone development. A key stage in endochondral ossification is chondrocyte hypertrophy, which has been associated with elevated levels of the p63 variant TAp63γ. To investigate the role of TAp63γ in chondrocyte differentiation and maturation, we developed stable TAp63γ expressing ATDC5 cells. Compared to control cells, TAp63γ cells showed significant upregulation of Col10a1 after 4 and 7 days in culture. Moreover, alkaline phosphatase, Alizarin red, and Alcian blue staining were stronger in TAp63γ cells, suggesting that TAp63γ promotes chondrocyte proliferation, hypertrophic differentiation, and possibly matrix mineralization. To investigate the in vivo function of TAp63γ during endochondral bone formation, we established transgenic mice that express flag-tagged TAp63γ driven by Col10a1 regulatory elements. Skeletal staining of transgenic mice at postnatal day 1 showed accelerated ossification in long bone, tail, and digit bones compared to wild-type littermates. Furthermore, Sox9 expression was reduced and Runx2 expression was increased in the proliferative and/or hypertrophic zones of these mice. Altogether, these results suggest that TAp63γ promotes endochondral ossification and skeletal development, at least partially via controlling chondrocyte differentiation and maturation.

Human cadaveric Study of Soleus Muscle arterial blood supply and its Application in peri-ankle Reconstruction

Introduction: Soft tissue defects of the lower limb are a formidable challenge to the plastic surgeon but a soleus muscle flap often provides the solution. Aim of the work: study the anatomy of the various patterns of arterial supply to soleus muscle based on cadaveric dissection for its application as a pedicle flap for lower leg and peri-ankle reconstruction. Methodology: The study included 8 adult lower limbs from the Department of Anatomy at Faculty of medicine Al-Azhar University. The study duration was from May 2018 to May 2019. The branches of popliteal, posterior tibial and peroneal arteries were traced till their point of entry into the soleus muscle.These were considered as extra muscular branches(EMB) to the soleus. Results: Popliteal artery supplies the muscle by 1 perforator at 2 samples , 2 perforator branches at 3 samples and absent at 3 samples .Posterior tibial artery: supplies the muscle by not less than 4 perforators at 8 samples. Peroneal artery: supplies the Soleus muscle by 2 to 4 perforators according to our study 2 samples were supplied by 2 perforators , 4 samples were supplied by 3 perforators and 2 samples were supplied by 4 perforators Conclusion: The proximal 25 % of length of soleus received EMB from all the three arteries and hence a proximally based soleus muscle flap is better than distally based muscle flap. Recommendations: Doppler ultrasonography and angiography are useful for detection the actual location and size of soleus perforators.

Versatility of Pedicled Perforator-Based V-Y Advancement Flaps for Reconstruction of the Upper Limb: A Case Series and Review of the Literature.

The aim of any reconstruction is to provide a robust and cosmetically pleasing result that does not significantly alter function. We describe our experience of using the V-Y principle in advancement flaps designed around a distinct perforator to reconstruct soft tissue defects of the upper limb. The shortcomings of fasciocutaneous and fascial flaps requiring skin grafting can be eliminated. This was a 10-year retrospective review of patients who had V-Y flaps based on a distinct perforator for defects of the shoulder, axilla, arm, elbow, forearm, wrist, and hand. Defects of the digits and thumb were excluded. There were 59 flaps in 52 patients with an average age of 44 years (18-72 years). Skin malignancy was the most common primary etiology. The average defect size was 35 cm (9-80 cm). There were no total flap failures; however, there were 4 partial losses, which healed by secondary intention. Seven flaps had to be explored for the hematoma evacuation. The use of V-Y flaps based on distinct perforators in the upper limb retains limb aesthetics, allows early mobility and is a safe and reliable technique.