Management of child abuse with flexor tendons, neurovascular injuries, and life-threatening condi... more Management of child abuse with flexor tendons, neurovascular injuries, and life-threatening conditions is challenging. It needs a multisectoral coordinated and synchronized team effort for successful outcomes. We present a case series of children abused by a parent with a sharp object. The children sustained multiple flexor tendon injuries, neurovascular injuries in upper limbs, and tracheal injury compromising respiration. We performed a tracheostomy to save a child and subsequently repaired numerous flexor tendons, nerves, and arteries. During follow-up, these children required secondary reconstruction (tenolysis, tendon lengthening, nerve reconstruction) for flexor contractures, stiffness, and sensory loss in distal forearms. We measured the range of movements and assessed the children's functional outcome using the Strickland score at 3-year follow-up. The range of movement and functional outcome was excellent in both children in our series. A timely performance of surgery, aided with efficient intensive care, therapy, and consistent posttraumatic psychosocial rehabilitation, produced excellent results in our series.
Eight cases, in which a new single-pedicled venous flap, based on the long saphenous vein, was us... more Eight cases, in which a new single-pedicled venous flap, based on the long saphenous vein, was used to close defects around the knee, are presented with the details of indications, size and survival. Of the eight cases, seven achieved their aim; five flaps survived completely, two had partial distal loss and one died completely. This clinical work is further confirmation that fasciocutaneous island flaps of fairly large dimensions, with a single cephalad vein, survive and can be used to cover defects in their adjacent areas.
A case is reported in which an island fasciocutaneous flap from the radial side of the forearm, w... more A case is reported in which an island fasciocutaneous flap from the radial side of the forearm, with only the cephalic vein connecting it to the rest of the body (Fig. 1) was successfully transposed to cover part of a defect on the ulnar side of the elbow. An earlier case in which such a venous flap was raised but not used for cover is also detailed. A brief discussion speculating on the way this flap survived without any arterial inflow and only proximal venous drainage is included. Case reports Case 1
Birth brachial plexus palsy (BBPP) is an unfortunate outcome of a difficult labor, which can ofte... more Birth brachial plexus palsy (BBPP) is an unfortunate outcome of a difficult labor, which can often lead to long-lasting upper limb impairments. Spontaneous recovery may or may not occur. Timely diagnosis of the condition and initiation of the appropriate treatment can be instrumental in decreasing the functional impact. The management begins right from the day the child presents first and ranges from physiotherapy to surgical intervention such as nerve repair/transfer or grafts. The sequelae of the condition are also quite common and need to be detected preemptively with initiation of appropriate treatment. However, prevention is the key to reducing the incidence of secondary deformities. In this study, the team of authors, based on their considerable experience, discuss their approach to the management of BBPP. This is done in the background of Indian cultural practices and social constraints. A detailed discussion has been done on importance of preoperative passive joint mobilization regime and role of botulinum toxin in the authors' preferred ways of surgical correction of primary as well as secondary deformities. An extensive review of peer-reviewed publications has been done in this study, including clinical papers, review articles, and systematic review of the subject. Good results are possible with early and appropriate intervention even in severe cases.
Experiments were performed to ascertain the perfusion and drainage of single cephalad channel sap... more Experiments were performed to ascertain the perfusion and drainage of single cephalad channel saphenous venous flaps in dogs. In the first experiment a standard saphenous flap and a single cephalad channel saphenous venous island flap were dissected on contralateral thighs of dogs. A radioactive tracer, ggmT~, was injected into a foreleg vein and its appearance in both flaps was monitored with the use of a static and dynamic scanner. After this experiment, Evans blue, a vital dye, was injected into the foreleg vein of the dog. Five minutes later both flaps were excised and the dye in the flaps was assayed quantitatively. In the third experiment radioactive tracer was injected into the single cephalad channel venous flap subcutaneously and its decay in the flap as well as its uptake in the rest of the body were measured dynamically. The experiments show that the single cephalad channel venous island flap is perfused by and drains through its single cephalad vein. A mathematical model to justify the above conclusion was worked out independently, based on standard values involved in mammalian circulatory mechanisms as in dog and man.
One of the earliest postulates concerning the physiological basis of flap survival is attributed ... more One of the earliest postulates concerning the physiological basis of flap survival is attributed to Sushruta, who, in his inimitable style, very succinctly noted in Sanskrit verse the following words: "through continuity survives." Sanskrit being a very telegraphic language, what derives from these words is as follows: Through (the flap's) continuity (with its original location) (it) survives. The principle of continuity has survived through the ages, though continuity has come to imply vascular continuity based on the Harvesian model of circulation. No matter how we classify flaps, i.e., random or axial, the Harvesian model of circulation is the key to the mechanism of survival. Lately, however, a new category of flaps, that is, "venous flaps," have been reported by a number of investigators where the classical Harvesian model is not in evidence, at least apparently. The following effort is directed toward presenting the existing data on this subject for future guidance in research and clinical applications.
Variations are inherent feature of the intricate brachial plexus. They can be at the level of ori... more Variations are inherent feature of the intricate brachial plexus. They can be at the level of origin, the course, or the innervation pattern of each peripheral nerve. Knowledge of the various described variations can be worthwhile during the routine hand surgery procedures. We present a case of an elderly patient with anomalous intramuscular course of the ulnar nerve presenting with ulnar neuropathy at the elbow. Level of Evidence: IV.
A typical muscle variation of latissimus dorsi-the axillary arch is represented by the muscular o... more A typical muscle variation of latissimus dorsi-the axillary arch is represented by the muscular or fibromuscular slip detached from the anteroinferior border of the musculus latissimus dorsi passing over the axilla under the axillary fascia crossing the medial side of the brachial plexus to continue as a septum intermusculare mediale brachii distally to the medial epicondyle of humerus. The full extent of the muscle is rarely present. Slips of muscle extend from the latissimus dorsi at the inferior angle of scapula to insert into pectoralis major (Langer), coracobrachilis, biceps or coracoid process forming what is described as a common variant-the muscular axillary arch. We report three cases of variants of latissimus dorsi, one of which has not been reported in the literature before.
To conclude, irrespective of the length of the scar, the size of the Z plasty drawn should be bas... more To conclude, irrespective of the length of the scar, the size of the Z plasty drawn should be based on the laxity available. If there is insufficient laxity, the contracture will require more than one Z plasty to lengthen the full length of the contracture. If the tissue laxity [L] is ≥ the length of the scar, a single Z plasty is required. By this method the surgeon can decide whether a single or multiple Z plasties are required. However, the clinical decision whether to use single or multiple Z plasties is determined by two other factorswhether a single or multiple Z plasty is more aesthetic and whether there is a confounding immovable anatomical feature (e.g., scar revision around the nose). Further since the skin doesn't behave as a mathematical model, one needs to find a method to accurately measure the amount of laxity in the skin.
Pollicisation of the index finger is perhaps one of the most complex and most rewarding operation... more Pollicisation of the index finger is perhaps one of the most complex and most rewarding operations in hand and plastic surgery. It however has a steep learning curve and demands very high skill levels and experience. There are multiple pitfalls and each can result in an unfavourable result. In essence we need to: Shorten the Index, recreate the carpo metacarpal joint from the metacarpo phalangeal (MP) joint, rotate the digit by about 120° for pulp to pulp pinch, palmarly abduct by 40-50° to get a new first web gap, Shorten and readjust the tension of the extensors, re attach the intrinsics to form a thenar eminence capable of positioning the new thumb in various functional positions and finally close the flaps forming a new skin envelope. The author has performed over 75 pollicisations personally and has personal experience of some of the issues raised there. The steps mentioned therefore are an algorithm for helping the uninitiated into these choppy waters.
Management of child abuse with flexor tendons, neurovascular injuries, and life-threatening condi... more Management of child abuse with flexor tendons, neurovascular injuries, and life-threatening conditions is challenging. It needs a multisectoral coordinated and synchronized team effort for successful outcomes. We present a case series of children abused by a parent with a sharp object. The children sustained multiple flexor tendon injuries, neurovascular injuries in upper limbs, and tracheal injury compromising respiration. We performed a tracheostomy to save a child and subsequently repaired numerous flexor tendons, nerves, and arteries. During follow-up, these children required secondary reconstruction (tenolysis, tendon lengthening, nerve reconstruction) for flexor contractures, stiffness, and sensory loss in distal forearms. We measured the range of movements and assessed the children's functional outcome using the Strickland score at 3-year follow-up. The range of movement and functional outcome was excellent in both children in our series. A timely performance of surgery, aided with efficient intensive care, therapy, and consistent posttraumatic psychosocial rehabilitation, produced excellent results in our series.
Eight cases, in which a new single-pedicled venous flap, based on the long saphenous vein, was us... more Eight cases, in which a new single-pedicled venous flap, based on the long saphenous vein, was used to close defects around the knee, are presented with the details of indications, size and survival. Of the eight cases, seven achieved their aim; five flaps survived completely, two had partial distal loss and one died completely. This clinical work is further confirmation that fasciocutaneous island flaps of fairly large dimensions, with a single cephalad vein, survive and can be used to cover defects in their adjacent areas.
A case is reported in which an island fasciocutaneous flap from the radial side of the forearm, w... more A case is reported in which an island fasciocutaneous flap from the radial side of the forearm, with only the cephalic vein connecting it to the rest of the body (Fig. 1) was successfully transposed to cover part of a defect on the ulnar side of the elbow. An earlier case in which such a venous flap was raised but not used for cover is also detailed. A brief discussion speculating on the way this flap survived without any arterial inflow and only proximal venous drainage is included. Case reports Case 1
Birth brachial plexus palsy (BBPP) is an unfortunate outcome of a difficult labor, which can ofte... more Birth brachial plexus palsy (BBPP) is an unfortunate outcome of a difficult labor, which can often lead to long-lasting upper limb impairments. Spontaneous recovery may or may not occur. Timely diagnosis of the condition and initiation of the appropriate treatment can be instrumental in decreasing the functional impact. The management begins right from the day the child presents first and ranges from physiotherapy to surgical intervention such as nerve repair/transfer or grafts. The sequelae of the condition are also quite common and need to be detected preemptively with initiation of appropriate treatment. However, prevention is the key to reducing the incidence of secondary deformities. In this study, the team of authors, based on their considerable experience, discuss their approach to the management of BBPP. This is done in the background of Indian cultural practices and social constraints. A detailed discussion has been done on importance of preoperative passive joint mobilization regime and role of botulinum toxin in the authors' preferred ways of surgical correction of primary as well as secondary deformities. An extensive review of peer-reviewed publications has been done in this study, including clinical papers, review articles, and systematic review of the subject. Good results are possible with early and appropriate intervention even in severe cases.
Experiments were performed to ascertain the perfusion and drainage of single cephalad channel sap... more Experiments were performed to ascertain the perfusion and drainage of single cephalad channel saphenous venous flaps in dogs. In the first experiment a standard saphenous flap and a single cephalad channel saphenous venous island flap were dissected on contralateral thighs of dogs. A radioactive tracer, ggmT~, was injected into a foreleg vein and its appearance in both flaps was monitored with the use of a static and dynamic scanner. After this experiment, Evans blue, a vital dye, was injected into the foreleg vein of the dog. Five minutes later both flaps were excised and the dye in the flaps was assayed quantitatively. In the third experiment radioactive tracer was injected into the single cephalad channel venous flap subcutaneously and its decay in the flap as well as its uptake in the rest of the body were measured dynamically. The experiments show that the single cephalad channel venous island flap is perfused by and drains through its single cephalad vein. A mathematical model to justify the above conclusion was worked out independently, based on standard values involved in mammalian circulatory mechanisms as in dog and man.
One of the earliest postulates concerning the physiological basis of flap survival is attributed ... more One of the earliest postulates concerning the physiological basis of flap survival is attributed to Sushruta, who, in his inimitable style, very succinctly noted in Sanskrit verse the following words: "through continuity survives." Sanskrit being a very telegraphic language, what derives from these words is as follows: Through (the flap's) continuity (with its original location) (it) survives. The principle of continuity has survived through the ages, though continuity has come to imply vascular continuity based on the Harvesian model of circulation. No matter how we classify flaps, i.e., random or axial, the Harvesian model of circulation is the key to the mechanism of survival. Lately, however, a new category of flaps, that is, "venous flaps," have been reported by a number of investigators where the classical Harvesian model is not in evidence, at least apparently. The following effort is directed toward presenting the existing data on this subject for future guidance in research and clinical applications.
Variations are inherent feature of the intricate brachial plexus. They can be at the level of ori... more Variations are inherent feature of the intricate brachial plexus. They can be at the level of origin, the course, or the innervation pattern of each peripheral nerve. Knowledge of the various described variations can be worthwhile during the routine hand surgery procedures. We present a case of an elderly patient with anomalous intramuscular course of the ulnar nerve presenting with ulnar neuropathy at the elbow. Level of Evidence: IV.
A typical muscle variation of latissimus dorsi-the axillary arch is represented by the muscular o... more A typical muscle variation of latissimus dorsi-the axillary arch is represented by the muscular or fibromuscular slip detached from the anteroinferior border of the musculus latissimus dorsi passing over the axilla under the axillary fascia crossing the medial side of the brachial plexus to continue as a septum intermusculare mediale brachii distally to the medial epicondyle of humerus. The full extent of the muscle is rarely present. Slips of muscle extend from the latissimus dorsi at the inferior angle of scapula to insert into pectoralis major (Langer), coracobrachilis, biceps or coracoid process forming what is described as a common variant-the muscular axillary arch. We report three cases of variants of latissimus dorsi, one of which has not been reported in the literature before.
To conclude, irrespective of the length of the scar, the size of the Z plasty drawn should be bas... more To conclude, irrespective of the length of the scar, the size of the Z plasty drawn should be based on the laxity available. If there is insufficient laxity, the contracture will require more than one Z plasty to lengthen the full length of the contracture. If the tissue laxity [L] is ≥ the length of the scar, a single Z plasty is required. By this method the surgeon can decide whether a single or multiple Z plasties are required. However, the clinical decision whether to use single or multiple Z plasties is determined by two other factorswhether a single or multiple Z plasty is more aesthetic and whether there is a confounding immovable anatomical feature (e.g., scar revision around the nose). Further since the skin doesn't behave as a mathematical model, one needs to find a method to accurately measure the amount of laxity in the skin.
Pollicisation of the index finger is perhaps one of the most complex and most rewarding operation... more Pollicisation of the index finger is perhaps one of the most complex and most rewarding operations in hand and plastic surgery. It however has a steep learning curve and demands very high skill levels and experience. There are multiple pitfalls and each can result in an unfavourable result. In essence we need to: Shorten the Index, recreate the carpo metacarpal joint from the metacarpo phalangeal (MP) joint, rotate the digit by about 120° for pulp to pulp pinch, palmarly abduct by 40-50° to get a new first web gap, Shorten and readjust the tension of the extensors, re attach the intrinsics to form a thenar eminence capable of positioning the new thumb in various functional positions and finally close the flaps forming a new skin envelope. The author has performed over 75 pollicisations personally and has personal experience of some of the issues raised there. The steps mentioned therefore are an algorithm for helping the uninitiated into these choppy waters.
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Papers by Mukund Thatte