We have compared the density of nerve fibres in the synovium in club foot with that of specimens obtained from the synovium of the hip at operations for developmental dysplasia. The study focused on the sensory neuropeptides substance P; calcitonin gene-related peptide; protein gene product 9.5, a general marker for mature peripheral nerve fibres; and growth associated protein 43, a neuronal marker for new or regenerating nerve fibres. In order to establish whether there might be any inherent difference we analysed the density of calcitonin gene-related peptide-positive nerve fibres in the hip and ankle joints in young rats.

Semi-quantitative analysis showed a significant reduction in the number of sensory and mature nerve fibres in the synovium in club foot compared with the control hips. Calcitonin gene-related peptide (CGRP) positive fibres were reduced by 28%, substance P-positive fibres by 36% and protein gene product 9.5-positive fibres by 52% in club foot. The growth associated protein 43-positive fibres also seemed to be less in six samples of club foot. No difference in the density of CGRP-positive nerve fibres was observed in the synovium between ankle and hip joints in rats.

The lack of sensory input may be responsible for the fibrosis and soft-tissue contractures associated with idiopathic club foot.

Reconstruction of large composite tissue defects with expose tendons, neurovascular structures, joints and bones is difficult and challenging problem. Such difficult situations can be handled in a single stage with free tissue transfer provided microsurgical expertise is available.

A review of 12 cases of free scapular flap is being presented, performed over period of 20 months from December 97 to July 1999. Free scapular flap is based on transverse branch of circumflex scapular artery, which is branch of subscapular artery. All the patients in this series were male, with average age of 29 years. The mechanism of injury leading to tissue defects was, RTA 7 cases, industrial accidents 3 cases and bomb blast injury 2 cases. The various sites requiring free scapular flaps were, plantar aspect of foot, heel and leg in 5 cases, dorsum of hand, first web space and forearm in 3 cases, axilla and upper arm in 2 cases and one each for popliteal fossa and dorsum of foot. Only 4 cases presented to AKUH within 6 hours of injury while remaining 8 cases had prior treatment somewhere else and subsequent polymicrobial infection. In three cases, 2-3 debridements were done before coverage with free flap. Average defect size was 18cm long and 11cm wide. All of these cases had associated fracture

Free scapular flap is very robust flap with long vascular pedicle and large lumen artery, which can be anastomosed very easily. Donor site is closed primarily without any morbidity and scar is hidden. Scapular flap can be considered as workhorse for extremity defects.