CT Angiography and CT-guided stereotaxy are useful adjuncts to Doppler ultrasound for imaging perforators prior to ALT flaps. A larger study is suggested to quantify the accuracy of these techniques.

This series provides good evidence that this evolving reconstructive technique may achieve excellent results and should be considered in traumatic common peroneal nerve injuries that would traditionally rely on conventional nerve grafting alone.

IV.

This preliminary analysis supports the internal construct validity of the Brachial Assessment Tool, a unidimensional targeted 4-response patient-reported outcome measure designed to solely assess activity after traumatic BPI regardless of level of injury, age at recruitment, premorbid limb dominance, and time postinjury. Further examination is required to determine test-retest reliability and responsiveness.

Use of this flap poses a greater challenge to the microsurgical breast reconstruction. We demonstrate its reliable use in women deemed unsuitable for a single-pedicle flap. Our structured system clarifies vascular options, and preoperative perforator mapping tools are essential to the success of this technique.

Isolated permanent femoral nerve palsy is a rare pathology that causes significant disability. 1,2 A true unilateral complete proximal femoral nerve palsy will result in the wasting of the quadriceps, iliacus and sartorius, variable wasting of pectineus and a sensory deficit in the anteromedial thigh and medial aspect of the leg. This causes a well-described gait disturbance and renders the patient unable to ambulate independently without significant difficulty or the use of gait aids. 3 The aetiology of isolated permanent femoral nerve palsy is varied. The vast majority of reported permanent unilateral femoral nerve palsy cases in the modern era are from unintended iatrogenic injury, or a planned necessity for oncologic clearance. 1 Other causes include iliopsoas haematoma, iliopectineal bursitis, trauma and diffuse large B-cell lymphoma. 2,4 Regardless of aetiology, this is a complex reconstructive problem with poor intrinsic idiopathic regenerative capabilities. There are few documented cases 4-6 of various pattern obturator nerve transfers for femoral nerve deficits with good functional outcomes.Here we present a novel technique with a clinical case including long-term follow-up, for the restoration of quadriceps function with no discernible donor deficit.Mr JV is a piano mover who was involved in a high-speed motor vehicle accident (MVA) at age 49. He sustained major pelvic fractures managed non-operatively, in addition to facial, chest and abdominal injuries. He originally had a diffuse critical illness polyneuropathy, which resolved to reveal an underlying isolated right-sided femoral nerve palsy. It was at this point, 4 months postinjury, that he was referred to the senior author (SF). The right quadriceps were completely wasted with 0/5 power and absent sensation consistent with complete femoral nerve palsy. Ipsilateral hamstrings, adductors and both anterior and posterior leg compartments were at least 4/5 power. There were multiple scars consistent with the original trauma but no evidence of surgery in the region of the proximal femoral nerve. Femoral nerve surgery was performed 5 months after the original trauma.There is little data in the literature regarding expected resolution ranges for critical illness polyneuropathy resolution, if any can occur from a few weeks after onset to months. 7 In this case, the indication for surgery at this time was the persisting isolated femoral palsy despite resolution of weakness in the other muscle groups.Intraoperatively, the right femoral nerve had a flat and empty appearance at the level of the inguinal ligament. There was no proximal stump available for reconstruction. These surgical findings were in keeping with the pre-operative hypothesis that the femoral nerve palsy was in addition to the resolved critical illness polyneuropathy.The following nerve transfers were performed (Fig. 1): 1. Nerve to gracilis transfer to a common intermediate quadriceps nerve. 2. Nerve to adductor longus transfer to definitive nerve to vastus medialis. Both transfers had good si...

Background Forensic professionals attach considerable importance to their patient's description of his or her index offence which is frequently used to inform the patient's management and predict future behaviour. However, despite the cardinal importance of the index offence there is no systematic approach to examining and formulating the patient's offence narrative. Aim To examine whether a clinical tool, which tapped into the patient's capacity to mentalize, could be developed from the index offence narratives of violent, personalitydisordered patients. To see whether this tool would capture how the patient represents his or her index offence and predict the patient's progress, in terms of institutional aggression, pro-social behaviour, inter-personal relationships and psychiatric symptomatology. Method This was a prospective, cohort study. The index offence narratives of 66 violent, personality disordered patients were obtained from a semi-structured interview and used to generate the Index Offence Representational Scales (IORS). The predictive validity of these scales was investigated across a range of outcome variables, controlling for the association between initial and final value of the dependent variable. Results The degree of interpersonal violence and malevolence as measured by the IORS predicted subsequent violent behaviour. In contrast to their actual aggressive behaviour these patients rated themselves as having fewer symptoms on the SCL-90-R and problems in interpersonal relationships on the IIP. A more empathic victim representation on the IORS predicted those patients who engaged better in the hospital's therapeutic regime. Conclusions The IORS may prove a useful tool to help clinicians predict both institutional aggression and pro-social engagement in these difficult to manage patients. Future replication studies would be useful to further validate the IORS.

Background: The anterolateral thigh flap is a workhorse reconstructive flap. Versatility in design is a key strength but perforator anatomy can be variable. Inability to locate perforators prompts consideration of contralateral thigh exploration. However, such exploration would be futile if the absence of perforators proves symmetrical. This study assesses the symmetry of anterolateral thigh flap vasculature using computed tomography angiography (CTA). Methods: A retrospective analysis of 20 bilateral thigh CTAs was performed. Each limb was assessed for number, course, location and size of perforators. Only vessels >0.5 mm in size at origin were included. Location was standardized between patients using perforator distance/thigh length ratio. Results were analysed using Wilcoxon signed-rank test. Results: In each thigh, the average number of perforators was 3.58 and average perforator distance/thigh length ratio was 0.358 AE 0.08. Between both limbs of the same patient, the mean difference in number of perforators was 0.55 (P = 0.002), and difference in average perforator size was 0.3 mm (P < 0.001). Average perforator location differed by a mean of 3% of thigh length (P < 0.001) between thighs. Conclusion: While average vessel size and location appear similar, there does not appear to be symmetry in the number of perforators. Surgical exploration of the contralateral thigh in an absence of perforators should be considered. In patients where abnormal anatomy is expected, mapping with CTA could be considered to reduce morbidity associated with unsuccessful surgical exploration and dissection.