Reconstruction of Achilles region defects: A single-centre experience.

BACKGROUND: Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes. METHOD: In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre. RESULTS: Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting. CONCLUSION: Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.

Temperature- and Pressure-Regulating Insoles for Prevention of Diabetic Foot Ulcers.

Diabetic foot ulcers (DFUs) pose a major threat to the United States healthcare system as well as patients and their families. High ulcer recurrence rates indicate that existing preventive measures are not effective. A new generation of multimodal preventive devices may reduce ulceration and amputation rates. Because previous research has revealed that tissue maintained at cooler temperatures is more resistant to breaking down, the evaluated technology may prevent foot ulceration. The purpose of this study was to test previously designed Temperature and Pressure Monitoring and Regulating Insoles (TAPMARI) in diabetic neuropathic and healthy subjects. A cooling unit, a mini-water pump, a battery pack, and a microcontroller (or simply thermostat) were placed inside a box attached to the subjects' calf, which provided cooling inside the shoe. The microcontroller was set at 28°C. Eight subjects provided informed consent, 3 of whom had diabetic neuropathy. Subjects used the instrumented shoe on the right foot and the matching control shoe on the left and walked on a treadmill for 5 minutes at self-selected speeds. Baseline and postwalking thermographs were obtained with a thermal camera. At the 2-hour midpoint, subjects again walked on the treadmill for 5 minutes at self-selected speeds. Second baseline and postwalking thermographs were captured. Plantar pressure distributions were also quantified. The TAPMARI successfully regulated foot temperatures at or below the target temperature. The mean baseline temperature of the right (regulated) and left (control) feet were 28.1 ± 1.9°C (mean ± standard deviation) for all subjects. The mean temperatures at the end of the study were 25.9 ± 2.5°C (right) and 31.7 ± 1.6°C (left) in all subjects. In the diabetic neuropathy group, the final mean temperatures were 27.5 ± 2.4°C (right) and 31.6 ± 0.8°C (left), which indicated that the temperature goal was met inside the instrumented shoe. By regulating temperatures, TAPMARI may reduce the metabolic demands in the foot and prevent cell autolysis by eliminating the imbalance between oxygen demand and supply. This study warrants further development and testing of TAPMARI as well as investigating the clinical effectiveness in preventing DFUs.

Total or Near-Total Lower Eyelid Defect Reconstruction Using Malar Myocutaneous Bridge and Nasojugal Flaps and Septal Chondromucosal Graft.

PURPOSE: The purpose of this study is to repair total or near-total lower eyelid defects by single-staged operative technique. METHODS: The procedure was performed on 7 referred patients who had a total or near-total lower eyelid defects after tumor extirpation or trauma. Patients ages were between 13 and 67 years (average, 46.5). Defects were repaired by simultaneous reconstruction of anterior and posterior lamellae using a bipedicled malar myocutaneous bridge flap, a nasojugal transposition flap, and a septal chondromucosal graft in combination. RESULTS: Patients were followed up for 12 to 24 months (average, 18 months). No necrosis, hematoma, or infection was observed in flaps, and no recurrence was observed in any patients. Mild scleral show was observed at postoperative 12 months in 2 cases. CONCLUSIONS: As an addition to classical methods, the present novel single-staged surgical procedure with the malar myocutaneous bridge flap, nasojugal transposition flap, and septal chondromucosal graft combination provides anatomical, functional, and stable reconstruction for total or near-total lower eyelid defects.

Outcomes of Anatomic Reconstruction of Gunshot-Inflicted Lower Face Defects by Free Osteoseptocutaneous Fibula Flap and Expanded or Nonexpanded Temporal Scalp Flap Combination in Males.

Reconstruction of gunshot-inflicted composite lower face defects is a challenge for plastic surgeons. Functional and aesthetic repair of such defects mostly requires free or pedicled flap applications or combinations of both.In this study, the authors evaluated 7 males with gunshot-inflicted composite mandibular defects. All patients underwent reconstruction with a free osteoseptocutaneous fibula flap (FOCF) for the composite mandibular defect and a pre or nonexpanded temporal artery-based scalp flap for beardless facial skin. All patients were evaluated aesthetically and functionally with a postoperative evaluation scale. Average patient follow-up time was 3.5 years.All FOCFs survived completely. Expander exposition was observed in 2 preexpanded temporal scalp flaps. The problem was solved by rapid expansion and early flap application. All patients had acceptable functional and aesthetic results.In conclusion, the scalp flap should be considered in male beardless skin reconstruction due to its ease of application, reliability, and proximity to the defect. Preexpansion of this flap can decrease donor area morbidities. Moreover, the FOCF and scalp flap combination is a convenient procedure for gunshot-inflicted lower face defects, and such procedures produce good aesthetic and functional long-term outcomes.

Outcomes of Tissue Expander Application for Scalp Reconstruction in Extensive Aplasia Cutis Congenita.

INTRODUCTION: Aplasia cutis congenita (ACC) is a rare congenital disorder. The purpose of this study was to present outcomes of tissue expander application for scalp reconstruction in extensive ACC. PATIENT/METHODS: In this retrospective study, medical records were reviewed for six patients who underwent serial tissue expander application for scalp reconstruction in ACC between 2000 and 2015. Patient average age was 14.5 (range, 4-25 years). One of the six cases had frontal bone defect, the others had bone and soft tissue defect at the vertex. In the newborn period, all patients have been managed by split-thickness skin grafts without cranioplasty procedures. After grafting and calvarial regeneration, one (or more) sessions of tissue expanders and scalp flap applications were performed for alopecia and soft tissue correction. Radiologic and clinical examination was performed for complications and outcomes. RESULTS: Computerized tomography showed intact calvarium with patchy hyperostosis in all patients. The mean size of grafted areas was 69.5 cm(2) (range, 32-148.5 cm(2)). Minimal distal flap necrosis (6 × 1 cm) was observed in one patient. Serial scalp tissue expansion was performed with at least one session in a 1-year interval. One expander was extracted due to exposition and infection. No total flap losses and no calvarial defects were observed during follow-up (mean; 8.6 years). Clinical examination revealed acceptable cosmetic results in all patients. CONCLUSION: We advocate late expander scalp reconstruction for management of extensive ACC cases. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

2-{(E)-[(2-Methyl-3-nitro-phen-yl)imino]-meth-yl}-4-nitro-phenol.

The title compound, C14H11N3O5, is a Schiff base that adopts the enol-imine tautomeric form in the solid state. The dihedral angle between the aromatic rings is 37.4 (3)° and the dihedral angles between the nitro groups and their attached rings are 4.0 (6) and 46.2 (8)°. The mol-ecular structure is stabilized by an intra-molecular O-H⋯N hydrogen bond, which generates an S(6) ring motif. In the crystal, molecules are linked by C-H⋯O interactions, forming a two-dimensional network parallel to the bc plane.

(Z)-2-Meth-oxy-N-[(5-nitro-thio-phen-2-yl)methyl-idene]aniline.

The dihedral angle between the benzene and thio-phene rings in the title compound, C(12)H(10)N(2)O(3)S, is 27.94 (13)°. An inter-molecular C-H⋯π inter-action contributes to the stability of the crystal structure.

A case of mammary myofibroblastoma diagnosed with cytomorphological, cell block and immunohistochemistry findings.

Myofibroblastoma (MFB) is a rare benign spindle cell tumor originating from myofibroblasts in the breast stroma. MFB typically presents as a slow-growing, well-circumscribed, solitary mass ranging from 1 to 4 cm in size. It has been reported in adults, and frequently seen in older males and in postmenopausal females. The lesion is composed of stromal cells showing fibroblastic and myofibroblastic differentiation at the morphological, immunohistochemical and ultrastructural levels. To date, the literature includes only about 24 MFB cases confirmed via fine-needle aspiration and cytological evaluation. Here, we present a patient with MFB that was diagnosed via conventional smear slides and cell block, in addition to immunohistochemical analysis.

A Biomechanical Examination of Prefabricated Total Contact Cast Kits: Relevance to Patients With Diabetic Neuropathy.

The traditional Total Contact Cast (TCC) is considered the gold standard for treating plantar diabetic ulcers. A number of prefabricated TCC kits have been introduced, which offer a user-friendly casting process for health care providers. Our objective was to evaluate pressure reduction and gait characteristics after application of a TCC kit (TCC-EZ) and traditional TCC. Fifteen individuals (9 males, 6 females; median age of 51.5 years [range = 40.5-71.2 years]) completed 30-m walking trials while fitted with TCC-EZ and TCC in a randomized order. A pair of automated wireless photogate sensors captured time to traverse the distance and pedobarographic insoles measured and recorded plantar pressures. Paired t tests were used to compare peak pressure, gait speed, and cast weights across the 2 modalities. Peak pressure and cast weight were significantly lower in the TCC-EZ arm (169.6 ± 41.3 kPa vs 214.9 ± 63.2 kPa, P = .0048; and 1.79 ± 0.17 kg vs 2.11 ± 0.25 kg, P = .0004). Contact area and gait speed were not significantly different between the 2 modalities (140.4 ± 25.8 cm2 vs 126.9 ± 37.8 cm2, P = .0228, Cohen's d = 0.40; and 0.94 ± 0.19 m/s vs 0.83 ± 0.26 m/s, P = .0532, Cohen's d = .48). TCC-EZ was found to provide more favorable pressure distributions compared with TCC. TCC-EZ is also lighter and may be a preferred treatment modality for patients. More research is necessary to reveal the clinical effectiveness of prefabricated total contact kits.

1-Benzoyl-methyl-3-(2-thienylmeth-yl)-4-(2-thienylmethyl-eneamino)-1H-1,2,4-triazol-5(4H)-one.

In the title compound, C(20)H(16)N(4)O(2)S(2), one of the thio-phene rings is disordered [occupancy ratio 0.710 (4):0.290 (4)] and the disorder is of the flip type. An intra-molecular C-H⋯O hydrogen bond generates a six-membered ring with an S(6) motif.

2-Amino-4-nitro-phenol monohydrate.

The title compound, C(6)H(6)N(2)O(3)·H(2)O, crystallizes with two formula units in the asymmetric unit. The mol-ecules are essentially planar with the nitro groups twisted slightly out of the ring planes [maximum deviations from the ring plane of 0.13 (2) and 0.22 (2) Šin the two mol-ecules]. The respective O-N-C-C torsion angles are 6.0 (4) and 12.5 (4)°. In the crystal structure, mol-ecules are linked by inter-molecular N-H⋯O, C-H⋯O, O-H⋯O and O-H⋯N inter-actions into a three-dimensional network.

Prediction of plantar shear stress distribution by artificial intelligence methods.

Shear forces under the human foot are thought to be responsible for various foot pathologies such as diabetic plantar ulcers and athletic blisters. Frictional shear forces might also play a role in the metatarsalgia observed among hallux valgus (HaV) and rheumatoid arthritis (RA) patients. Due to the absence of commercial devices capable of measuring shear stress distribution, a number of linear models were developed. All of these have met with limited success. This study used nonlinear methods, specifically neural network and fuzzy logic schemes, to predict the distribution of plantar shear forces based on vertical loading parameters. In total, 73 subjects were recruited; 17 had diabetic neuropathy, 14 had HaV, 9 had RA, 11 had frequent foot blisters, and 22 were healthy. A feed-forward neural network (NN) and adaptive neurofuzzy inference system (NFIS) were built. These systems were then applied to a custom-built platform, which collected plantar pressure and shear stress data as subjects walked over the device. The inputs to both models were peak pressure, peak pressure-time integral, and time to peak pressure, and the output was peak resultant shear. Root-mean-square error (RMSE) values were calculated to test the models' accuracy. RMSE/actual shear ratio varied between 0.27 and 0.40 for NN predictions. Similarly, NFIS estimations resulted in a 0.28-0.37 ratio for local peak values in all subject groups. On the other hand, error percentages for global peak shear values were found to be in the range 11.4-44.1. These results indicate that there is no direct relationship between pressure and shear magnitudes. Future research should aim to decrease error levels by introducing shear stress dependent variables into the models.

2-Methyl-6-[2-(trifluoro-meth-yl)phenyl-imino-meth-yl]phenol.

The title compound, C(15)H(12)F(3)NO, is a Schiff base which adopts the phenol-imine tautomeric form in the solid state. The dihedral angle between the aromatic rings is 38.79 (5)°. The mol-ecular structure is stabilized by an intra-molecular O-H⋯N hydrogen bond, which generates an S(6) ring. In addition, there is an intra-molecular short C-H⋯F contact.

4-(2,3-Dihydroxybenzyl-ideneamino)-3-methyl-1H-1,2,4-triazol-5(4H)-one.

All the non-H atoms of the title compound, C(10)H(10)N(4)O(3), are almost coplanar, the maximum deviation from planarity being 0.065 (3) Å. The dihedral angle between the aromatic rings is 1.66 (6)°. The mol-ecule adopts the enol-imine tautomeric form with an intra-molecular hydrogen-bonding inter-action between the Schiff base N atom and the hydr-oxy group. In the crystal, inter-molecular N-H⋯O and O-H⋯O hydrogen bonds link the mol-ecules into a three-dimensional network.

2-Hydr-oxy-5-nitro-benzaldehyde.

The title compound, C(7)H(5)NO(4), is essentially planar, with a maximum deviation from the mean plane of 0.0116 (11) Šfor the hydr-oxy O atom. The mol-ecular and crystal structure are stabilized by intra- and inter-molecular inter-actions. An intra-molecular O-H⋯O hydrogen bond generates a six-membered ring, producing an S(6) ring motif. The C-H⋯O inter-actions result in the formation of C(5) chains and R(2) (2)(8) rings forming an approximately planar network parallel to (10). These planes are inter-connected through π-π inter-actions [centroid-centroid distance 3.582 (2) Å].

2-[(2,4-Dimethyl-phen-yl)imino-meth-yl]-6-methyl-phenol.

The title compound, C(16)H(17)NO, is a Schiff base which adopts the phenol-imine tautomeric form in the solid state. The mol-ecule is almost planar, with a dihedral angle of 4.61 (4)° between the aromatic rings. The molecular structure is stabilized by an intramolecular O-H⋯N hydrogen bond which generates a six membered ring.

2-[(2,4-Dimethyl-phen-yl)imino-meth-yl]-3,5-dimethoxy-phenol.

X-ray analysis reveals that the title Schiff base compound, C(17)H(19)NO(3), possesses both OH and NH tautomeric character in its mol-ecular structure. The occupancies of the enol and keto tautomers are 0.62 (3) and 0.38 (3), respectively. The presence of the minor keto form could not be confirmed from the IR spectrum. The mol-ecule is approximately planar, the dihedral angle between the planes of the two aromatic rings being 6.97 (8)°. The mol-ecular structure of the major component is stabilized by an intra-molecular O-H⋯N hydrogen bond, which generates an S(6) ring motif (N-H⋯O hydrogen bond in the minor component).

Temperature as a Causative Factor in Diabetic Foot Ulcers: A Call to Revisit Ulceration Pathomechanics.

BACKGROUND: Diabetic foot ulcers (DFUs) are a major burden to patients and to the health-care systems of many countries. To prevent or treat ulcers more effectively, predictive biomarkers are needed. We examined temperature as a biomarker and as a causative factor in ulcer development. METHODS: Thirty-seven individuals with diabetes were enrolled in this observational case-control study: nine with diabetic neuropathy and ulcer history (DFU), 14 with diabetic neuropathy (DN), and 14 nonneuropathic control participants (DC). Resting barefoot plantar temperatures were recorded using an infrared thermal camera. Mean temperatures were determined in four anatomical regions-hallux and medial, central, and lateral forefoot-and separate linear models with specified contrasts among the DFU, DN, and DC groups were set to reveal mean differences for each foot region while controlling for group characteristics. RESULTS: The mean temperature reading in each foot region was higher than 30.0°C in the DFU and DN groups and lower than 30.0°C in the DC group. Mean differences were greatest between the DFU and DC groups, ranging from 3.2°C in the medial forefoot to 4.9°C in the hallux. CONCLUSIONS: Increased plantar temperatures in individuals with a history of ulcers may include acute temperature increases from plantar stresses, chronic inflammation from prolonged stresses, and impairment in temperature regulation from autonomic neuropathy. Diabetic foot temperatures, particularly in patients with previous ulcers, may easily reach hazard thresholds indicated by previous pressure ulcer studies. The results necessitate further exploration of temperature in the diabetic foot and how it may contribute to ulceration.

Temporal characteristics of plantar shear distribution: relevance to diabetic patients.

Diabetic foot ulcers are known to have a biomechanical etiology. Among the mechanical factors that cause foot lesions, shear stresses have been either neglected or underestimated. The purpose of this study was to determine various plantar pressure and shear variables in the diabetic and control groups and compare them. Fifteen diabetic patients with neuropathy and 20 non-diabetic subjects without foot symptoms were recruited. Subjects walked on a custom-built platform capable of measuring local normal and tangential forces simultaneously. Pressure-time integral quantities were increased by 54% (p=0.013) in the diabetic group. Peak AP and resultant shear magnitudes were found to be about 32% larger (p<0.05), even though diabetic subjects walked at a slower velocity. Lower AP and ML stress range (peak-to-peak) values were observed in the control subjects (p<0.05). Shear-time integral values were increased in the diabetic group by 61% and 132% for AP and resultant shear cases, respectively (p<0.05). Plantar shear is known to be a factor in callus formation and has previously been associated with higher ulcer incidence. During gait, shear stresses are induced with twice the frequency of pressure characteristically. Therefore, plantar shear should be investigated further from a broader perspective including the temporal specifications and fatigue failure characteristics of the affected plantar tissue.

Squamous cell carcinoma in discoid lupus erythematosus: reconstruction with a free forearm fasciocutaneous flap.

We present the first free flap operation to our knowledge for a patient with squamous cell carcinoma on a lesion of discoid lupus erythematosus. Although the disease affects the skin, the defect was reconstructed successfully with a free radial forearm fasciocutaneous flap.