Angiosomal Vascular Occlusions, Deep-Tissue Pressure Injuries, and Competing Theories: A Case Report.

ABSTRACT: Compression of the soft tissue between a support surface and a bony prominence has long been the accepted primary mechanism of pressure injury (PrI) formation, with the belief that said compression leads to capillary occlusion, ischemia, and tissue necrosis. This explanation presupposes an "outside-in" pathophysiologic process of tissue damage originating at the local capillary level. Despite advances in prevention protocols, there remains a stubbornly consistent incidence of severe PrIs including deep-tissue injuries, the latter usually evolving into stage 4 PrIs with exposed bone or tendon. This article presents just such a perioperative case with the aim of providing further evidence that these more severe PrIs may result from ischemic insults of a named vessel within specific vascular territories (labeled as angiosomes). Pressure is indeed a factor in the formation of severe PrIs, but these authors postulate that the occlusion occurred at the level of a named artery proximal to the lesion. This vascular event was likely attributable to low mean arterial pressure. The authors suggest that the terminology proposed three decades ago to call both deep-tissue injuries and stage 4 PrIs "vascular occlusion pressure injuries" should be the topic of further research and expert consensus.

Definition and Characteristics of Chronic Tissue Injury: A Unique Form of Skin Damage.

BACKGROUND: The purpose of this article is to examine the evidence related to a unique phenomenon of purple-maroon discoloration of the buttocks found in homecare patients and to recommend a label for this phenomenon. CASES: Initially, we searched the literature to identify and retrieve any evidence related to this unique form of purple-maroon discoloration of the buttocks. No evidence was found. To illustrate the condition, we compared 4 cases of what we have labeled chronic tissue injury to 6 patients with purple-maroon discoloration of the buttocks from different causes. CONCLUSION: Chronic tissue injury is characterized by a persistent purple-maroon discoloration located on the fleshy portion of the buttocks that does not improve or deteriorate. Unlike other causes of purple discoloration such as deep tissue pressure injury, there is minimal change in the discoloration over time. Additional research is needed to further our understanding of the histopathology of this phenomenon.

Case report: absence of the right piriformis muscle in a woman.

We report a very rare case of a unilaterally absent piriformis muscle in a 60 year old woman. Accompanying variations comprised a common gluteal artery (instead of two distinct superior and inferior gluteal arteries), and an absent gemellus inferior muscle. The contralateral left side showed a normally developed piriformis muscle. In hominoids, the piriformis is constant, but is regularly missing in several other vertebrates. The piriformis muscle is an anatomical landmark for ultrasound investigations and ultrasound-guided interventions in the deep gluteal region such as a superior gluteal nerve block or even a sacral plexus block, also for any surgical approach such as total hip arthroplasty. A missing piriformis muscle therefore affects the orientation in the deep gluteal region and therefore the identification of the targeted structures.

Gluteoplastia Técnica Intramuscular (XYZ) / Gluteoplasty using the Intramuscular (XYZ) Method

INTRODUÇÃO: No conceito de beleza corporal, a forma e o tamanho das nádegas são fundamentais, provocando uma crescente busca não só de mulheres, como também de homens, pela cirurgia de gluteoplastia. O objetivo deste trabalho é apresentar a experiência do autor em gluteoplastia com a técnica intramuscular (XYZ). MÉTODO: No período de 2010 a 2015 foram operados 29 pacientes com idades entre 22 e 64 anos (média 43 anos), sendo 26 mulheres (89,66%) e três homens (10,34%). Foram usados implantes redondos ou ovais, com volumes entre 240 e 420 ml (média de 330 ml), dependendo da melhor indicação para cada caso. RESULTADOS: Foram obtidos bons resultados sob o aspecto de aumento de volume e harmonia da região glútea, com alto índice de satisfação dos pacientes. CONCLUSÕES: Na casuística do estudo a técnica intramuscular (XYZ) se mostrou segura, tanto nas cirurgias primárias como nas cirurgias secundárias, para tratar casos de assimetria e/ou implantes visíveis. Com a pré- determinação dos pontos fixos XYZ, o procedimento torna-se seguro e reprodutível.

INTRODUCTION: The shape and size of the buttocks are essential to the notion of bodily beauty. This has resulted in a growing interest in gluteoplasty among both women and men. The aim of the present study was to present the author's experience with gluteoplasty using the intramuscular XYZ method. METHOD: Between 2010 and 2015, 29 patients aged 22 to 64 years (average, 43 years) underwent gluteoplasty; of these 26 were women (89.66%) and 3 were men (10.34%). Round or oval implants were used, with volumes of 240 to 420 ml (average, 330 ml), depending on the individual case. RESULTS: Good results were obtained in terms of volume increase and harmony of the gluteal region, with a high degree of patient satisfaction. CONCLUSIONS: The intramuscular XYZ method was safe, both for primary and secondary surgery, to treat cases of asymmetry and/or visible implants. Predetermining the XYZ reference points makes this procedure safe and reproducible.

LUMBAR syndrome: A case manifesting as cutaneous infantile hemangiomas of the lower extremity, perineum and gluteal region, and a review of published work.

We herein report a rare case of LUMBAR syndrome. A 1-month-old female infant presented with extensive segmental hemangiomas on the left lower extremity, left perineum and gluteal region with ulceration. Bilateral labia minoras were asymmetrical. Both legs were asymmetrical with left leg atrophy, and the intergluteal cleft was deviated. A dark red pustule and a sacrococcygeal dimple could be seen in the lumbosacral region. Lipomyelomeningocele, tethered cord and sacrum dysplasia were noted by magnetic resonance imaging. The patient was found to have an absent left kidney at 32 weeks of pregnancy. Eventually, we draw the diagnosis of LUMBAR syndrome. In addition, we discuss the clinical manifestation, diagnosis, treatment and pathogenesis by a review of published work.

Posterior resection and fusion of a lumbosacral hemivertebra in a case of dipygus.

Dipygus or pygomelia is an incomplete form of twinning due to the incomplete division of the embryonic disc. This extremely rare condition consists in the presence of an accessory limb that generally inserts into the buttock or perineum. Associated anomalies such as duplication of the genitourinary or the intestinal tract are frequent, and recurrently appear associated with spinal anomalies such as congenital scoliosis due to hemivertebra. We present our experience with a 20-year-old girl, the first and only case of dipygus recorded and treated in Switzerland, who came to us complaining of increasing low back pain along with a progressive congenital scoliosis due to the presence of a hemivertebra between L5 and S1, which was removed in a single stage exclusively through a posterior approach.

Liposculpture and fat grafting for aesthetic correction of the gluteal concave deformity associated with multiple intragluteal injection of penicillin in childhood.

BACKGROUND: The gluteal concave deformity, a complication of repeated intragluteal injections in childhood, is a relatively common complaint of many young women in China. This issue could be addressed by lipofilling, as the method could produce aesthetically acceptable results in correcting soft tissue contour defects. METHODS: Twelve patients with bilateral gluteal concave deformities associated with repeated intragluteal injections were operated on from June 2006 to June 2010. The deformities were classified as major or minor. Overall satisfaction with body appearance after gluteal fat grafting and liposculpture was rated on a scale of 1 (poor), 2 (fair), 3 (good), 4 (very good), and 5 (excellent). The evaluation was performed at 3-44 months after surgery. RESULTS: The average volume of fat injected was 196.9 ± 41.4 ml. No serious adverse events occurred. One patient with major deformity had one additional fat grafting procedure. One patient developed cellulitis in the feet and lower legs, upon which the grafted areas were incised and drained on suspicion of infection but with negative cultures. The patient recovered uneventfully with intravenous antibiotic application for 7 days. At the office visit nine cases judged that their appearance after the operation as "very good" (4) to "excellent" (5) and three cases responded that their contour was "good." Improvement in skin texture and alleviation of the pigmentation in the concave area were observed in all cases during the 3-44-month follow-up intervals after the fat grafting, and softening of the hypertrophic scar was also observed as early as 1 month after the fat grafting and continuously improved during the 12-month follow-up. CONCLUSION: Autologous lipografting for gluteal concave deformity, combining a liposculpture procedure adjacent to the defects, accomplishes good aesthetic results with high patient satisfaction. The key to success is complete release of fibrosis adhesion, meticulous manipulation of fat grafts, and multitunnel and multiplane injections to ensure maximum take of the grafts. 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 .

Diagnostic methods, treatment modalities, and follow-up of extracranial arteriovenous malformations.

OBJECTIVE: Arteriovenous malformations (AVMs) are an uncommon vascular pathology that remains challenging to accurately diagnose and successfully treat. This study introduces a novel way to evaluate AVM treatment outcomes using transarterial lung perfusion scintigraphy (TLPS) and reports our treatment results. MATERIAL AND METHODS: The patients treated for extracranial AVMs were studied retrospectively. Diagnosis and outcomes were based on clinical data, ultrasonography, magnetic resonance imaging, computed tomography, angiography, and TLPS studies. The influence of gender; location, form, and stage of AVMs; first attempt at treatment; and treatment modalities was analyzed. Outcomes were defined as positive (cure, improvement, and remission) or negative (no remission and aggravation). RESULTS: Of the 324 patients with congenital vascular malformations, 129 (39.8%) presented with AVMs, and the data of 56 treated patients with AVMs were analyzed. Of the 29 patients in the endovascularly treated group, 15 in the surgically treated group, and 12 in the combined treatment group, 24 (82.8%), 14 (93.3%), and 10 patients (83.3%), respectively, had positive outcomes (P>0.05). All outcomes were positive in surgically treated patients with extratruncular limited AVMs, and these patients were more likely to be cured as compared with those who had other forms of AVMs (OR, 5.8; 95% CI, 1.1-29; P=0.02). The patients with more advanced AVMs (stages III and IV) and with AVMs in the gluteal and pelvic region were more likely to have the worst outcomes than those with stage II AVMs (OR, 8.2; 95% CI, 1-72; P=0.03) and with AVMS in other locations (OR, 5.8; 95% CI, 1.1-29; P=0.02), respectively. Gender and age did not significantly influence treatment results (P>0.05). The TLPS data of 17 patients showed AV shunting ranging from 0% to 92%, which combined with other results helped identify 9 patients who needed further interventions, 6 who were treated successfully, and 2 who had insignificant shunting. CONCLUSIONS: The best outcomes were achieved in surgically treated patients with localized lesions and less advanced AVMs. For the first time in Lithuania, a modified TLPS method has been introduced that enhances a hemodynamic assessment of AV shunting and provides with a more accurate evaluation of AVMs to better serve in planning future treatments.

Implantes glúteos - técnica intramuscular: nuestra experiencia / Gluteal implants - Intramuscular technique: Our experience

El objetivo es mostrar nuestra experiencia en el aumento glúteo con la utilización de la técnica intramuscular, con la presentación de 61 casos en el término de 3 años. Método: Fueron tratados 61 pacientes de entre 30 y 76 años, de los cuales 56 eran mujeres y 5 hombres, desde junio de 2005 a mayo del 2008. Se utilizaron implantes lisos de gel de silicona altamente cohesivo, redondos o anatómicos, de entre 200 y 280 cc. Resultados: se obtuvieron resultados satisfactorios en 59 procedimientos de los 61 realizados; las complicaciones fueron hematoma 2 (3.2 por ciento), deshidencia de herida 4 (6.5 por ciento), implantes palpables 1 (1.6 por ciento), infección 1 (1.6 por ciento) y extrusión de implantes 1 (1.6 por ciento). No hubo casos de ruptura de los implantes. Conclusiones: El aumento glúteo por la técnica intramuscular produce excelentes resultados estéticos, con muy pocas complicaciones, pero con una curva de aprendizaje mayor que otras técnicas.

Purpose: To show our experience in gluteal augmentation with the use of the intramuscular technique, presenting 61 cases studied within a period of 3 years. Method: 61 patients participated, 56 were women aged between 30 and 76, and 5 wre men aged between 30 and 60. The study was carried out from June, 2005 until May. 2008. Smooth, round or anatomic highly cohesive silicone gel implants were used. Their size was between 200 and 280 cc. Results: Out of the 61 implants performed, satisfactory results were obtained in 59 patients; complications were bruising 2 (3.2 percent), wound disruption 4 (6.5 percent), palpable implants 1 (1.6 percent), infection 1 (1.6 percent) and implant extrusion 1 (1.6 percent); there were no cases of implant rupture. Conclusions: Gluteal augmentation using the intramuscular technique produces excellent aesthetic results, with very few complications, but with a bigger learning curve compared with other techniques.

Superior gluteal artery injury during iliosacral screw placement due to aberrant anatomy.

Percutaneous iliosacral screws are considered the standard of care for disruptions of the sacroiliac joint. This article describes a case of iatrogenic injury to the superior gluteal artery during iliosacral screw insertion and analyzes the possible reasons for this complication.A 32-year-old man diagnosed with an unstable pelvic ring injury underwent percutaneous fixation of the right sacroiliac joint. A 2-cm skin incision was made, and a straight cannulated awl was placed with the tip directly lateral to the S1 body. A guide wire was inserted and a partially threaded 6.5-mm cannulated screw with a washer was then placed over the guide wire and was found to be in excellent position. At this time, increased bleeding from the incision was observed. The incision was enlarged and dissection was carried down through the muscle. The bleeding vessel could not be visualized. Therefore, the wound was packed with sponges, and coil embolization of the right superficial gluteal artery was successfully performed.Analysis of the angiography reveled that our patient's superficial branch of the superior gluteal artery measured more than twice the average length reported in a previous anatomic study. We believe this is the first case of superior gluteal artery bleeding due to aberrant superior gluteal artery anatomy. When planning iliosacral screw insertion, the possibility of anatomical variance of the superior gluteal artery should be acknowledged and sought after in preoperative angiography, when available.

A rare bimuscular conglomeration gluteopiriformis case report.

The present paper reports a rare anomalous muscle in the gluteal region, which appears to be a conglomeration of gluteus maximus and piriformis muscles. The muscle was proximally attached to the gluteus maximus and distally merged with the piriformis muscle. The innervation of the anomalous muscle was derived from the inferior gluteal nerve. Recognition of such a muscle variant may facilitate early clinical diagnosis and treatment of patients with symptoms of piriformis syndrome or sciatica of unexplained etiology. Contraction of such an anomalous muscle could lead to altered biomechanics of the piriformis and the gluteus maximus. Such a rare muscle, which morphologically resembles the piriformis and developmentally appears to be a part of gluteus maximus could be a challenging puzzle for the present day surgeon and radiologist.

Variations of the piriformis and sciatic nerve with clinical consequence: a review.

The deep gluteal region is often encountered when performing injections, when performing surgery such as total hip replacements, or diagnosing problems of this region or lower limbs using clinical or imaging techniques. Previously, the prevalence figures of piriformis and sciatic nerve anomalies have ranged from 1.5 to 35.8% in dissected specimens. This study systematically reviews and meta-analyses the prevalence of piriformis and sciatic nerve anomalies in humans using previously published literature. A further review is conducted regarding the anatomical abnormalities present in surgical case series of procedures for patients suffering from piriformis syndrome. After pooling the results of 18 studies and 6,062 cadavers, the prevalence of the anomaly in cadavers was 16.9%; 95% confidence interval (CI) 16.0-17.9%. The prevalence of the piriformis and sciatic nerve anomaly in the surgical case series was 16.2%, 95% CI: 10.7-23.5%. The difference between the two groups was not found to be significant 0.74%; 95% CI: -5.66 to 7.13; P = 0.824. Because of the high likelihood of an anomaly being present in a patient, clinicians and surgeons should be aware of the potential complications this anomaly may have on medical or surgical interventions. Furthermore, because the prevalence of the anomaly in piriformis syndrome patients is not significantly different from what is thought to be a normal population, it indicates that this anomaly may not be as important in the pathogenesis of piriformis syndrome as previously thought.

Successful separation of pygopagus conjoined twins.

Conjoined pygopagus twins are very rare. They represent about 17% of all conjoined twins and commonly share the gluteal region, terminal spine, and lower gastrointestinal, urological, and reproductive tracts. Meticulous preoperative investigations and planning as well as a multispecialty team approach contribute to the success of surgical separation. We report a case of successful surgical separation of pygopagus conjoined twins.

Ischiopagus and pygopagus conjoined twins: neurosurgical considerations.

BACKGROUND: Neurosurgeons are familiar with the challenges presented by craniopagus twins, but other types of conjoined twins may also have neurosurgical implications. We report our experience in the management of ischiopagus and pygopagus conjoined twins. METHODS: This is a retrospective review of the management of conjoined twins at Red Cross Children's Hospital in Cape Town, South Africa. RESULTS: Twenty-three pairs of symmetrical conjoined twins were managed over a 40-year period (1964-2003), of which 16 (70%) were separated. Of these cases, 6 are the focus of this study, namely 4 pairs of ischiopagus twins and 2 pairs of pygopagus twins seen between 1993 and 2003. In 2 cases, there was direct involvement of the nervous system at the site of union, with 1 pair of ischiopagi manifesting end-to-end union of their spinal cords, while a pair of pygopagi had back-to-back fusion of the conus. Another pair of ischiopagi had a fused dural sac without joined neural elements, but one of these children developed syringomyelia 2 years after separation. Neuroimaging was invaluable in detecting these abnormalities. The one pair of ischiopagi who died before separation were HIV positive and had severe brain atrophy and cystic encephalmalacia at autopsy. Nine of the 12 children (75%) had bony abnormalities of the spine remote from the area of conjunction. The most common finding was the presence of hemivertebrae, usually in the thoracic spine. Six children manifested scoliosis, which has already progressed in the oldest two. Technical aspects such as timing and sequence of separation, the division of neural tissues and reconstruction are discussed, as are the long-term complications of their spinal abnormalities. CONCLUSIONS: Ischiopagus and pygopagus conjoined twins manifest an interesting array of spinal abnormalities, which present challenges, not only at the time of separation, but also in their long-term management.

Coincidence of multiple, disseminated, tardive-eruptive blue nevi with cutis marmorata teleangiectatica congenita.

A 71-year-old woman reported a slow progression of multiple bluish dark asymptomatic macules and papules on the pretibial region of both lower legs for over 30 years. At birth a left-sided hypoplasia of the leg including the buttock accompanied by a connatal vascular nevus had been diagnosed. The ipsilateral deep veins of the pelvis and leg had a normal anlage. Histopathological examination revealed multiple blue nevi of the common type. The association of multiple blue nevi and cutis marmorata teleangiectatica congenita with limb hypoplasia has not previously been reported and is discussed in this paper. One could speculate whether these symptoms represent a new syndrome, because by thorough examination the NAME syndrome could be ruled out.