Gastrocnemius fascia release under local anaesthesia as a treatment for neuropathic foot ulcers in diabetic patients: a short series.

BACKGROUND: Diabetic foot ulceration is the leading cause of major amputation in the developed world. Plantar neuropathic ulcers at the forefoot can be managed conservatively with off-loading, but treatment is not invariably successful. Achilles tendon lengthening procedures aim at increasing dorsiflexion and decreasing forefoot pressure but can be associated with complications and require prolonged postoperative immobilization to prevent tendon rupture. We assessed the feasibility and clinical outcome of a comparative minimal invasive procedure: the gastrocnemius fascia release. This technique targets the same goals but is performed under local anaesthesia and allows immediate postoperative weight bearing and ambulation. METHODS: Diabetic patients with plantar neuropathic ulcers Wagner grade 2 or 3 were recruited from our diabetic foot clinic. Patients with infected wounds or untreatable peripheral arterial disease were excluded from the study. Conservative treatment with off-loading and local wound care was attempted for six weeks and surgical procedure only contemplated upon failure. Primary end-points were improved range of dorsiflexion and time to healing. Secondary end-points were local ulcer recurrences, new plantar ulcers, and minor or major amputation. Post-operative follow-up was 12 months. RESULTS: Seven patients were included in the study. An improvement in dorsiflexion of 10.4° (mean) was recorded post-operatively (p < 0.01). After 30 days, complete healing was accomplished in six of the seven patients. Long-term results were excellent as no ulcer recurrence or amputation was noted. CONCLUSIONS: Gastrocnemius fascia release under local anaesthesia can be performed safely in diabetic patients with plantar neuropathic ulcers under the metatarsal heads. Clinical outcome is excellent and long-term results promising.

ULTRAPRO® Hernia System: Toward an Ideal Solution? The Bonheiden Experience with a Partially Absorbable and Macroporous Bilayer Device.

In 1998, Gilbert introduced the Prolene Hernia System (PHS), a bilayer polypropylene mesh device composed of an onlay patch, a connector, and an underlay patch. The overall concept of its design was to include the best features of all currently available techniques while eliminating their undesirable features. This device is now available in a lightweight version, the Ultrapro® Hernia System (UHS; Johnson & Johnson, Somerville, NJ). We present the Bonheiden experience. From 2006 until 2009, we used 890 UHS devices in 712 patients. All patients were requested to join a prospective analysis with follow-up at one week and one month. Follow-ups at one and two years were organized using a telephone questionnaire. We were able to monitor 668 UHS implants in 526 patients. Bilateral primary hernias were repaired simultaneously in 142 patients and 6 hernias were a recurrence of a previous nonmesh repair. There were 472 men and 54 women in our cohort, with an average age of 57.5 years and average BMI of 24.79. No recurrences have occurred to date. Superficial wound infection presented in 3 patients. They were treated with antibiotics and no mesh needed to be removed. Seromas are much more common after this bilayer technique and are not considered a true complication. Whereas ecchymosis is very common, large hematomas were seen in 5 patients. One patient presented with a DVT of the iliac vein. She was treated with anticoagulation for three months, stockings, and early mobilization. The Ultrapro Hernia System is a good alternative to other preperitoneal hernia repairs, feasible in a day hospital under locoregional or general anesthesia. It has a very low recurrence rate but carries a more extensive dissection. We think the price paid for this extensive dissection is more than acceptable and is comparable to the Lichtenstein experience.

Comparison of Recurrence Rates in Obese and Non-Obese Patients Undergoing Ventral Hernia Repair with Lighter-Weight, Partially Absorbable Mesh.

Lighter-weight, large pore meshes with absorbable layers are designed for intra-abdominal placement in laparoscopic ventral hernia repair. This retrospective review of 86 patients who underwent ventral hernia repair with PROCEED™ Surgical Mesh (Ethicon, Inc., Somerville, NJ) represents an evaluation of a cohort of patients implanted with this mesh. All patients implanted with PROCEED Mesh for ventral hernia repair between October 2006 and December 2007 were contacted and asked to participate in an evaluation of their hernia repair. Patients were evaluated for pain, recurrence of their hernia and other potential complications. Eight patients underwent open repair; all others were performed laparoscopically. One patient continued to have pain at 1 year. Twelve developed seromas early on and 5 required drainage by a single puncture each. None persisted. There were 4 recurrences with none in patients with a Body Mass Index 3 32. One case of abdominal wall cellulitis responded to antibiotics. There were no wound infections, mesh infections, bowel obstructions or enteric fistulas. This study demonstrates the utility of a lighter-weight, large pore, partially absorbable mesh for intraperitoneal use in laparoscopic ventral hernia repair and indicates this mesh is strong enough for use in obese patients.

Angiosarcoma in an arteriovenous fistula after kidney transplantation: Case report and review of treatment options.

We present a patient with an angiosarcoma in an arteriovenous fistula and we reviewed current treatments for angiosarcomas. We extended the systematic review by Oskrochi et al. on this topic in 2015, using the same search query. We searched systematically OVID, EMBASE and PubMed from April 2015 until January 2020 with the aim to update the state of the art in managing this rare but serious condition. We retrieved 12 new case reports about 11 unique patients. Mean age was 61.5 ± 11 years. Six arteriovenous fistulas had failed spontaneously. Two fistulas were operatively closed post-transplant. Nine patients (81.8%) were receiving ongoing immunosuppressive therapy. Pain and growing lesions, mass or swelling were the most frequent symptoms. Angiosarcoma mostly presents with a nonspecific clinical picture of pain, growing lesions and swelling of a previously normal arteriovenous fistula. Amputation of the limb was most frequently conducted as treatment in localized disease. Treatment of systemic disease included supportive care, chemotherapy, especially with paclitaxel and change of immunosuppressive regimen. Metastasized angiosarcoma has a very poor prognosis. Classical chemotherapy has rather low response rates. There is limited data supporting treatment of angiosarcomas with tyrosine kinase inhibitors or immunotherapy. Further comparative research is needed.

Subclavian artery stenosis caused by a prominent first rib.

Thoracic outlet syndrome is a mechanical space problem in which the brachial plexus and/or subclavian vessels are compressed. Arterial compression is least common and almost always associated with a bony anomaly. We present a case of a 49-year-old woman with a prominent first rib which caused a subclavian artery stenosis. There are many options for subclavian artery repair through open surgery. In high-risk patients, minimal invasive techniques are favorable. To date, few case reports exist on an endovascular artery repair combined with open first rib resection. While long-term follow-up will be necessary, our preliminary results seem promising.