Second toe metatarsophalangeal joint transfer for sternoclavicular joint reconstruction.

PURPOSE: We describe the anatomical basis for microsurgical reconstruction of the sternoclavicular joint using a vascularized, innervated second metatarsophalangeal joint, the surgical technique, and outcomes in 2 patients. METHODS: We harvested the second metatarsophalangeal joint along with the joint capsule, portions of the metatarsal and phalanx, the flexor sheath and flexor tendon, the extensor sheath and tendon, the first metatarsal artery, and the deep peroneal nerve. This composite tissue was used for reconstruction of an excised sternoclavicular joint following infection or chondrosarcoma. The proximal phalanx was dowel-jointed into the manubrium and fixed with 1 or 2 screws; the metatarsal was plated to the remaining clavicle. The joint was oriented to allow maximal elevation and restricted depression, and the normal mediolateral laxity allowed anterior and posterior movement. Vascular anastomoses were performed to branches of the thoracoacromial axis vessels, and digital nerves were connected to a supraclavicular nerve. RESULTS: Two patients had their excised sternoclavicular joints reconstructed using this technique. Both achieved union at the clavicular and sternal junctions. Both obtained restoration of movement of the sternoclavicular joint and upper limb. One patient developed joint subluxation and pain requiring tendon graft reconstruction of the costoclavicular ligament. CONCLUSIONS: In these 2 cases, the vascularized second toe metatarsophalangeal joint satisfactorily reconstructed the widely excised sternoclavicular joint and costoclavicular ligament and restored function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

High volume, drainless lipoabdominoplasty with progressive tension sutures -UK experience.

BACKGROUND: Lipoabdominoplasty is an established technique, however outcomes for high lipoaspirate volumes in large series are lacking. We present the UK experience of high-volume, drainless lipoabdominoplasty using progressive deep tension sutures. METHODS: 286 consecutive patients at a single centre underwent drainless lipoabdominoplasty with a lipoaspirate volume of 500 ml or greater between 2017 and 2023. Surgery was performed under total intravenous anaesthesia with SAFELipo©, MicroAire® and a superwet technique. Abdominoplasty was commenced via a low convex abdominal incision with multilayer rectus plication, and abdominal closure undertaken with progressive tension sutures. Logistic regression was used to determine the relationship between lipoaspirate volume and four primary outcomes - all complications, delayed healing, seroma, and need for revision. RESULTS: The mean lipoaspirate volume was 2392.4 ml (500-5900), and abdominal tissue resection weight 1392.0 g (346-3802). One third of patients had local complications - minor irregularities (14.0%), abdominal scar problems (12.9%), umbilical shape/scar (4.5%), localised infection (4.2%) and delayed healing (3.8%). One (0.3%) had a small area of localised necrosis successfully managed by further tissue advancement. There was one abdominal haematoma, and two systemic complications- venous thromboembolism (0.3%) and drug-induced hepatitis. Seroma rate was 3.1%. 16.0% of patients required revision under general anaesthesia, and 6.6% under local anaesthetic. There was no significant relationship between the lipoaspirate volume and any of the four primary outcome measures. CONCLUSIONS: High-volume liposuction can safely be performed simultaneously with abdominoplasty. Our complication rates are equivalent to, or lower than other published data on lipoabdominoplasy, challenging current concepts in body sculpting.

The Arteria Lymphatica and Lymphatic Microperforators: A Dedicated Blood Supply to Collecting Lymphatics and Their Potential Implications in Lymphedema: Anatomical Description.

Background: Lymphedema is common after lymphatic damage in cancer treatment, with negative impacts on function and quality of life. Evidence suggests that blood vessel microvasculature is sensitive to irradiation and trauma; however, despite knowledge regarding dedicated mural blood supply to arteries and veins (vasa vasorum), equivalent blood vessels supplying lymphatics have not been characterized. We studied collecting lymphatics for dedicated mural blood vessels in our series of 500 lymphaticovenous anastomosis procedures for lymphedema, and equivalent controls. Methods: Microscopic images of lymphatics from lymphedema and control patients were analyzed for lymphatic wall vascular density. Collecting lymphatics from 20 patients with lymphedema and 10 control patients were sampled for more detailed analysis (podoplanin immunostaining, light/confocal microscopy, microcomputed tomography, and transmission electron microscopy) to assess lymphatic wall ultrastructure and blood supply. Results: Analysis revealed elaborate, dense blood microvessel networks associating with lymphatic walls in lymphedema patients and smaller equivalent vessels in controls. These vasa vasora or "arteria lymphatica" were supplied by regular axial blood vessels, parallel to lymphatic microperforators linking dermal and collecting lymphatics. Lymphatic walls were thicker in lymphedema patients than controls, with immunohistochemistry, computed tomography, transmission electron microscopy, and confocal microscopy characterizing abnormal blood vessels (altered appearance, thickened walls, elastin loss, narrow lumina, and fewer red blood cells) on these lymphatic walls. Conclusions: Dedicated blood vessels on lymphatics are significantly altered in lymphedema. A better understanding of the role of these vessels may reveal mechanistic clues into lymphedema pathophysiology and technical aspects of lymphedema microsurgery, and suggest potential novel therapeutic targets.

Macrodactyly in the setting of a plexiform schwannoma in neurofibromatosis type 2: case report.

Macrodactyly is a rare anomaly. Little is understood about the etiology and underlying mechanisms. To our knowledge, macrodactyly has not previously been associated with neurofibromatosis type 2. We present a case of macrodactyly of the small finger associated with a digital nerve plexiform schwannoma in a patient with neurofibromatosis type 2.

Frank-ter Haar syndrome associated with sagittal craniosynostosis and raised intracranial pressure.

BACKGROUND: Frank-ter Haar syndrome is a rare disorder associated with skeletal, cardiac, ocular and craniofacial features including hypertelorism and brachycephaly. The most common underlying genetic defect in Frank-ter Haar syndrome appears to be a mutation in the SH3PXD2B gene on chromosome 5q35.1. Craniosynostosis, or premature fusion of the calvarial sutures, has not previously been described in Frank-ter Haar syndrome. CASE PRESENTATION: We present a family of three affected siblings born to consanguineous parents with clinical features in keeping with a diagnosis of Frank-ter Haar syndrome. All three siblings have a novel mutation caused by the deletion of exon 13 of the SH3PXD2B gene. Two of the three siblings also have non-scaphocephalic sagittal synostosis associated with raised intracranial pressure. CONCLUSION: The clinical features of craniosynostosis and raised intracranial pressure in this family with a confirmed diagnosis of Frank-ter Haar syndrome expand the clinical spectrum of the disease. The abnormal cranial proportions in a mouse model of the disease suggests that the association is not coincidental. The possibility of craniosynostosis should be considered in individuals with a suspected diagnosis of Frank-ter Haar syndrome.

Occult deep vein thrombosis in lower limb trauma requiring microsurgical reconstruction-A retrospective cohort study.

BACKGROUND: Delayed microsurgical reconstruction of lower extremity trauma is associated with increased risk of free flap loss, frequently following failure of the venous anastomosis. This has been attributed to thrombocytosis, but occult deep vein thrombosis (DVT) may contribute to this risk. METHODS: We performed a retrospective cohort study of consecutive patients presenting to our service with lower limb injuries requiring microsurgical reconstruction between 2013 and 2017, and examined venous Duplex ultrasound reports, operation notes and free flap outcomes. RESULTS: A total of 165 free flap reconstructions for lower limb trauma were performed for 162 limbs in 158 patients. Seventy-two limbs (44.4%) underwent preoperative venous Duplex ultrasound identifying occult DVT in 14 (19.4%) patients. Occult DVT was identified intraoperatively in a further 7 cases. Bilateral lower limb injuries (p = 0.0002), the level of injury at or above the knee (p < 0.0001), multiple levels of injury within the affected limb (p = 0.0008) and critical care admission (p = 0.0008) were significant risk factors for DVT. All 7 cases of DVT diagnosed intraoperatively prompted a change in the surgical plan for the recipient vein; however, preoperative identification of occult DVT also lead to an adjustment in the microsurgical plan in 4 out of 14 cases. CONCLUSIONS: Prevalence of DVT is high in severe lower limb injury, potentially increasing the risk of free flap loss. Preoperative identification of occult DVT may influence the microsurgical plan and mitigate for this risk.

Should first-line empiric treatment strategies cover coagulase-negative staphylococcal infections in severely malnourished or HIV-infected children in Kenya?

BACKGROUND: Bloodstream infection is a common cause of morbidity in children aged <5 years in developing countries. In studies reporting bacteremia in Africa, coagulase-negative Staphylococci (CoNS) are commonly isolated. However, it is currently unclear whether children who are highly susceptible to infection because of severe acute malnutrition (SAM) or HIV should be treated with antimicrobials specifically to cover CoNS. We aimed to determine the clinical significance of CoNS amongst children admitted to a rural hospital in Kenya in relation to nutritional and HIV status. METHODS: Systematically collected clinical and microbiological surveillance data from children aged 6-59 months admitted to Kilifi County Hospital (2007-2013) were analysed. Multivariable regression was used to test associations between CoNS isolation from blood cultures and SAM (MUAC <11.5cm or nutritional oedema (kwashiorkor)), and HIV serostatus; and among children with SAM or HIV, associations between CoNS isolation and mortality, duration of hospitalization and clinical features. RESULTS: CoNS were isolated from blood culture in 906/13,315 (6.8%) children, of whom 135/906 (14.9%) had SAM and 54/906 (6.0%) were HIV antibody positive. CoNS isolation was not associated with SAM (MUAC<11.5cm (aOR 1.11, 95% CI 0.88-1.40) or kwashiorkor (aOR 0.84, 95% CI 0.48-1.49)), or a positive HIV antibody test (aOR 1.25, 95% CI 0.92-1.71). Among children with SAM or a positive HIV antibody test, CoNS isolation was not associated with mortality or prolonged hospitalization. CONCLUSION: In a large, systematic study, there was no evidence that antimicrobial therapy should specifically target CoNS amongst children with SAM or HIV-infection or exposure.

Success of free flap anastomoses performed within the zone of trauma in acute lower limb reconstruction.

Traditionally, in free flap cover of lower limb injuries, every attempt is made to perform anastomoses proximal to the zone of injury. We report on the success of anastomoses within the zone of trauma, at the level of the fracture, avoiding further dissection and exposure. The records of free flap reconstructions for fractures of the lower extremity at a tertiary trauma centre between 2004 and 2010 were retrospectively reviewed. A total of 48 lower limb fractures required free flap reconstruction, performed at 28 days post injury (0-275 days). Anastomoses were proximal (21), distal (5) or within the zone of trauma (22). There was no significant difference (p > 0.05) in return to theatre, revision of anastomosis or flap survival between groups. Of the 22 performed within the zone of injury, five returned to theatre but only two for revision of anastomosis and 20 (91%) of these flaps survived. Of the 48 free flaps, arterial anastomoses were end to end in 34 (71%) and end to side in 14 (30%). There was no significant difference (p > 0.05) in return to theatre, revision of anastomosis or flap survival between the end-to-end and end-to-side groups. There was a tendency for arterial anastomoses to be performed end to end outside the zone of trauma (23/26) compared to within the zone of trauma (11/22). Our data suggest that free flap anastomoses can be performed safely in the zone of trauma in lower limb injuries.

Comparison of outcomes of peripheral nerve schwannoma excision in neurofibromatosis type 2 patients and non-neurofibromatosis type 2 patients: A case control study.

BACKGROUND: Patients with neurofibromatosis type 2 (NF2) are an important subgroup of patients undergoing peripheral nerve schwannoma excision, however data on their outcomes are lacking. Co-existing peripheral neuropathy can complicate the clinical presentation and recovery in NF2. We designed a study to compare outcomes of peripheral nerve schwannoma excision in NF2 patients with excision of isolated, sporadic schwannomas in non-NF2 patients. METHODS: 30 peripheral nerve schwannoma excisions from 15 NF2 patients were compared to 30 excised isolated schwannomas. These were matched for age, size, nerve and level of involvement. Final outcomes were scored on a scale of 0 (no improvement) to 3 (complete symptom resolution). Data were analysed by McNemars test and Wilcoxen matched pairs test. RESULTS: NF2 patients had multiple lesions and more pre-operative weakness (p = 0.041) and sensory loss (p = 0.133) compared to controls. Post-operative neurological morbidity occurred in both groups after schwannoma excision. Final outcome scores of 2.4 in NF2 and 2.2 in controls indicate great improvement or complete resolution in the majority. CONCLUSIONS: Outcomes in the NF2 group are not different to controls, despite NF2 patients having more significant pre-operative deficit and co-existing neuropathology. These findings suggest that surgical intervention should be offered to NF2 patients with peripheral nerve schwannomas.

The relationship between scaphocephaly at the skull vault and skull base in sagittal synostosis.

HYPOTHESIS: The skull vault is scaphocephalic in sagittal synostosis but little is known about the deformity at the skull base. If differential progressive deformity occurs between the vault and base, this might affect decision making regarding the timing of surgical intervention. We used 3-dimensional CT (3DCT) scans to compare deformity at the vault, base and posterior fossa in sagittal synostosis. Cephalic index (CI) was measured in 34 consecutive cases of isolated sagittal synostosis and 16 controls using predefined landmarks on the 3DCT volume data set. Planes were generated by a Vitrea™ workstation. Data were analysed by Student's t-test and Pearson coefficient. RESULTS: Ratios of CI between the vault and base, and the vault and posterior fossa were significantly reduced in sagittal synostosis (p < 0.0001 and p = 0.0031) demonstrating a milder deformity at the base and posterior fossa. However there was strong positive correlation between CI at the vault and base (r = 0.77, p < 0.0001). We have therefore shown for the first time that the deformity at the base is less severe, but is still closely correlated with the vault in unoperated sagittal synostosis. This study provides a basis for future work analysing the progression of these deformities before and after surgery.

The aesthetic outcome of surgical correction for sagittal synostosis can be reliably scored by a novel method of preoperative and postoperative visual assessment.

BACKGROUND: Aims of surgical correction for isolated sagittal synostosis are functional and aesthetic. Multiple surgical techniques exist; however, reliable assessment of aesthetic outcome is poorly documented, limiting direct comparisons. The pinched appearance of the temporal regions is particularly challenging to correct. A visual analogue scale was designed to grade skull shape in patients who had total or subtotal calvarial remodeling for isolated sagittal synostosis. METHODS: Twenty-two assessors graded preoperative and postoperative photographs from 42 consecutive cases of sagittal synostosis under a single surgeon. Five aspects were graded (i.e., narrow elongated skull, frontal bossing, temporal pinching, occipital bullet, and overall shape) from 0 (normal) to 100 (severe). Interobserver and intraobserver agreement were analyzed by calculating within-subject standard deviation, coefficient of variation, and intraclass correlation coefficient. Linear regression analysis determined predictors of outcome. RESULTS: Surgery improved outcome dramatically across all five aspects of skull shape, with a 72.6 to 76.4 percent decrease in severity score. Improvements in severity score were greater after total calvarial remodeling, and type of calvarial remodeling (total versus subtotal) was an independent predictor of outcome in all aspects of skull shape (p≤0.001). Temporal pinching was improved in a subset of patients who also had onlay bone grafts in this region. CONCLUSIONS: Calvarial remodeling is a powerful technique for improving skull shape. A panel can detect gross and subtle aesthetic changes after surgical correction of sagittal synostosis using a visual analogue scale, with moderate interobserver and intraobserver agreement. This provides a tool for future outcome assessment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Potential mechanisms of postmenopausal endometriosis.

Endometriosis is a chronic gynaecological disorder, the cause of which remains a subject of controversy. Oestrogen dependence is considered central to development and progression, and endometriosis is widely viewed as a disease of the premenopausal years, which normally regresses during the menopause. Increasingly however, reports of cases of postmenopausal endometriosis challenge our current understanding of the pathophysiology and raise further questions concerning the processes involved. Exploring the limited evidence available on postmenopausal disease we attempt to draw comparisons with pre-menopausal endometriosis, and in doing so to propose mechanisms for postmenopausal disease that are compatible with our current general understanding of the condition.