Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): early results of a novel approach.

INTRODUCTION: In a previous cadaveric study, we described the Posterior to Anterior Malleolar Extended Lateral Approach (PAMELA) to address complex ankle fractures. It was demonstrated to provide optimal exposure of the posterior and lateral malleoli, and of the anterolateral portion of the ankle through a single incision. The aim of this study is to report the clinical results of this novel approach. METHODS: Between January 2019 and January 2021, all patients presenting with a complex ankle fracture in our institution were assessed by CT scan. Indication to use the PAMELA was determined by the fracture pattern, according to our previous guidelines, including combination of complex lateral and displaced posterior malleolar fractures, associated in most cases with anterolateral fracture avulsion. The approach was performed according to the steps previously described. Intraoperative evaluation included quality of exposure, ease of performing the osteosynthesis, and any complication encountered. The postoperative course was assessed for wound healing, quality of reduction, and the occurrence of any complication. RESULTS: The PAMELA was performed in 20 patients (aged 17-73). The most common combination of fractures was a comminuted lateral malleolus fracture associated with a displaced fracture of the posterior malleolus and a Wagstaffe-Le Fort or Chaput avulsion. We encountered no intraoperative complication. X-rays showed anatomical reduction in all cases. Postoperative complications included three delayed wound healing resolved with local treatment and one sural nerve traction injury. CONCLUSIONS: The main potential concern regarding this novel approach was the healing of the flap. Our results reject this concern and are in line with wound healing complications reported following surgical treatment of ankle fractures. This study confirms the safe in vivo feasibility of the PAMELA and opens a new perspective in the optimal management of complex fractures of the ankle. A larger prospective clinical study is ongoing in our institution.

Transgenic modeling of Ndr2 gene amplification reveals disturbance of hippocampus circuitry and function.

Duplications and deletions of short chromosomal fragments are increasingly recognized as the cause for rare neurodevelopmental conditions and disorders. The NDR2 gene encodes a protein kinase important for neuronal development and is part of a microduplication region on chromosome 12 that is associated with intellectual disabilities, autism, and epilepsy. We developed a conditional transgenic mouse with increased Ndr2 expression in postmigratory forebrain neurons to study the consequences of an increased gene dosage of this Hippo pathway kinase on brain circuitry and cognitive functions. Our analysis reveals reduced terminal fields and synaptic transmission of hippocampal mossy fibers, altered hippocampal network activity, and deficits in mossy fiber-dependent behaviors. Reduced doublecortin expression and protein interactome analysis indicate that transgenic Ndr2 disturbs the maturation of granule cells in the dentate gyrus. Together, our data suggest that increased expression of Ndr2 may critically contribute to the development of intellectual disabilities upon gene amplification.

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): a cadaveric anatomic study.

INTRODUCTION: The posterolateral approach is used in most cases of surgical treatment of ankle fractures involving the posterior and lateral malleoli. However, this approach does not allow access to the anterolateral structures of the ankle, which represent important landmarks to allow an anatomical reduction in case of complex ankle fracture. Our objective is to propose a novel surgical approach for optimal management of injuries including both a fracture of the posterior malleolus and a complex lesion of the lateral and/or anterolateral portions of the ankle. METHODS: Cadaveric dissection, including a vascular study, was performed on eight specimens. Assessment included density of the vascular supply around the lateral malleolus, identification of the structures at risk, quality of exposure of the bony structures, and convenience of hardware fixation. RESULTS: The cutaneous flap benefits from a rich interconnected arterial supply. Structures at risk, including the superficial peroneal and sural nerves, the lesser saphenous vein, and the peroneal artery are easily identified and protected. The interval between the peroneal tendons and the flexor hallucis longus muscle provides optimal access to the posterior malleolus. The lateral malleolus is exposed by retracting the peroneal tendons medially. An anterolateral arthrotomy, respecting the anterior talofibular and tibiofibular ligaments, offers a sharp view on the talo-tibio-fibular junction. Hardware placement can be done with optimal access to any exposed surfaces. CONCLUSIONS: The PAMELA opens a new perspective in the optimal management of complex fractures of the ankle. The approach allows optimal exposure to address fractures of the posterior malleolus, of the lateral malleolus, and of the anterolateral portion of the ankle through a single incision. Application in clinical practice is the subject of a future study in our institution.

Calcaneocuboid and Naviculocuneiform Dislocation: An Unusual Injury of the Midfoot.

Introduction. Midfoot dislocations are rare traumatic injuries. The best known patterns involve the Lisfranc and Chopart joints, although some other types have been described. Dislocations that occur at the level of the naviculocuneiform and calcaneocuboid joints simultaneously represent a very rare configuration of dislocation. Case Presentation. A 34-year-old man sustained a crush injury to his left foot causing a complete dislocation through the naviculocuneiform and calcaneocuboid joints. Immediate closed reduction and percutaneous pinning were performed, followed by open reduction and stabilization of both joints two weeks later. Anatomical reduction was obtained, and the clinical outcome remained satisfactory 10 months after surgery. Discussion. Anatomical reduction is essential to obtain favorable outcomes in traumatic midfoot injuries. An unusual pattern of midfoot dislocation can be treated according to the same principles as those for classical Lisfranc or Chopart injuries.

Complete Cubonavicular Coalition Associated with Midfoot Osteoarthritis.

Introduction. Cubonavicular coalitions represent a relatively rare condition with less than forty cases described in the literature, the majority of which are fibrocartilaginous. To our knowledge, cubonavicular osseous coalition associated with osteoarthritis of the midfoot has never been described. Case Presentation. We present the case of a 26-year-old man with bilateral Achilles tendinosis, in whom radiological studies show an incidental finding of a complete osseous cubonavicular coalition, as well as a partial osseous cubo-third cuneiform coalition and a fibrous band between the first and second cuneiforms of the right foot, associated with arthritic changes of the tarsometatarsal joint. A nonosseous calcaneocubonavicular coalition was found on the left foot. These multiples coalitions were asymptomatic in this case. Discussion. Cubonavicular coalition, even asymptomatic, can cause midfoot osteoarthritis in young patients. We may therefore suspect that the immobility of the cubonavicular joint causes additional stress on the midfoot.

Effect of Sonication on the Elution of Antibiotics from Polymethyl Methacrylate (PMMA).

Background: In the setting of prosthetic joint infections treated with a two-stage procedure, spacers can be sonicated after removal. We hypothesize that the sonication process may cause an increased elution of antibiotics from the spacer, leading to elevated concentrations of antibiotics in the sonication fluid inhibiting bacterial growth. We aimed to evaluate in vitro the influence of sonication on the elution of antibiotics from polymethyl methacrylate (PMMA) over time and to determine whether these concentrations are above the minimum inhibitory concentrations (MIC) for microorganisms relevant in prosthetic joint infections. Methods: PMMA blocks impregnated with vancomycin, fosfomycin, gentamicin or daptomycin were incubated in phosphate-buffered saline (PBS) at 37°C for up to 6 weeks. PBS was changed once a week. Concentrations were determined from samples of each antibiotic every week, and after 5 minutes of sonication at 2, 4 and 6 weeks. Results: With sonication there was a trend toward an increase of the elution of antibiotics. This increase was significant for vancomycin at 2 and 4 weeks (p=0.008 and 0.002 respectively) and for fosfomycin at 2 weeks (p=0.01). Conclusion: The effect of sonication could play a role in clinical results, especially for daptomycin and gentamicin for which the MIC is close to the concentration of antibiotics at 4 and 6 weeks. We conclude that elution of antibiotics from PMMA along with the effect of sonication could inhibit bacterial growth from spacers, resulting in false negative results in the setting of two-stage exchange procedures for prosthetic joint infections.

Postoperative ileus in an enhanced recovery pathway-a retrospective cohort study.

PURPOSE: Enhanced recovery after surgery (ERAS) protocols advocate no nasogastric tubes after colorectal surgery, but postoperative ileus (POI) remains a challenging clinical reality. The aim of this study was to assess incidence and risk factors of POI. METHODS: This retrospective analysis included all consecutive colorectal surgical procedures since May 2011 until November 2014. Uni- and multivariate risk factors for POI were identified by multiple logistic regression and functional and surgical outcomes assessed. RESULTS: The study cohort consisted of 513 consecutive colorectal ERAS patients. One hundred twenty-eight patients (24.7%) needed postoperative reinsertion of nasogastric tube at the 3.9 ± 2.9 postoperative day. Multivariate analysis retained the American Society of Anesthesiologists group 3-4 (odds ratio (OR) 1.3; 95% CI 1-1.8, p = 0.043) and duration of surgery of >3 h (OR 1.3; 95% CI 1-1.7, p = 0.047) as independent risk factors for POI. Minimally invasive surgery (OR 0.6; 95% CI 0.5-0.8, p ≤ 0.001) and overall compliance of >70% to the ERAS protocol (OR 0.7; 95% CI 0.6-1, p = 0.031) represented independent protective factors. POI was associated with respiratory (23 vs. 5%, p ≤ 0.001) and cardiovascular (16 vs. 3%, p ≤ 0.001) complications. CONCLUSIONS: POI was frequent in the present study. Overall compliance to the ERAS protocol and minimally invasive surgery helped to prevent POI, which was significantly correlated with medical complications.

Listeriosis downregulates hepatic cytochrome P450 enzymes in sublethal murine infection.

PURPOSE: Listeria monocytogenes (Lm) can cross the intestinal barrier in humans and then disseminates into different organs. Invasion of the liver occurs even in sublethal infections, however, knowledge of affected physiological processes is scarce. This study employed a sublethal murine infection model to investigate liver responses systematically by proteomics. EXPERIMENTAL DESIGN: Liver samples from three stages of the sublethal infection covering the initial invasion, the peak of infection, and the clearance phase (1, 3, 9 days postinoculation) were analyzed in comparison to samples from noninfected mice. Apart from flow cytometry and RT-PCRs for immune status control, liver responses were analyzed by quantitative peptide sequencing (HPLC-Orbitrap Fusion) using 4-plex iTRAQ-labeling. RESULTS: Accurate MS characterized about 3600 proteins and statistics revealed 15% of the hepatic proteome as regulated. Immunological data as well as protein regulation dynamics strongly indicate stage-specific hepatic responses in sublethal infections. Most notably, this study detected a comprehensive deregulation of drug metabolizing enzymes at all stages, including 25 components of the cytochrome P450 system. CONCLUSIONS AND CLINICAL RELEVANCE: Sublethal Lm infection deregulates hepatic drug metabolizing pathways. This finding indicates the need to monitor drug administration along Lm infections, especially in all patients needing constant medication.

Enhanced Recovery Pathway for Right and Left Colectomy: Comparison of Functional Recovery.

BACKGROUND: Enhanced recovery (ERAS) guidelines do not differentiate between left- and right-sided colectomies, but differences in recovery have been reported for the two procedure types. We aimed to compare compliance with the ERAS protocol and outcomes after right versus left colectomy. METHODS: Between June 2011 and September 2014, all patients undergoing elective colonic resection were treated according to a standardized ERAS protocol and entered a prospective database. This retrospective analysis compared right and left colectomy regarding application of the ERAS pathway, bowel recovery, complications, and hospital stay. RESULTS: Eighty-five patients with right colectomy matched well with 138 left-sided resections for baseline demographics. Overall compliance with the ERAS protocol was 76 % for right versus 77 % for left colectomy patients (p = 0.492). First flatus occurred at postoperative day 2 in both groups (p = 0.057); first stool was observed after a median of 3 (right) and 2 days (left), respectively (p = 0.189). Twenty patients (24 %) needed postoperative nasogastric tube after right colectomy compared to 11 patients (8 %) after left colectomy (p = 0.002). Overall complication rates were 49 and 37 % for right and left colectomy, respectively (p = 0.071). Median postoperative length of stay was 6 days (IQR 4-9) after right and 5 days (IQR 4-7.5) after left colectomy (p = 0.020). CONCLUSION: Overall compliance with the protocol was equally high in both groups showing that ERAS protocol was applicable for right and left colectomy. Functional recovery however, tended to be slower after right colectomy, and postoperative ileus rate was significantly higher. More cautious early feeding after right colectomy should be considered.

Carotid artery rupture and cervicofacial actinomycosis.

Cervicofacial actinomycosis is an uncommon, progressive infection caused by bacilli of the Actinomyces genus. Actinomyces are common commensal saprophytes in the oral cavity which may have medical importance as facultative pathogens. Subsequent to local injuries to the oral mucosa, they may penetrate the deep tissues and be responsible for suppurative or granulomatous infections. We herein report a case of a 65-year-old man who underwent surgery followed by chemotherapy and radiotherapy for a tonsillar carcinoma. An ulcerous lesion in the base of the tongue developed and spread to the carotid artery wall. The man died of a massive hemorrhage due to left carotid artery rupture. Postmortem computed tomography angiography performed prior to autopsy allowed the precise localization of the source of bleeding to be detected. Postmortem biochemical investigations confirmed the presence of inflammation associated with local bacterial infection. Histological investigations revealed the rupture of the left carotid artery surrounded by numerous colonies of Actinomyces. Acute and chronic inflammation with tissue necrosis as well as post-actinic, fibrotic changes were also found in the tissues surrounding the ruptured artery wall.