Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience.

PURPOSE: Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization. METHODS: Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health. RESULTS: Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications. CONCLUSIONS: Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.

Novel Sternal Reconstruction With Custom Three-Dimensional-Printed Titanium PoreStar Prosthesis.

Resection of sternal tumors can leave large defects, which exposes major mediastinal structures, and can affect respiratory mechanics. If feasible, resection is potentially a complex reconstructive challenge to restore normal and functional anatomy using conventional techniques. We report the first Australian use of a three-dimensional-printed titanium and PoreStar prosthesis in a 39-year-old woman for reconstruction after major surgical resection of the sternum for metastatic breast cancer. The patient successfully underwent excision of the sternum and costal cartilages as well as implantation of the prosthesis. We conclude that three-dimensional-printed prostheses are technically feasible to deliver excellent cosmetic result.

The Lymphatic Response to Injury with Soft-Tissue Reconstruction in High-Energy Open Tibial Fractures of the Lower Extremity.

BACKGROUND: Severe compound tibial fractures are associated with extensive soft-tissue damage, resulting in disruption of lymphatic pathways that leave the patient at risk of developing chronic lymphedema. There are limited data on lymphatic response following lower limb trauma. Indocyanine green fluorescence lymphography is a novel, real-time imaging technique for superficial lymphatic mapping. The authors used this technique to image the superficial lymphatic vessels of the lower limbs in patients with severe compound tibial fracture. METHODS: Baseline demographics and clinical and operative details were recorded in a prospective cohort of 17 patients who had undergone bone and soft-tissue reconstruction after severe compound tibial fracture between 2009 and 2014. Normal lymphatic images were obtained from the patients' noninjured limbs as a control. In this way, the authors investigated any changes to the normal anatomy of the lymphatic system in the affected limbs. RESULTS: Of the 17 patients, eight had free muscle flaps with split-thickness skin grafting, one had a free fasciocutaneous flap, one had a full-thickness skin graft, six had local fasciocutaneous flaps, and one had a pedicled gastrocnemius flap. None of the free flaps demonstrated any functional lymphatic vessels; the fasciocutaneous flaps and the skin graft demonstrated impaired lymphatic vessel function and dermal backflow pattern similar to that in lymphedema. Local flaps demonstrated lymphatic blockage at the scar edge. CONCLUSION: Severe compound fractures and the associated soft-tissue injury can result in significant lymphatic disruption and an increased risk for the development of chronic lymphedema.

In-Transit Metastasis From Squamous Cell Carcinoma.

BACKGROUND: In-transit metastasis from cutaneous squamous cell carcinoma (SCC) is an uncommon form of metastasis through lymphatics and occurs more commonly in immunosuppressed patients. OBJECTIVE: To identify cases of in-transit SCC and determine patient characteristics, tumor features, management, and prognosis. METHODS AND MATERIALS: A multicenter case series treated by Australian and New Zealand clinicians. RESULTS: In 31 patients, median age was 72 years (range 52-99) and 68% were immunocompetent. Tumors occurred on the head and neck in 94% of cases, with 71% of all tumors occurring on the scalp, forehead, or temple. The median time to presentation with in-transit SCC from treatment of the initial tumor was 5 months. Management included surgery (94%), radiotherapy (77%), chemotherapy (10%), and reduction of immunosuppression (3%). Median follow-up was 12 months. Overall survival at 3 and 5 years were 27% and 13%, respectively. CONCLUSION: In-transit metastases are described in 31 patients, of whom the majority was immunocompetent. The scalp, forehead, and temple were the most common sites. New clinical and histological diagnostic criteria are proposed. Prognosis was poor with 5-year survival of 13%. Recommended management is a combination of surgery and adjuvant radiotherapy. Reduction of any iatrogenic immunosuppression should be considered.

Thoracic outlet syndrome following breast implant rupture.

We present a patient with bilateral breast implant rupture who developed severe locoregional silicone granulomatous lymphadenopathy. Poly Implant Prothese silicone implants had been used for bilateral breast augmentation 5 years prior. Extracapsular implant rupture and bilateral axillary lymphadenopathy indicated explantation, capsulectomy, and selective lymph node excision. Histology demonstrated silicone lymphadenopathy with no evidence of malignancy. Over the subsequent 12 months, she developed progressive locoregional lymphadenopathy involving bilateral cervical, axillary, and internal mammary groups, resulting in bilateral thoracic outlet syndrome. We report the unusual presentation, progression, and the ultimate surgical management of this patient.

Relative active motion programs following extensor tendon repair: A pilot study using a prospective cohort and evaluating outcomes following orthotic interventions.

STUDY DESIGN: Prospective cohort. INTRODUCTION: The Immediate Controlled Active Motion program, used to manage extensor tendon repairs in the hand, immobilizes the wrist in an orthosis with the affected finger(s) placed in a separate yoke orthosis allowing controlled flexion. PURPOSE: To compare our outcomes using similar programs in patients with simple extensor tendon lacerations to those previously reported. To compare our 4-week orthotic intervention to our 6-week orthotic intervention. METHODS: 18 subjects received a 4-week orthotic intervention, 45 subjects received a 6-week orthotic intervention. Range of motion was measured 4, 6 and 8 weeks post-repair, grip strength at 6 and 8 weeks, and patient-rated outcomes at baseline, 6 and 12 weeks post-repair. RESULTS: Significant improvements in all outcomes were seen over time (p < 0.0001), with no significant differences between programs. CONCLUSION: Outcomes were comparable with those previously published and similar between the 4-week and 6-week orthotic interventions. LEVEL OF EVIDENCE: III.

Approaches to routine handling of basal cell carcinoma re-excision specimens: a survey of Australian histopathologists.

AIMS: To investigate and assess variation in routine approaches to the handling of basal cell carcinoma (BCC) re-excision specimens by Australian histopathologists. METHODS: A questionnaire was sent to 440 Australian histopathologists requesting details of their routine approach to the handling of BCC re-excision specimens. Responses were collated and compared to demonstrate any variation in approach. RESULTS: Responses received from 208 pathologists indicated that variation was present in most aspects of specimen handling, including cut-up, examination of the specimen and reporting. CONCLUSIONS: Variation demonstrated in the routine handling of BCC re-excision specimens may have important academic and clinical implications. It is important for pathologists to communicate their specimen handling approach to the surgeon. Further study should be conducted to specifically compare the various specimen handling approaches that were identified in this study. The development of evidence-based guidelines for the routine handling of BCC re-excision specimens may be appropriate.

Approaches to routine handling of basal cell carcinoma re-excision specimens: a survey of Australian histopathologists.

AIMS: To investigate and assess variation in routine approaches to the handling of basal cell carcinoma (BCC) re-excision specimens by Australian histopathologists. METHODS: A questionnaire was sent to 440 Australian histopathologists requesting details of their routine approach to the handling of BCC re-excision specimens. Responses were collated and compared to demonstrate any variation in approach. RESULTS: Responses received from 208 pathologists indicated that variation was present in most aspects of specimen handling, including cut-up, examination of the specimen and reporting. CONCLUSIONS: Variation demonstrated in the routine handling of BCC re-excision specimens may have important academic and clinical implications. It is important for pathologists to communicate their specimen handling approach to the surgeon. Further study should be conducted to specifically compare the various specimen handling approaches that were identified in this study. The development of evidence-based guidelines for the routine handling of BCC re-excision specimens may be appropriate.

The medial sural artery as recipient vessel and the impact on the medial gastrocnemius.

Microsurgical free tissue transfer is a valuable technique for the reconstruction of soft-tissue defects around the knee, and the medial sural artery (MSA) is an ideal recipient vessel for anastomosis. Previously, the vessel has been described as the dominant supply to the medial gastrocnemius, but no research has addressed the subsequent effect to the muscle after interruption of MSA. The volume of the postoperative medial gastrocnemius of 4 patients treated with free flap reconstruction using MSA as recipient, was assessed clinically and using magnetic resonance imaging, with muscle function assessed using a patient questionnaire, and measurement of ankle torque with concurrent electromyography. Magnetic resonance imaging volume assessment revealed the postoperative medial head of gastrocnemius proportional to its synergist of separate blood supply, the lateral gastrocnemius and functional assessment suggest little difference between limbs such that the MSA should be used with confidence as recipient vessel for free flap reconstruction of soft-tissue defects around the knee.