Negative Pressure Wound Therapy versus Conventional Dressing in Lower Limb Fractures: Systematic Review and Meta-analysis.

Gustilo 3 lower limb fractures represent a significant challenge because of high complication risk. Two management strategies are commonly used for wound coverage until final closure: negative pressure wound therapy (NPWT) and conventional wound dressing (CWD), also described as standard wound coverage without subatmospheric pressure. Understanding their relative effectiveness is essential to improve patient outcomes. The aim of this systematic review and meta-analysis was to compare the efficacy of NPWT and CWD in Gustilo 3 lower limb fracture management, with a focus on overall rates, superficial infection, and deep infection rates. A systematic review of medical research databases was conducted in accordance with PRISMA guidelines. Studies comparing NPWT with CWD for Gustilo 3 fractures were included. Data extraction and quality assessment were performed. Treatment with CWD was associated with significantly higher rates of overall infection [pooled risk ratio (RR): 0.33; 95% confidence interval (CI): 0.14-0.51] and pooled risk difference (RD: 0.27; 95% CI: 0.15-0.38), superficial infection (pooled RR: 0.35; 95% CI: 0.04-0.66), and deep infection (pooled RR: 0.20; 95% CI: 0.02-0.38) compared with NPWT treatment. Overall infection rate remained significantly higher in the CWD group after analyzing only open tibia fractures (pooled RR: 0.35; 95% CI: 0.21-0.48). Nonunion rate was significant higher in the CWD group (pooled RR: 0.30; 95% CI: 0.00-0.59). Flap failure rate was similar in both groups (pooled RR: 0.09; 95% CI: -0.05 to 0.23). NPWT appears to be a reasonable option for wound management in Gustilo 3 lower limb fractures in terms of infection rates.

Medial Femoral Condyle Free Flap: A Systematic Review and Proportional Meta-analysis of Applications and Surgical Outcomes.

Background: Recalcitrant bone nonunion and osseous defect treatment is challenging and often requires vascularized bone transfer. The medial femoral condyle flap has become an increasingly popular option for reconstruction. The study aims at reviewing its different applications and synthesizing its surgical outcomes. Method: A systematic review including all studies assessing surgical outcomes of free medial femoral condyle flap for bone reconstruction in adults was conducted on January 31, 2023. Flap failure and postoperative complications were synthesized with a proportional meta-analysis. Results: Forty articles describing bony reconstruction in the head and neck, upper limb, and lower limb areas were selected. Indications ranged from bony nonunion and bone defects to avascular bone necrosis. Multiple flaps were raised as either pure periosteal, cortico-periosteal, cortico-cancellous-periosteal, or cortico-chondro-periosteal. A minority of composite flaps were reported. Overall failure rate was 1% [95% confidence interval (CI), 0.00-0.08] in head & neck applications, 4% in the lower limb (95% CI, 0.00-0.16), 2% in the upper limb (95% CI, 0.00-0.06), and 1% in articles analyzing various locations simultaneously (95% CI, 0.00-0.04). Overall donor site complication rate was 4% (95% CI, 0.01-0.06). Major reported complications were: femoral fractures (n = 3), superficial femoral artery injury (n = 1), medial collateral ligament injury (n = 1), and septic shock due to pace-maker colonization (n = 1). Conclusion: The medial femoral condyle flap is a versatile option for bone reconstruction with high success rates and low donor site morbidity.

Sensory and pain outcomes of neurotized skin-grafted free gracilis muscle flaps for lower extremity reconstruction.

BACKGROUND: Skin-grafted free gracilis muscle flaps are commonly used for lower extremity reconstruction. However, the loss of sensory function may lead to increased patient morbidity. This study prospectively analyzed the sensory and neuropathic pain outcomes of neurotized skin-grafted free gracilis muscle flaps used for the reconstruction of lower extremity defects. METHODS: Patients undergoing lower extremity reconstructions between 2020 and 2022 with neurotized skin-grafted free gracilis muscle flaps were prospectively enrolled. Sensation was assessed at 3, 6 and 12 months postoperatively using monofilaments, two-point discrimination, a vibration device, and cold and warm metal rods. Sensations were tested in the center and periphery of the flaps, as well as in the surrounding skin. The contralateral side served as the control. Patients completed the McGill pain questionnaire to evaluate patient-reported neuropathic pain. RESULTS: Ten patients were included. At 12 months postoperatively, monofilament values improved by 44.5% compared to that of the control site, two-point discrimination, cold detection, warmth detection, and vibration detection improved by 36.2%, 48%, 50%, and 88.2%, respectively, at the reconstructed site compared to those at the control site. All sensory tests were significantly better than 3 and 6 months values (p < 0.05), but remained significantly poorer than the control site (p < 0.05). Sensation in the central flap areas were similar to peripheral flap areas throughout the follow-up period (p > 0.05). The surrounding skin reached values similar to the control site at 12 months (p > 0.05). Moreover, 50% of patients reported neuropathic pain at 3 months postoperatively, 40% at 6 months, and 0% at 12 months (p < 0.05). CONCLUSION: Mechanical detection, vibration detection, temperature detection, and two-point discrimination significantly improved over time but without reaching normal sensory function at 12 months postoperatively. Neuropathic pain resolved at 12 months.

Successful Treatment of SIADH after Removal of Ruptured Breast Implants.

Local adverse reactions to breast implants and systemic reactions, mostly autoinflammatory, are numerously described in the literature. A patient presented at our institution with severe neurologic symptoms, including confusion and phasic troubles due to severe hyponatremia as part of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Common etiologies for SIADH, primarily malignancy and central nervous system disturbances, have been ruled out by imaging. On the computed tomography scan of the thorax and abdomen, several masses were found in the pectoral region, inferior to the sternum and in the left axilla that were biopsied and verified as silicone. While evaluating the patient's medical history, the patient remembered having undergone breast augmentation with silicone implants several decades ago. The only explanation left for the persisting SIADH was her ruptured silicone implants, causing an inflammatory systemic reaction. Literature was searched, and one abstract was found, in which a woman presenting with SIADH was treated successfully after removal of her silicone breast implants. We offered the same treatment to our patient, and siliconomas were removed through a bilateral inframammary approach as well as axillary on the left. There were no complications encountered. Postoperatively, the patient's hyponatremia improved and normalized 1 month later even without hydric restriction. This potential form of etiology and treatment of SIADH is a novelty in the medical literature. Surgical removal of dispersed silicone is presumed to be the cure for this syndrome. It represents a diagnosis of exclusion after more life-threatening causes, such as central nervous system disturbances and malignancies, have been ruled out.

Incidence Trends of Melanoma of the Lower Limbs and Hips in the United States: A Surveillance, Epidemiology, and End Results Analysis 2000-2019.

BACKGROUND/AIM: No specific studies on the changes in the incidence of melanoma in the lower limbs and hips have been performed. This article aimed to examine trends in incidence rates of melanoma of the lower extremities in the U.S. PATIENTS AND METHODS: Data from the SEER program provided by the National Cancer Institute were used to examine trends in melanoma incidence from 2000 to 2019. Data analysis was performed from October to December 2022. RESULTS: A total of 192,327 cases of melanoma of the lower limbs and hips were diagnosed from 2000 to 2019 and included in our study. The incidence rate increased from 9.78 to 13.65 cases per 100,000 person-year and by an average annual percent change (AAPC) of 2% (95%CI=1.4-2.9%). The incidence increased by an AAPC of 2.1% in men and 1.7% in women. The incidence among people under 50 remained stable but increased among those over 50 years. Localized stage disease was the only stage where a continuously increasing incidence was observed, with an AAPC of 1.7% (95%CI=0.9-2.5%). Lentiginous melanoma showed the highest incidence trend rate with an AAPC of 2.3% (95%CI=1.0-3.5%). CONCLUSION: The incidence rate of melanoma in the lower limbs and hips increased between 2000 and 2019, with a higher incidence in men, reversing the previously described trend of higher incidence among women. However, incidence among people under 50 remained stable, suggesting the efficacy of prevention campaigns in this population.

Oncoplastic reduction mammoplasty: Systematic review and proportional meta-analysis of surgical outcomes.

BACKGROUND: Breast-conserving surgery is the standard of care for early-stage breast cancer but can often result in unsatisfactory cosmetic outcomes. Oncoplastic surgery aims to address these issues by combining local excision with plastic surgery techniques to improve oncologic and esthetic outcomes. By incorporating breast reduction techniques into cancer surgery, wider margins of excision can be achieved, leading to enhanced oncological safety and reduced recurrence rates without causing significant asymmetry. This systematic review and meta-analysis aims to provide an updated understanding of the surgical outcomes associated with oncoplastic reduction mammoplasty. METHODS: A systematic review of the literature was conducted according to PRISMA guidelines. Articles reporting post-operative outcomes following the oncoplastic reduction mammoplasty were included. A proportional meta-analysis of post-operative complications was performed to obtain their proportions and 95% Confidence Intervals (CIs). RESULTS: Eighteen studies met the inclusion criteria, representing a total of 2711 oncoplastic reduction mammoplasty procedures in 2680 patients. The overall complication rate was 20% (95% CI: 15-25%). The positive margin rate following oncoplastic reduction mammoplasty was 11% (95% CI: 6-17%). The re-excision rate was 6% (95% CI: 3-12%). The completion mastectomy rate was 3% (95% CI: 2-6%). CONCLUSIONS: Oncoplastic reduction mammoplasty is a safe and effective alternative to mastectomy and traditional breast-conserving surgery in the treatment of early-stage breast cancers.

Reverse Abdominoplasty in a Patient Presenting with Subcostal Nephrectomy Scar and Transverse Muscle Incisional Hernia.

Abdominoplasty and its different approaches have been widely described to improve abdominal wall contour. However, the role of reverse abdominoplasty, a less commonly performed technique, and its indications are not fully understood. Recent advances in the understanding of the vascular supply to the anterior abdominal wall have made this technique more popular, but there is still limited information available in the literature. In this report, we present the case of a 52-year-old woman who underwent a reverse abdominoplasty using an existing subcostal scar from a previous nephrectomy. No surgical complications were observed, and the patient achieved both aesthetic and functional improvement after 6 months of follow-up. Reverse abdominoplasty can be a reliable option for maintaining adequate blood supply and achieving a satisfactory cosmetic result in cases where there is a pre-existing subcostal scar.

Melanoma of the Lower Limbs and Hips: A Surveillance, Epidemiology, and End Results Analysis of Epidemiology and Survival 2000-2019.

BACKGROUND/AIM: Melanoma, an aggressive skin cancer, poses a significant threat to patients' lives, with lower limbs and hips being among the most affected regions. Epidemiology and survival outcomes of patients with melanoma in the lower extremities were investigated and compared to other sites to better understand tumoral behavior and identify predictors of decreased survival. PATIENTS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to search for all skin melanoma cases between 2000 and 2019. Demographic, pathological, and therapeutic factors were compared between affected regions. Overall and disease specific survival were calculated and compared among subgroups. A multivariable analysis was conducted to identify independent prognostic factors. RESULTS: A total of 50,109 patients were diagnosed with melanoma in lower limbs and hips, while 224,121 patients had melanomas in other areas. More women (70.8%) and younger people (mean 55.2 years, SD 16.5) were affected with lower extremities melanoma, with better survival rates than other skin regions. Factors associated with better survival included female sex, younger age, horizontal growth pattern melanomas, and surgery with <1 cm margins. CONCLUSION: Melanoma affecting lower extremities is commonly diagnosed in young females. Prognosis depends on age, stage at diagnosis, and histologic subtype, but remains better compared to other locations.

Inferior gluteal artery perforator (IGAP) flap in autologous breast reconstruction: A proportional meta-analysis of surgical outcomes.

BACKGROUND: The inferior gluteal artery perforator (IGAP) flap is an alternative technique for autologous breast reconstruction. In contrast to other commonly used techniques, there is a paucity of literature on the safety and efficacy of the IGAP flap. The aim of this study was to perform a systematic literature review and meta-analysis of postoperative outcomes and complications associated with the IGAP in autologous breast reconstructions to validate its safety. METHODS: A systematic review of literature was performed following PRISMA guidelines. Articles reporting post-operative outcomes of IGAP flaps in autologous breast reconstruction were included. A proportional meta-analysis of post-operative complications was performed to obtain their proportions with 95% confidence intervals (CIs). RESULTS: Seven studies met the inclusion criteria, which represented a total of 239 IGAP flaps in 181 patients The total flap loss rate was 3% (95% CI 0-8%), partial flap loss rate was 2% (95% CI 0-4%), haematoma rate was 3% (95% CI 0-7%), overall donor-site complication rate was 15% (95% CI 5-28%), overall recipient-site complication rate was 24% (95% CI 15-34%), and the overall complication rate was 40% (95% CI 23-58%). CONCLUSIONS: This meta-analysis provides comprehensive knowledge on the safety and efficacy of the IGAP flap in autologous breast reconstruction. It evidences the IGAP flap in autologous breast reconstruction's overall safety and validates its role as an effective option in breast reconstruction.

Mesenchymal Stem Cells in Nerve Tissue Engineering: Bridging Nerve Gap Injuries in Large Animals.

Cell-therapy-based nerve repair strategies hold great promise. In the field, there is an extensive amount of evidence for better regenerative outcomes when using tissue-engineered nerve grafts for bridging severe gap injuries. Although a massive number of studies have been performed using rodents, only a limited number involving nerve injury models of large animals were reported. Nerve injury models mirroring the human nerve size and injury complexity are crucial to direct the further clinical development of advanced therapeutic interventions. Thus, there is a great need for the advancement of research using large animals, which will closely reflect human nerve repair outcomes. Within this context, this review highlights various stem cell-based nerve repair strategies involving large animal models such as pigs, rabbits, dogs, and monkeys, with an emphasis on the limitations and strengths of therapeutic strategy and outcome measurements. Finally, future directions in the field of nerve repair are discussed. Thus, the present review provides valuable knowledge, as well as the current state of information and insights into nerve repair strategies using cell therapies in large animals.

Cutaneous Melanoma of the Lip: A SEER Analysis of Epidemiology and Survival Outcomes With Focus on Surgery and Other Treatment Options.

BACKGROUND/AIM: Cutaneous melanoma of the lip (LM) is a rare malignancy with a low overall survival (OS). Few studies exist in the literature to aid its diagnosis and treatment. The purpose of this study was to assess the different treatment modalities by collecting cases from a single database and to provide current information on the epidemiologic characteristics of cutaneous lip melanoma. PATIENTS AND METHODS: The SEER database was searched for demographic, clinical-pathological, and therapeutic characteristics. The Kaplan-Meier model was used to analyze the overall survival (OS) of the study population, and survival curves were modelled. Univariable analysis between subgroups was carried out using the log-rank test. Surgery was further assessed with a multivariable cox regression, where the surgical procedure was adjusted for Breslow thickness. RESULTS: Patients aged 62.4 years on average, and 62.7% of them were males. A total of 386 melanomas of the cutaneous lip were identified. Mean OS was 155.1 months, median OS was 187 months, and 67.4% had localized disease. CONCLUSION: LM has a poor prognosis with a 5-year OS of 75.2%. Surgery remains the mainstay of treatment, with less invasive surgical approaches yielding a comparable overall survival to surgery with greater margins.

Demographic and Clinicopathological Factors as Predictors of Lymph Node Metastasis in Merkel Cell Carcinoma: A Population-Based Analysis.

Merkel cell carcinoma is an aggressive malignant skin tumor with high recurrence and low survival. Lymph nodal metastases are associated with a worse overall prognosis. Our aim was to assess how lymph node procedures and positivity are influenced by demographic, tumor, and treatment characteristics. The Surveillance, Epidemiology and End Results database was searched for all cases of Merkel cell carcinoma of the skin between 2000 and 2019. Univariable analysis was conducted using the chi-squared test with the aim of identifying differences in lymph node procedures and lymph node positivity for each variable. We identified 9182 patients, of which 3139 had sentinel lymph node biopsy/sampling, and 1072 had therapeutic lymph node dissection. Increasing age, increasing tumor size, and truncal location were associated with higher positive lymph node rates.

Spiradenocarcinoma: SEER Study of Epidemiology, Survival, and Treatment Options.

(1) Background: Spiradenocarcinoma is an extremely rare malignant adnexal tumor and there are only few studies on survival outcomes. Our aim was to perform an analysis of the demographic and pathological characteristics, treatment patterns, and survival outcomes of patients affected by spiradenocarcinoma. (2) Methods: The Surveillance, Epidemiology, and End Results program database of the National Cancer Institute was searched for all cases of spiradenocarcinoma diagnosed between 2000 and 2019. This database is considered representative of the US population. Demographic, pathological, and treatment variables were retrieved. Overall and disease-specific survival were computed according to the different variables. (3) Results: 90 cases of spiradenocarcinoma (47 females, 43 males) were identified. Mean age at diagnosis was 62.8 years. Regional and distant disease at diagnosis were rare, occurring in 2.2% and 3.3% of cases, respectively. Surgery alone was the most frequent treatment (87.8%), followed by a combination of surgery and radiotherapy (3.3%) and radiation therapy only (1.1%). Five-year overall survival was 76.2% and five-year disease-specific survival was 95.7%. (4) Conclusions: Spiradenocarcinoma equally affects males and females. Regional and distant invasion rates are low. Disease-specific mortality is low and is probably overestimated in the literature. Surgical excision remains the main form of treatment.

Chin Augmentation Techniques: A Systematic Review.

BACKGROUND: Chin augmentation has maintained a high level of popularity among patients and facial plastic surgeons. Several procedures exist to enhance the appearance of a small chin. The aim of this study was to perform a systematic literature review to determine outcomes and complications associated with the different techniques described. METHODS: MEDLINE, PubMed, PubMed Central (PMC), and Cochrane Central Registry of Controlled Trials (CENTRAL) databases were screened using a search algorithm. The techniques were classified, and related outcomes and complications tabulated and analyzed. RESULTS: A total of 54 studies on primary chin augmentation published from 1977 to 2020 met inclusion criteria, representing 4897 treated patients. Six main surgical techniques were identified: chin augmentation with implants (silicone, Gore-Tex, Mersilene, Prolene, Medpor, Proplast, hard tissue replacement, porous block hydroxyapatite, or acrylic; n = 3344), osteotomy ( n = 885), autologous grafts (fat, bone, derma, or cartilage; n = 398), fillers (hyaluronic acid, hydroxyapatite, or biphasic polymer; n = 233), local tissue rearrangements ( n = 32), and a combination of implant placement and osteotomy ( n = 5). All techniques provided consistently satisfactory cosmetic outcomes. The overall complication rate of the most represented groups was 15.7% for implants and 19.7% for osteotomy, including 2.4% and 16.4% cases of transient mental nerve-related injuries, respectively. CONCLUSIONS: All described chin augmentation techniques achieved good outcomes with high patient satisfaction. Thorough knowledge of each technique is essential to minimize each procedure's specific complications. Caution is generally needed to avoid nerve injuries and potential overcorrection or undercorrection.

Multistage Reconstruction of Large Arm Defect Using Keystone Type I Flap and Temporary Synthetic Skin Substitute.

Large arm defects remain a challenge to the reconstructive surgeon, as local and regional flaps are limited regarding size and free flaps have disadvantages such as poor color match, technical complexity, prolonged operative time, and the risk of total flap loss. Keystone flaps are fascia-based flaps and combine perforator-based vascularity with relative simplicity of nonmicrosurgical techniques and do not distort local anatomy in cases of malignant excision with wide defects. This article highlights the approach of a multistaged procedure to reconstruct a large arm defect using a keystone type I flap and a temporary synthetic skin substitute for closure in a patient referred to our department for wide resection of a large melanoma in situ on the posterior aspect of the left arm. The defect, measuring 14 cm × 8 cm, was initially reconstructed with a keystone type I flap. Part of the wound was temporarily covered with EpiGARD (Biovision GmbH, Ilmenau, Germany) to avoid excessive wound tension. One week later, the wound was partially narrowed, and a smaller EpiGARD was placed in office under local anesthesia. The multistaged approach was completed with direct closure 1 week later after removal of the smaller EpiGARD. No complications occurred and the result was satisfactory with a pleasing cosmetic result after an 8-month follow-up. In conclusion, the keystone flap allows reconstruction of large arm defects. Temporary synthetic skin substitute coverage can serve as a good addition for those cases where tension on the margins is observed at the price of a small in-office procedure.

[Total knee arthroplasty and soft tissue defect: what are the reconstructive options?] / Prothèse totale de genou et lésion des tissus mous : quelles options pour la reconstruction ?

Wound healing issues are not rare after total knee arthroplasty. While most patients heal with local wound care, a minority is susceptible to develop serious complications such as peri-prosthetic joint infection. If direct closure is not feasible, we recommend a multidisciplinary approach based on the ortho-plastic model to determine the optimal wound closure strategy. Negative pressure wound therapy can be used while waiting for definitive coverage to optimise wound environment. Medial gastrocnemius flap is considered as the gold standard procedure for peri-prosthetic substance loss around the knee.

Les problèmes de cicatrisation ne sont pas rares après l'implantation d'une prothèse totale de genou. La plupart des patients guérissent avec des soins locaux mais une minorité d'entre eux peut développer des complications redoutables allant jusqu'à l'infection périprothétique. Hormis les situations pour lesquelles une fermeture directe de la cicatrice chirurgicale peut être réalisée, nous recommandons une approche multidisciplinaire basée sur le modèle de l'ortho-plastique afin de déterminer la stratégie de reconstruction la plus adaptée. La thérapie par pression négative peut être utilisée pour conditionner la plaie en vue d'un geste de couverture définitive. Le lambeau gastrocnémien médial est considéré comme la procédure de référence pour les pertes de substance périprothétique du genou.

Melanoma of the Scalp and Neck: A Population-Based Analysis of Survival and Treatment Patterns.

Introduction: Melanoma is an aggressive skin cancer. Large demographic and clinic-pathologic studies are required to identify variations of tumour behavior. The aim of our study was to offer updated epidemiologic data on the scalp and neck melanoma with an overall survival analysis. Method: The SEER database was searched for all scalp and neck melanoma in adult patients between 2000 and 2019. Demographic and clinic-pathologic variables were described. Their impact on overall survival was assessed with the log-rank test after Kaplan−Meier model. A multivariable cox-regression was conducted to identify predictors of decreased survival. A p-value of <0.005 was considered statistically significant. Results: 20,728 Melanomas of the scalp and neck were identified. Mean age was 62.5 years. Gender ratio was 76.3% males. 79% of the tumours were localized at diagnosis. Increasing age, male gender, tumour ulceration, high mitotic rate or nodular subtype were independent prognostic factors of decreased overall survival. Surgery with less than 1 cm margin is associated with the best overall survival in this cohort. No significant difference in OS was seen between less than 1 cm and 1 to 2 cm margins. Conclusion: Knowledge of negative prognostic factors might help identify subgroups at risk and adapt their oncologic treatment.

Merkel Cell Carcinoma of the External Ear: Population-Based Analysis and Survival Outcomes.

(1) Background: Due to its highly aggressive behavior, the ability to identify and manage Merkel Cell Carcinoma (MCC) with a full understanding of its characteristics is essential. Because the external ear is an exposed area, resection can have dramatic consequences on patient's self-image, which is why it is fundamental to detect MCC, typically found on UV-exposed regions such as the ears, at an early stage. (2) Methods: The Surveillance, Epidemiology, and End Results (SEER) database was searched for all external ear MCC between 2000 and 2019. A descriptive analysis based on frequencies was made to describe the demography of pathophysiologic features linked to MCC. Overall survival (OS) was studied and compared between variables with a log rank test. A multivariable Cox regression analysis was then computed to identify independent prognostic factors. (3) Results: A total of 210 patients (160 men) were identified with a median age of 80 years. The median OS was 47 months. Factors associated with lower OS included an age of over 80 years, the male gender, a tumor size of >5 cm, and metastatic disease. Gross (<1 cm) and wide (>1 cm) surgery excision margins were the surgery types with the best OS. (4) Conclusions: MCC of the external ear is diagnosed mostly in old men. Among the 182 patients who received a surgical procedure, gross and wide excision without radiotherapy were associated with the best OS.