RESUMO
Psoriasis is a debilitating chronic inflammatory systemic condition largely affecting the skin. Major surgery is relatively contraindicated due to the propensity for triggering psoriatic flares and koebnerization of the surgical scars. We detail an interesting case of complete psoriasis remission following a right nipple-sparing mastectomy with sentinel lymph node biopsy with vascular augmented pedicled transverse rectus abdominal myocutaneous (TRAM) flap in a patient with systemic psoriasis vulgaris and arthropathy. Intra-operatively, majority of the psoriatic plaques were excised or de-epithelized and used as part of the ipsilateral TRAM flap. Post-operatively, koebnerization did not occur and her psoriasis was cured completely even after cancer chemotherapy. One of several hypotheses include excision with de-epithelization of most of the psoriatic plaques reduces disease and inflammatory burden leading to complete remission. Perhaps, surgery could one day play a supporting role to existing treatment options to achieve psoriasis remission.
RESUMO
BACKGROUND: Proximal, distal, and combined proximal and distal procedures have been performed for patellofemoral instability in the presence of patella alta. No consensus exists regarding the accepted surgical management for this condition. PURPOSE: To pool the outcomes of surgical management for patellofemoral instability in the presence of patella alta and to determine whether the outcomes differ for different surgical techniques. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: This systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported surgical outcomes for patellofemoral instability in the presence of patella alta were included. The random-effects model was used to analyze pooled estimates of preoperative and postoperative differences for outcomes that were reported in ≥3 studies. If heterogeneity existed among the studies, further analysis was performed using random-effects meta-regression analysis, which allowed for the identification of moderators. RESULTS: A total of 11 studies with 546 knees were included. The pooled relative risk (RR) of having no patellofemoral dislocation and no patellofemoral apprehension or subjective instability postoperatively was 51.80 (95% CI, 20.75-129.31) and 48.70 (95% CI, 17.22-137.71), respectively. The pooled weighted mean improvement (WMI) for the Kujala and Lysholm scores postoperatively was 31.98 (95% CI, 28.66-35.30) and 35.93 (95% CI, 30.12-41.74), respectively. The pooled WMI for patellar tilt angles postoperatively was 10.94 (95% CI, 7.87-14.01). These outcomes were homogeneous across all studies. The pooled WMI for Insall-Salvati ratio, Caton-Deschamps index, and tibial tubercle-trochlear groove distance postoperatively was 0.31 (95% CI, 0.17-0.45), 0.24 (95% CI, 0.12-0.36), and 6.77 (95% CI, 1.96-11.58), respectively. These outcomes were heterogeneous across the studies, with the presence of distal procedures being a significant moderator. The presence of distal procedures had a significantly higher unweighted RR of 38.07 (95% CI, 2.37-613.09) for major complications compared with proximal procedures alone, although the incidence of minor complications was comparable (unweighted RR, 1.25; 95% CI, 0.35-4.48). CONCLUSION: Surgical management for patellofemoral instability in the presence of patella alta consistently led to improvement in clinical and functional outcomes, regardless of the type of procedure performed. Distal procedures were better able to correct the patellar height and tibial tubercle-trochlear groove distance, although these procedures also posed a higher RR of subsequent surgery compared with proximal procedures alone.