[Analysis of the effect of all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture].

Objective: To examine the feasibility and clinical effect of all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture. Methods: This is a retrospective case series study. From February 2021 to February 2023, the clinical data of 24 patients (30 feet) with Achilles tendon contracture treated with all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening were analyzed retrospectively. There were 10 males and 14 females, aged (32.8±16.1) years (range: 9 to 62 years). There were 8 cases of left side only, 10 cases of right side only and 6 cases of bilateral. There were 14 cases (16 feet) of foot varus, 4 cases (6 feet) of foot valgus, and 6 cases (8 feet) without deformity. All patients underwent all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening. The surgical effects were evaluated using the maximum dorsal extension angle of ankle joint in knee extension position, the visual analogue scale (VAS) of pain, the American Orthopedic Foot and Ankle Society ankle-hindfoot score(AOFAS-AH). Paired sample t test was used to compare the scores before and after operation. Results: All patients successfully completed the operation, and the operation time of Achilles tendon lengthening was (22.0±5.7)minutes (range: 15 to 35 minutes) and the intraoperative blood loss was (6.5±2.7)ml (range: 2 to 15 ml). All patients primarily healing without any complications such as sural nerve injury, Achilles tendon rupture, important blood vessel injury, and obvious decrease of lift heel strength of achilles tendon. All 24 patients were followed up for (17.2±4.5) months (range: 12 to 28 months). One patient suffered from lift heel's weakness in one foot after operation, and recovered after repeated lift heel functional exercises. The ankle dorsiflexion function of two patients with calf triceps spasm were not improved after operation, and it was obviously improved after botulinum toxin injection. At the last follow-up, the maximum dorsal extension angle of ankle joint in knee extension position increased from -9.2°±7.6°(range:-25° to 5°) preoperatively to 14.5°±7.0°(range:0° to 28°)(t=24.83, P<0.01); the VAS score was reduced from (4.5±1.7) points (range:1 to 8 points) preoperatively to (1.5±0.9) points (range:0 to 3 points) (t=9.53, P<0.01), the AOFAS-AH was increased from (60.5±11.4)points (range:38 to 85 points) to (90.8±5.4) points (range:80-100 points)(t=14.21, P<0.01). Conclusions: All-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture not only provides Achilles tendon lengthening, but also avoids complications such as Achilles tendon rupture and sural nerve injury. It is an effective method for the treatment of Achilles tendon contracture.

[Posterior arthroscopic subtalar arthrodesis for symptomatic adult talocalcaneal coalition].

Objective: To investigate the functional outcomes of posterior arthroscopic subtalar arthrodesis (PASTA) for adult patients presenting with symptomatic talocalcaneal coalition. Methods: The study was a retrospective case-series research.The data of 17 adult patients (17 feet) with symptomatic talocalcaneal coalitions,treated with PASTA from March 2018 to February 2022 in Xuzhou Central Hospital were collected.This procedure involved 10 males and 7 females,aged (42.4±7.5) years(range:31 to 58 years).There were 9 cases on the right side and 7 cases on the left side.According to the Rozansky classification,there were 4 cases of type Ⅰ,7 cases of type Ⅱ, 3 cases of type Ⅲ,3 cases of type Ⅳ.The following items such as wound healing and bony union of the subtalar joint were observed.Clinical assessment was performed using pain visual analogue scale (VAS),American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and 36-item short form health survey (SF-36) scores.The paired t test was used for data comparison. Results: The follow-up time was (24.8±6.9) months(range:12 to 40 months).There were no complications such as wound infection,deep vein thrombosis,nonunion,or screw breakage.One patient with preoperative spasm,relieved after the second surgical procedure (peroneal brevis tendon lengthening).The union time of the subtalar joint was (8.8±2.2) weeks(range:6 to 12 weeks).At the final follow-up,the VAS decreased from (6.4±1.3) to (1.3±0.9)(t=14.114,P<0.01), the AOFAS ankle-hindfoot score increased from (49.0±8.1) to (90.0±5.1)(t=38.782,P<0.01),and the SF-36 score increased from (50.8±9.5) to (91.0±4.9)(t=20.468,P<0.01). Conclusion: PASTA for adult patients presenting with symptomatic talocalcaneal coalition offers advantages of minimal trauma,fast recovery,and few complications,which is an effective method.

[Clinical analysis of nodular fasciitis in the head and neck].

Objective: To analyze the clinical features, diagnosis, treatment and prognosis of nodular fasciitis (NF) in the head and neck. Methods: Seven cases of primary NF in the head and neck admitted to Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from 1990 to 2022 were retrospectively analyzed, including 3 males and 4 females, aged from 2 to 67 years, and the location, course of disease, clinical manifestations, imaging findings, and treatment results of the disease were summarized. Results: Of the 7 patients, the primary sites were respectively nasal vestibule, paranasal sinus, nasal dorsum, sella turcica and clivus, neck, subglottis, and tonsil. Three cases presented with rapidly growing subcutaneous painless masses within 2 months, 1 case presented with hemoptysis, hoarseness and asthma for 28 days, 1 case presented with blood in the nasal discharge for 2 months, 1 case presented with headache for 1 month, and 1 case was found to have tonsillar neoplasms on physical examination for 3 days. CT was performed in 5 patients and the lesions showed soft tissue density shadows, and MRI was also performed in 2 of them, which showed T1 isointensity or T2 slightly long abnormal signal shadows. All patients underwent simple surgical resection of the mass. The patients were followed up for 13 months to 10 years, and none had recurrence. Conclusion: Primary NF in the head and neck is rare, with atypical clinical symptoms and imaging findings. Surgery is the mainstay of treatment for NF with good results.

[Arthroscopic treatment of acute closed noninsertional rupture of Achilles tendon].

Objective: To investigate the clinical efficacy of arthroscopic treatment of acute closed noninsertional rupture of Achilles tendon. Methods: The clinical and imaging data of 30 patients (30 feet) with acute closed noninsertional rupture of Achilles tendon who were treated with all-inside arthroscopic technique at the Department of Hand and Foot Microsurgery,Xuzhou Central Hospital from June 2018 to June 2020 were analyzed retrospectively. There were 26 males and 4 females,aged (38.3±8.5)years old(range:19 to 66 years). There were 22 cases on the right side and 8 cases on the left side. The duration from injury to surgery was (2.1±1.4) days (range:1 to 7 days).All patients were treated with all-inside arthroscopic technique.The function of the ankle and the foot was assessed using visual analogue scale (VAS),the American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scale and the Achilles tendon total rupture score (ATRS). The Arner-Lindholm score system was used to evaluate the excellent and good rate of clinical effect. Paired sample t test or rank-sum test was used for data comparison. Results: The patients were followed up for (18.6±2.2)months(range:12 to 28 months).All the wounds healed at the first stage.No complication such as infection,sural nerve injury or re-rupture happened.Two patinets felt mild pain after a long time exercise, and were alleviated by microwave therapy and stretching the Achilles tendon consistently.Another patient was unable to do a sustained single stance heel raise,which was recovered after repeated function practice.At the last follow-up,the VAS (M(IQR)) decreased from 6(5) preoperatively to 0(1)(Z=6.512,P<0.01),the AOFAS ankle hindfoot scale improved from 60.6±8.3 preoperatively to 96.3±4.8(t=-29.774,P<0.01),and the ATRS improved from 61.7±7.8 preoperatively to 97.1±2.3 (t=-53.661,P<0.01).According to the Arner-Lindholm score system,27 cases were excellent,3 cases were good,and the excellent and good rate was 100%. Conclusions: The all-inside arthroscopic technique not only ensures the quality of tendon ananstomosis,but also avoids injury to the sural nerve.It has the advantages of small trauma,faster recovery and fewer complications.

KEAP1/NRF2 signaling pathway mutations in cervical cancer.

OBJECTIVE: The aim of the present study was to explore the potential involvement of mutations in the KEAP1/NRF2 signaling pathway in Chinese samples with cervical cancer. PATIENTS AND METHODS: 236 Chinese patients with various types of cervical cancer were recruited, and the coding exons and the corresponding intron-exon boundaries of the KEAP1 and NRF2 genes were analyzed for the potential mutations in the KEAP1/NRF2 signaling pathway. RESULTS: A novel KEAP1 missense somatic mutation (c.1408C>T, p.R470C) and 5 NRF2 missense somatic mutations (c.72G>C, p.W24C; c.85G>T, p.D29Y; c.101G>A, p.R34Q; c.230A>C, p.D77A and c.242G>A p.G81D) were identified in 187 patients with cervical squamous cell carcinoma, respectively; no mutations were detected in other subtypes. All these mutations were heterozygous and predicted to be pathogenic by PolyPhen-2, MutationTaster programs, and evolutionary conservation analysis. Among these mutations, the KEAP1 (p.R470C) and 3 NRF2 mutations (p.D29Y, p.D77A, and p.G81D) were detected in cervical cancer for the first time. Also, no mutations were identified in our 21 adenosquamous carcinomas or 25 adenocarcinomas. CONCLUSIONS: We identified 6 potential diseases causing mutations in the KEAP1/NRF2 signaling pathway in 187 (3.2%) Chinese cases with cervical squamous cell carcinoma, implicating KEAP1/NRF2 signaling pathway might play an active role in the pathogenesis of this subtype of cervical cancer. Furthermore, among these detected mutations, the KEAP1 and 3 NRF2 mutations were reported in cervical cancer for the first time.

Repair and sensory reconstruction of the children's finger pulp defects with perforator pedicled propeller flap in proper digital artery.

OBJECTIVE: This study was designed to investigate the clinical effects of adopting perforator pedicled propeller flap in the proper digital artery for treatment and sensory reconstruction of finger pulp defects in children. PATIENTS AND METHODS: Perforator pedicled propeller flap of proper digital arteries in thirty-one fingers from twenty-three children patients were selected for repairing the pulp defects on the 2nd to the 5th fingers. All cases were treated from September 2012 to December 2013. To properly reconstruct the pulps' feeling we needed the dorsal branch of the proper digital nerve in the flap to be consistent with the broken end of proper digital nerve in pulps' wound. A free skin graft was carried out with full-thickness skin taken from the medial thigh for flap donor area. We scheduled two post-operation return visits, one in six months and the second visit in twelve months following the operation. Parents' satisfaction with the postoperative appearance of their children's fingers was assessed based on Michigan Hand Outcome Questionnaire. RESULTS: All operations were performed successfully and all wounds healed in the first period and all flaps survived. During the final follow-up, the shape recovery of flaps and their donor areas were examined and satisfactory results were obtained. All pulps were full and round without any obvious pigmentation or scar contracture. The sensory recovery of pulps was achieved S3+, and the two-point discrimination was 4.5 to 6.0 mm (with 5.1 mm being the average value). Parents' satisfaction with the postoperative results was very promising with twenty-one cases of very satisfied and two cases of satisfied parents. CONCLUSIONS: The operation method used in this study demonstrated to be a safe and reliable procedure producing a very good flap blood supply as well as excellent sensory recovery and satisfactory postoperative appearance.

Clinical application of anterolateral thigh perforator flap for the reconstruction of severe tibia exposure.

OBJECTIVE: Exposure of tibia can result from severe traumatic wounds, such as injuries due to traffic accidents, crush injuries (machine) and amputation wounds. The free anterolateral thigh perforator flap is increasingly being used for trauma reconstruction. Here we report our case load with this surgical intervention. PATIENTS AND METHODS: We reviewed 27 patients who underwent free anterolateral thigh flap reconstruction for tibia exposure in the proximal-middle part. The flap size ranged from 64 cm2 to 270 cm2 (mean, 35 cm2). The recipient artery was the anterior tibial artery (3 cases), the posterior tibial artery (8 cases), the dorsal pedal artery (8 cases) and the contralateral posterior tibial vessels (8 cases). RESULTS: Among the flaps, 20 successfully survived (74%), and the others suffered from partial skin necrosis at flap edge (5 cases, 18.5%) and flap loss was caused by venous or arterial thrombosis (2 cases, 7.4%). The lost flap was reconstructed with a split-thickness skin graft or a cross-leg soleus muscle flap coverage. The follow-up period ranged from 3 to 30 months. Three patients had sinus formation and healed in one year with the repeated debridement and drainage. Among the 27 cases, only one case presented reinfection at the sixth postoperative month, due to the plate fixation and was healed in one month by the removal of steel plate and thorough debridement and drainage. CONCLUSIONS: Our results suggest that free anterolateral thigh flap would be an alternative choice for reconstruction of severe tibia exposure, and careful selection of the location and number of perforators as well as the proper selection of recipient artery are of great importance.

Haemoglobin, neutrophil to lymphocyte ratio and platelet count improve prognosis prediction of the TNM staging system in nasopharyngeal carcinoma: development and validation in 3,237 patients from a single institution.

AIMS: To improve prediction efficiency by incorporating complete blood count (CBC) into the TNM system on 5 year disease-specific survival (DSS) for patients with nasopharyngeal carcinoma (NPC). MATERIALS AND METHODS: The CBC of 3237 patients undergoing radiotherapy was retrospectively evaluated. In total, 2820 patients treated with non-intensity-modulated radiotherapy (IMRT) were randomly divided into development (1895 patients) and validation cohorts (925 patients). The association of potential risk factors with 5 year DSS was tested by Cox proportional hazards analysis and a prognostic index was created by assigning weighted scores proportional to a regression coefficient to each factor. Each cohort was divided into low, intermediate and high prognostic index. The prognostic index was validated in the validation cohort and compared with the TNM system on prediction of 5 year DSS. Validation was repeated in another independent group of 417 patients treated with IMRT. RESULTS: Eight independent prognostic factors were identified: gender, age, T or N stages, anaemia or thrombocytosis during radiotherapy, continuous reduction in haemoglobin, high neutrophil-lymphocyte ratio before radiotherapy. Each was assigned a number of points. The area under curve (AUC) of the prognostic index was larger than that of Union Internationale Contre le Cancer/American Joint Cancer Committee TNM system 2009 (0.697 versus 0.619, P < 0.001). CONCLUSION: A CBC-based prognostic index was developed and had a higher prediction efficiency on 5 year DSS in NPC than the TNM system alone.

[Huge benign mesenchymoma in the pharynx-esophagus].

OBJECTIVE: To investigate the diagnosis and management of the benign mesenchymoma in pharynx-esophagus. METHOD: Records of 2 cases with the benign mesenchymoma, arising from the pharynx-esophagus, were reviewed. RESULT: These tumors, their pedicle attached to the lateral pharynx or esophageal orifice and the body fall down to the esophagus, were large and solitary. Complete surgical resection is believed to be the most suitable treatment by lateral pharyngotomy. CONCLUSION: The benign mesenchymoma in pharynx-esophagus is a rare disease which might be misdiagnosis. Diagnosis is based on typical histologic features as well as clinical information. The prognosis is favorable.