Primary trapeziectomy with Regjoint(TM), a poly-L/D-lactide spacer, a two-year follow-up study with new radiological assessment tool.

The aim of this retrospective study was to evaluate the potential bony erosion and the clinical and radiological results of primary trapeziectomy with RegjointTM interposition, in patients with peritrapezial arthritis. Data were recorded on twenty patients over a period of two years (January 2015-December 2016). On average 24 months, patients were reconvened for a post-operative evaluation (subjective evaluation of pain, function and patient satisfaction; clinical evaluation with strength and mobility measures; post-operative X-rays). On X-rays, 2 criteria were evaluated: the bony erosion and the shortening of the thumb column (trapezium+metacarpal height measure, ratio between first and second metacarpal bones, a new radiological assessment tool based on a trapezoid relationship gradation). In most patients, surgery relieved pain and offered good functional results, according to the Quick Disabilities of the Arm, Shoulder and Hand scale. Following surgery, our patients showed a subjective improvement, both in terms of pain and functional results. For plain X-ray, only 3 patients showed an osteolytic lesion (maximum of 2.8 millimeters) on the first metacarpal base. A statistically significant reduction in the thumb column height was generally observed on follow-up X-rays. However, all of these radiologic changes were present without any clinical impact. We show that the RegjointTM spacer is an available alternative in the surgical treatment of peritrapezial arthritis. We did not highlight any significant associated complications, no important adverse tissue reaction or bone erosion, no pain or functional disorder. Type of study/level of evidence Therapeutic IV.

Lymphatic Alterations Under Tattoos: Preliminary Reports of One Observational Study.

Background: The number of people within the European population having at least one tattoo has increased notably and with it the number of tattoo-associated clinical complications. The injected inks are known to be removed by the lymphatic vessels and can be found in the draining lymph nodes. Aim of the Study: To report our observations on the lymphatic drainages seen under tattoos using near infrared fluorescence imaging of these lymphatic vessels after the injection of indocyanine green. Material and Methods: Indocyanine green was injected intradermally at the basis of the 20 tattooed area(s) in 19 subjects (nine women and ten men; mean age = 28.6). Ten subjects had only black tattoos (six upper limbs and four lower limbs), five (two upper limbs and three lower limbs) black and white tattoos and five multi-colored tattooed limbs (four lower limbs and one upper limb). Results: The imaging exams revealed alterations in eight individuals, seven of whom had tattoos on their lower limbs. Furthermore, the imaging results showed that the abnormalities might be related to the tattooed limb, the tattoo extent and colour. Conclusion: Alterations of the cutaneous lymphatic channels are frequently observed under tattooed territories. Their causal factors should be more precisely studied in future works and these lymphatic alterations should be considered in tattooed patients when using similar imaging techniques for therapeutic and surgical assessments.

A Surgical Alternative in the Treatment of Hypopharyngeal Perforation.

Pharyngo-esophageal perforation is a rare, life-threatening complication of anterior cervical discectomy and fusion surgery with an incidence estimated to be between 0.2 and 1.51%. Early diagnosis and appropriate treatment of this complication is the key to reduce morbidity and mortality, as the main prognostic factor is the interval between the onset of the fistula, diagnosis and treatment. Conservative management has shown encouraging results in small and localized defects, whereas surgical approaches using flaps are to be considered for most of the cases. However, there is no clear consensus on the first choice of treatment in esophageal perforation. This case report presents the use of a supra-clavicular fascio-cutaneous pedicled propeller flap as a patch combined to primary repair of a hypopharyngeal perforation, 10 years after anterior cervical spine arthrodesis.

Anatomical Study of Lumbar Artery Perforators in Male Subjects.

INTRODUCTION: The lumbar artery perforator (LAP) flap takes an important place in lumbosacral reconstruction and in breast reconstruction. Although studies on the location of lumbar perforators in women are common, no anatomical study has focused solely on male subjects. Our objective is to facilitate the surgical approach to the LAP flap in male subjects by precisely ascertaining the characteristics of the perforators. METHODS: We performed a retrospective review of computed tomographic angiography images of a cohort of 30 patients evaluating the perforator position from the 4 lumbar arteries. In addition, 4 characteristics were studied: the length, the diameter, the path of the lumbar pedicle, and the thickness of tissues available for transfer. RESULTS: One hundred five lumbar perforating vessels were analyzed on 60 posterior hemi-bodies, of which 86% came from the third and fourth lumbar arteries. The average location was situated 7.4 cm from the midline and in a 6-cm vertical wide area. The position of the lumbar perforator was independent of body mass index, abdominal circumference, and subject size. Our results, compared to previous studies, show no difference in this position between men and women. CONCLUSIONS: The LAP flap is useful for regional reconstructions and as a free flap for both women and men. We provide male-specific tracking values for the dissection of lumbar perforating vessels. Dominant perforators were found to be situated in a wide region of 4 cm × 6 cm in the lumbosacral region at 7.4 cm from the midline.

From Open to Robotic-assisted Latissimus Dorsi Muscle Flap Harvest.

The latissimus dorsi muscle is the largest muscle in the body. The classic open flap harvest technique of this muscle results in a long posterolateral thoracic vertical oblique incision that can leave an unappealing scar. The minimally invasive robotic approach has the potential to reduce scar length and to overcome technical limitations of endoscopic techniques. METHODS: Six robotically assisted latissimus dorsi muscle flaps were harvested by a single surgeon. One was used as reversed turnover pedicled flap based on lumbar perforators for lumbosacral bone coverage, another flap was transposed for a Poland syndrome anterior axillary line reconstruction, and the remaining 4 were dissected as free flaps for upper and lower limb reconstruction. All 6 procedures used a short 5-cm axillary crease incision along the posterior axillary fold and two 8-mm port incisions for robotic access. RESULTS: The first robotic flap harvest was converted to the classic open technique due to malposition of the 2 lower port incisions too close to the latissimus dorsi anterior border. The 5 other flaps were successfully transferred without flap or donor site complications. The average flap dissection time was 110 minutes; latter surgeries took less time than the early surgeries as the surgeon became more familiar with the robotic system and due to the use of a newer system. CONCLUSION: Robotic-assisted latissimus dorsi muscle flap harvest is a safe, reproducible, and effective tool that offers precise dissection control and that leaves a minimal thoracic scar.

Surgical Fixation of Metacarpophalangeal Collateral Ligament Rupture of the Fingers.

BACKGROUND: Collateral ligament injury of the metacarpophalangeal joint of the fingers is underreported in the literature and widely underestimated by the medical community. Here, the authors present results from a large series of patients and review factors influencing success of surgery. METHODS: The authors performed a retrospective study of 46 patients who underwent surgical fixation of the metacarpophalangeal collateral ligament using bone anchor in an acute or chronic setting. The diagnosis was predominantly clinical, based on laxity testing of the joint. The authors collected demographic data and intraoperative findings and postoperative results. RESULTS: Following surgery, with a median follow-up of 17 months, all patients presented with a stable joint and complete resolution of pain. The mean flexion of the metacarpophalangeal joint was 77.11 degrees, and mean extension was 0.84 degrees. The authors measured the injured grip strength at a mean of 88.52 percent of the opposite hand, and the mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score used to evaluate disability was 9.56 on a scale of 100 (with 100 being complete disability). CONCLUSIONS: Surgical treatment of metacarpophalangeal collateral ligament rupture of the fingers is a safe technique that gives reproducible positive results in terms of mobility, strength, and disability scale score. The authors' results show that anchoring of the ligament should be performed even with prolonged time from injury to surgery.

Case 247: Jersey Finger of the Fifth Finger.

History A 34-year-old man without underlying medical conditions came to the emergency department for evaluation of persistent pain over the volar portion of his right fifth finger after a fall during a football match 3 days before. At physical examination, the injured finger was swollen and purple. Passive and active flexion of the proximal and distal interphalangeal joints were compromised, without interphalangeal instability. Radiography was performed in the emergency department, and the patient was released with a diagnosis of a fifth digit sprain. After the senior radiologist (V.M.C.) reviewed the radiographs, the patient was called back for assessment with ultrasonography (US) on the same day. US was performed with an Aplio 500 unit (Toshiba Medical Systems, Tokyo, Japan) using a multifrequency linear array 7.2-18.0-MHz PLT-1204BX transducer focused at the level of the flexor tendon. The patient was sitting in front of the examiner, with the hand lying palm up on the examination bed. No abnormality was observed during color Doppler US.

Successful (neo)adjuvant BRAF-targeted therapy in a patient with locally advanced BRAF V600E mutant melanoma.

The treatment of locally advanced metastasized melanoma is challenging because there is no level 1 evidence to guide clinical decision-making. Moreover, the treatment options available fail to improve overall survival and are associated with considerable morbidity. Here, we show that systemic treatment with BRAF inhibitor vemurafenib substituted by dual BRAF/MEK inhibition (dabrafenib and trametinib) before surgery can offer the potential to cure the initially difficult or inoperable melanoma. A 62-year-old woman was diagnosed with an AJCC stage IIIB melanoma harboring the BRAF V600E mutation after a complete initial evaluation. Clinically, the patient presented a large primary lesion that was surrounded by ∼25 secondary epidermotropic lesions both satellite and 'in transit' with a diameter between 1 and 6 mm. Following multidisciplinary consultation, the patient was started on 960 mg twice-daily vemurafenib, which was stopped and resumed at 720 mg twice daily, and finally substituted with the combination dabrafenib and trametinib to reduce the persistent side effects. Successive clinical examinations had shown a progressive reduction in the thickness of the melanoma lesions. After about 5 months of therapy, surgery was performed and the histopathological analysis showed an almost complete regression of tumor cells. The treatment with dabrafenib/trametinib was continued only 3 months after surgery and stopped at the patient's request. The patient currently remains in complete remission at 8 months after surgery. The case presented here supports the use of neoadjuvant treatment with BRAF inhibitors in advanced 'in transit' melanoma.

Early one-stage repair of complete unilateral cleft lip and palate.

BACKGROUND: The purpose of this prospective study was to evaluate craniofacial morphology in children with complete unilateral cleft lip and palate treated at the Brussels cleft center after a 1-stage complete closure at 3 months and compare the results with a series of children operated on at 3 and 6 months of age according to the Malek surgical protocol. METHODS: A series of 72 consecutive patients who were operated on for nonsyndromic complete unilateral cleft lip and palate were included in this study at approximately the age of 10 years. Thirty-four were treated according to the Malek surgical treatment protocol: the soft palate was closed at a mean (SD) age of 3.04 (0.20) months, followed by simultaneous repair of the lip and hard palate at 6.15 (0.67) months. Thirty-eight underwent 1-stage all-in-one (AIO) closure of the lip and hard and soft palates at 2.98 (0.16) months. Craniofacial morphology was evaluated by means of a digital cephalometric analysis. Cephalometric data were compared with a noncleft control group (n = 40) matched according to age. The same 2 series of children were followed up until 15 years of age, and the results were again compared. RESULTS: Statistical analysis (analysis of variance with post hoc Tukey test) showed in both groups who were operated on a decreased anteroposterior growth compared with the children without cleft at 10 years but the AIO group only was not different from the group without cleft. The maxillary (MxPI/SN) plane was significantly (P = 0.002) increased in the Malek cleft group compared with the AIO group with cleft. At 15 years of age, a difference was not observed anymore between the 2 groups for the anteroposterior growth or for the maxillary plane inclination. CONCLUSIONS: One-stage AIO closure based on the Malek surgical principles provided good anteroposterior midfacial morphology and resulted in less opening of the maxillary plane to the anterior cranial base.

Hyperoxia enhances metaboreflex sensitivity during static exercise in humans.

Peripheral chemoreflex inhibition with hyperoxia decreases sympathetic nerve traffic to muscle circulation [muscle sympathetic nerve activity (MSNA)]. Hyperoxia also decreases lactate production during exercise. However, hyperoxia markedly increases the activation of sensory endings in skeletal muscle in animal studies. We tested the hypothesis that hyperoxia increases the MSNA and mean blood pressure (MBP) responses to isometric exercise. The effects of breathing 21% and 100% oxygen at rest and during isometric handgrip at 30% of maximal voluntary contraction on MSNA, heart rate (HR), MBP, blood lactate (BL), and arterial O2 saturation (SaO2) were determined in 12 healthy men. The isometric handgrips were followed by 3 min of postexercise circulatory arrest (PE-CA) to allow metaboreflex activation in the absence of other reflex mechanisms. Hyperoxia lowered resting MSNA, HR, MBP, and BL but increased Sa(O2) compared with normoxia (all P < 0.05). MSNA and MBP increased more when exercise was performed in hyperoxia than in normoxia (MSNA: hyperoxic exercise, 255 +/- 100% vs. normoxic exercise, 211 +/- 80%, P = 0.04; and MBP: hyperoxic exercise, 33 +/- 9 mmHg vs. normoxic exercise, 26 +/- 10 mmHg, P = 0.03). During PE-CA, MSNA and MBP remained elevated (both P < 0.05) and to a larger extent during hyperoxia than normoxia (P < 0.05). Hyperoxia enhances the sympathetic and blood pressure (BP) reactivity to metaboreflex activation. This is due to an increase in metaboreflex sensitivity by hyperoxia that overrules the sympathoinhibitory and BP lowering effects of chemoreflex inhibition. This occurs despite a reduced lactic acid production.

Acute cardiovascular and sympathetic effects of nicotine replacement therapy.

Sympathetic overactivity is implicated in the increased cardiovascular risk of cigarette smokers. Excitatory nicotinic receptors are present on peripheral chemoreceptor cells. Chemoreceptors located in the carotid and aortic bodies increase ventilation (Ve), blood pressure (BP), heart rate (HR), and sympathetic nerve activity to muscle circulation (MSNA) in response to hypoxia. We tested the hypothesis that nicotine replacement therapy (NRT) increases MSNA and chemoreceptor sensitivity to hypoxia. Sixteen young healthy smokers were included in the study (8 women). After a randomized and blinded sublingual administration of a 4-mg tablet of nicotine or placebo, we measured minute Ve, HR, mean BP, and MSNA during normoxia and 5 minutes of isocapnic hypoxia. Maximal voluntary end-expiratory apneas were performed at baseline and at the end of the fifth minute of hypoxia. Nicotine increased HR by 7+/-3 bpm, mean BP by 5+/-2 mm Hg, and MSNA by 4+/-1 bursts/min, whereas subjects breathed room air (all P<0.05). During hypoxia, nicotine also raised HR by 8+/-2 bpm, mean BP by 2+/-1 mm Hg, and MSNA by 7+/-2 bursts/min (all P<0.05). Nicotine increased MSNA during the apneas performed in normoxia and hypoxia (P<0.05). Nicotine also raised the product of systolic BP and HR, a marker of cardiac oxygen consumption, during normoxia, hypoxia, and the apneas (P<0.05). Ve, apnea duration, and O2 saturation during hypoxia and the apneas remained unaffected. In conclusion, sympathoexcitatory effects of NRT are not because of an increased chemoreflex sensitivity to hypoxia. NRT increases myocardial oxygen consumption in periods of reduced oxygen availability.

Increased peripheral chemoreceptors sensitivity and exercise ventilation in heart transplant recipients.

BACKGROUND: Heart failure is characterized by increased ventilation during exercise, which is positively related to increased peripheral and central chemoreceptor sensitivity. Heart transplantation does not normalize the ventilatory response to exercise, and its effects on the chemoreflex control of ventilation remain unknown. We tested the hypothesis that chemoreceptor sensitivity is increased in heart transplant recipients (HTRs) and linked to exercise hyperpnea. METHODS AND RESULTS: We determined the ventilatory, muscle sympathetic nerve activity (MSNA), and circulatory responses to isocapnic hypoxia and hyperoxic hypercapnia 7+/-1 years after transplantation in 19 HTRs with a normal left ventricular ejection fraction of 60+/-2%. Results were compared with those of 11 closely matched referent subjects. Sixteen patients and 10 referent subjects also underwent cycle ergometer exercise tests. HTRs compared with referent subjects presented higher MSNA (52+/-4 versus 34+/-3 bursts/min; P<0.01) and heart rates (83+/-3 versus 68+/-3 bpm; P<0.01) during room air breathing. The ventilatory response to hypoxia was higher in HTRs than in referent subjects (P<0.01, ANOVA). The increase in MSNA also was more marked during hypoxia in the HTRs than in the referent group (P<0.05, ANOVA). Responses to hyperoxic hypercapnia did not differ between the HTRs and the referent group. The ventilatory response to exercise, characterized by the regression slope relating minute ventilation to CO2 output, was steeper in HTRs than in referent subjects (38+/-2 versus 29+/-1 L/mm Hg; P<0.01). Exercise ventilation in HTRs was related to the ventilatory response to isocapnic hypoxia (r=0.57; n=16; P<0.05) and to the ventilatory response to hyperoxic hypercapnia (r=0.50; n=16; P<0.05). CONCLUSIONS: Peripheral chemoreceptor sensitivity is increased in HTRs and is related to exercise hyperpnea after heart transplantation.

Effects of peripheral chemoreceptors deactivation on sympathetic activity in heart transplant recipients.

Heart transplantation initially normalizes sympathetic hyperactivity directed at the muscle circulation. However, sympathetic activity increases with time after transplantation and the exact mechanisms responsible for sympathetic control in heart transplant recipients remain unclear. We examined the effects of peripheral chemoreflex deactivation caused by breathing 100% oxygen on muscle sympathetic nerve activity (expressed as number of burst per minute and mean burst amplitude), heart rate, and mean blood pressure in 13 heart transplant recipients, 13 patients with essential hypertension, and 10 controls. Heart transplant recipients disclosed the highest sympathetic activity, whereas it did not differ between controls and patients with essential hypertension (51+/-16 versus 37+/-14 versus 39+/-12 burst/min, respectively; P<0.05). Breathing 100% oxygen, in comparison with 21% oxygen, reduced sympathetic activity (-4+/-4 versus -1+/-2 burst/min, P<0.01; 85+/-9 versus 101+/-8% of amplitude at baseline, P<0.001) and mean blood pressure (-4+/-5 versus +3+/-6 mm Hg; P<0.05) in heart transplant recipients, decreased sympathetic activity (-4+/-4 versus 0+/-3 burst/min, P<0.05; 90+/-16 versus 101+/-9% of amplitude at baseline, P<0.05) in patients with essential hypertension, but did not reduce sympathetic activity (2+/-4 versus 3+/-3 burst/min, P=NS; 95+/-11 versus 95+/-13% of amplitude at baseline, P=NS) in control subjects. The sympathetic response to hyperoxia was more marked in heart transplant recipients than in controls (85+/-9 versus 95+/-11% of baseline amplitude; P<0.05). The decrease in sympathetic activity was most evident in patients with the longest time after heart transplantation (r=-0.75, P<0.01). In conclusion, tonic chemoreflex activation increases resting muscle sympathetic nerve activity and favors blood pressure elevation after heart transplantation.