Satisfactory functional results and complication rates after anterior glenoid bone block reconstruction in recurrent shoulder dislocation: a mean 4-year follow-up comparative study.

BACKGROUND: Anterior recurrent instability of the glenohumeral joint is a common clinical problem among the young population. Glenoid reconstruction with bone graft has become the treatment of choice, particularly in significant deficiency (˃20%). This study aims to assess the functional results of glenoid reconstruction using Latarjet and iliac bone graft in the management of glenoid insufficiency associated with recurrent anterior dislocation of the glenohumeral joint. METHODS: Patients suffering from anterior shoulder instability with glenoid defect >20% were included in this study between 2016 and 2021. The university of California at Los Angeles (UCLA) shoulder scale and Constant score were used to assess the functional improvement. Preoperative and final postoperative continuous outcomes were compared with a one-tailed paired t-test and the outcomes across groups were compared using a two-tailed independent t-test. A P-value of <0.05 was considered statistically significant for both tests. RESULTS: This trial included 50 patients; twenty-five underwent mini-open Latarjet, and 25 underwent arthroscopic tricortical iliac crest bone grafting (ICBG). The mean follow-up durations were 50.1 ± 5.9 months for Laterjet and 51.6 ± 6.8 months for ICBG. Both techniques showed statistically significant improvement in the final UCLA (31.1 ± 2.1 in Laterjet and 30.2 ± 2.2 in ICBG) and Constant (90.2 ± 4.6 in Laterjet and 89 ± 5.01 in ICBG) scores. There was no statistically significant difference regarding mean age, sex, side of injury, mechanism of injury, follow-up period and clinical outcome between both surgical treatments. At the end of the study, both groups demonstrated statistically significant improvement in the range of motion (p Ë‚ 0.00001). Only one, non-adherent patient in Laterjet group had post-operative dislocation. In ICBG group, two patients had partial bone graft resorption, 3 graft site morbidities and 1 hardware prominence. CONCLUSION: Both Laterjet and iliac bone graft procedures had satisfactory functional results in reconstruction of glenoid defect >20% in unstable shoulders with a mean 4-year follow-up. No statistically significant difference was reported in the last postoperative Constant and UCLA scores between both techniques, but Latarjet procedure had fewer complications (4%) than ICBG (24%). LEVEL OF EVIDENCE: Prospective non-randomized comparative study; level II.

3-Dimensional fasciectomy: A highly efficacious common ground approach to Dupuytren's surgery.

BACKGROUND: Numerous Dupuytren's fasciectomy techniques have been described, each associated with unique surgical challenges, complications and recurrence rates. We describe a common ground surgical approach to Dupuytren's disease; 3-dimensional fasciectomy (3DF). 3DF aims to address the potential contributors to the high recurrence rate of Dupuytren's disease and unite current limited fasciectomy practice that varies considerably between surgeons. METHODS: We describe the 3DF principles; raising thin skin flaps (addressing dermal involvement), excising diseased palmar fascia with a 3-5 mm clearance margin (treating highly locally recurrent conditions) and excising the vertical septae of Legueu and Juvara (providing deep clearance, hence addressing all potentially involved pathological tissue). The surgical outcomes between traditional limited fasciectomy (LF) and 3DF are compared. RESULTS: From the 786 operations included (n=585), postoperative recurrence rates were significantly lower for the 3DF group (2/145, 1.4%) than the LF group (72/641, 11.2%) (P=0.001), and the time to recurrence was significantly longer (5.0±0 years vs. 4.0±0.2 years; P<0.0001). With recurrence excluded, there were no differences between the postoperative complication rates for 3DF (5/145, 3.5%) and LF (41/641, 6.4%) (P=0.4). CONCLUSIONS: Our results suggest that 3DF leads to lower recurrence rates and a longer disease-free period for patients, without increasing complications. 3DF provides a safe, efficacious, common ground surgical approach in the treatment of Dupuytren's flexion deformity.

Postsurgical Pyoderma Gangrenosum Versus Necrotizing Fasciitis: Can We Spot the Difference?

BACKGROUND: Pyoderma gangrenosum is a rare noninfectious cutaneous disease characterized by expanding areas of skin ulceration around necrotic centers with purulent debris. Exceptionally, it can be precipitated by surgery alone, and this entity has been described as postsurgical pyoderma gangrenosum (PSPG). Cases of PSPG in the literature are rare. METHODS: We performed a retrospective review of the current literature on PSPG and highlight some observed differences between these conditions. We also present our experience of PSPG imitating an infectious process post reduction mammoplasty. RESULTS: Although PSPG can demonstrate fever, malaise, systemic signs, and serology that mimic the sepsis of necrotizing fasciitis, we identify some features that can aid diagnosis of pyoderma gangrenosum in the absence of pathergy (which is pathognomonic). These include premorbid inflammatory bowel disease, hematological malignancy, or inflammatory polyarthritis; the exquisite and disproportionate pain associated (in particular within surrounding normal skin); symmetrical changes on both breasts; specific histopathological changes with absence of microorganisms; cutaneous wounds demonstrating an ulcerated, violaceous, and undermined edge; and, in this case, bilaterally spared nipple-areola complexes suggesting progression within continuous skin up to but not across incision lines. CONCLUSIONS: We hope that, in encouraging a higher index of suspicion, prompt diagnosis, and accurate treatment, a better outcome for both patient and surgeon can be achieved in future cases.

Axillary skin malignancy: a rare breast cancer presentation.

A rise in incidence and decrease in mortality rates from breast cancer have lead to an increase in prevalence within developed countries. Presentation is classically with a palpable breast tissue mass that may metastasize to bone, lung, liver, brain, lymph nodes, and skin. We describe a delayed diagnosis, in an 80-year-old female patient, where, on 2 occasions, the primary initial presentation was with a cutaneous squamous cell carcinoma in the right axilla. It was not until the third referral, with an ipsilateral breast lump, that breast cancer was clinically diagnosed. This was histologically identified as the primary malignancy, most likely in-keeping with squamous cell carcinoma of the breast. This unique atypical presentation represents a diagnostic challenge and highlights a clinically relevant learning point that may avoid subsequent diagnostic delay. Cutaneous axillary lesions should be treated with a high index of suspicion, necessitating the requirement for chest examination because of the possible presence of an associated primary breast carcinoma.

The sitting, oblique, and supine marking technique for reduction mammaplasty and mastopexy.

BACKGROUND: Reduction mammaplasty is one of the most common procedures in plastic surgery. It presents both artistic and technical challenges. Breast reduction surgery aims to reduce the vertical and horizontal planes, shape the parenchyma, reposition the nipple-areola complex, and resect redundant skin. The surgery on paired organs has the added challenge of symmetry. Much of the outcome of our work as plastic surgeons is determined by preoperative planning and designing. METHODS: A number of techniques have been described for the preoperative marking of breast reduction, with particular reference to the precision of the angle between the two vertical limbs. Few, if any, of the previous techniques have gained total popularity or acceptance by plastic surgeons. RESULTS: The freehand marking technique is probably the most widely used technique. Devices such as templates, shaped wires, and goniometers, and geometric techniques, have also been recommended. Some of these devices have stood the test of time; others have been modified or abandoned. CONCLUSIONS: The authors propose a new preoperative marking technique dependent on the natural breast fall. The patient is marked in three positions: sitting, oblique, and supine. This technique has been adopted for the past 10 years.