Long-term outcomes of trapeziectomy with Gore-Tex® ligament reconstruction for trapezio-metacarpal osteoarthritis.

BACKGROUND: Trapezio-metacarpal osteoarthritis is a common condition for which the reference standard treatment after failure of non-operative measures is trapeziectomy. Several techniques have been devised to avoid proximal migration of the first metacarpal bone (M1) with impingement on the scaphoid bone. We have developed a Gore-Tex® ligament reconstruction technique that avoids potential complications of tendon harvesting. The objective of this study was to assess the long-term outcomes of this technique. HYPOTHESIS: Trapeziectomy with Gore-Tex® ligament reconstruction is a reliable option for providing lasting pain relief in patients with trapezio-metacarpal osteoarthritis. MATERIALS AND METHODS: We conducted an observational, single-centre, single-surgeon, retrospective cohort study in consecutive patients managed by primary trapeziectomy. We excluded patients with revision trapeziectomy or less than 10 years' follow-up. The primary outcome was event-free survival, defined as absence of revision surgery and of a numerical rating scale score for pain above 3/10. The secondary criteria were clinical tolerance of the Gore-Tex® implant and radiological changes. The patients were assessed at last follow-up either in person or during a teleconsultation. RESULTS: Of 78 included joints, 64 were assessed during patient visits and 24 by teleconsultation. At 10 years, the event-free survival rate was 91.3%, and 60.3% of patients were free of pain. Evidence of osteolysis was visible in 24% of patients. No patient experienced clinical intolerance of the Gore-Tex® implant. The mean Disabilities of Arm, Shoulder and Hand score was 25.5. Metacarpo-phalangeal hyperextension was significantly increased, to 30.6°, and the mean trapezial space ratio was significantly decreased, to 39.1% of the baseline value. CONCLUSION: Long-term event-free survival was high. Functional outcomes and pain were similar to previous reports. Trapeziectomy with Gore-Tex® ligament reconstruction obviates the need for tendon harvesting. Osteolysis developed in some patients but did not correlate with clinical intolerance. Long-term clinical and radiological monitoring is in order after Gore-Tex® implantation. LEVEL OF EVIDENCE: IV, Observational, single-centre, single-surgeon, retrospective cohort study.

Pectoral Plane Block versus Local Anesthetic Infiltration in Breast Implant Augmentation Surgery: A Retrospective Study.

BACKGROUND: Pectoral plane blocks are routinely used in analgesia for patients undergoing dual-plane breast augmentation with implants. Local anesthetic infiltration is a simple alternative technique with the same aim. The authors evaluated both techniques. METHODS: In this single-center retrospective study, patients received pectoral plane block (ropivacaine 0.2%, 10 ml for pectoral plane I; 20 ml for pectoral plane II) or local anesthetic infiltration. The primary outcome measure was pain, according to the visual analogue scale, at 24 hours after surgery. Secondary outcomes included the measure of pain at 1, 2, 6, and 12 hours after surgery; total opioid consumption at 24 hours; and opioid side effects. RESULTS: Eighty-one patients were finally recruited: 37 in the pectoral plane group and 44 in the local anesthetic infiltration group. Patient characteristics were comparable between the two groups. At 24 hours after surgery, the local anesthetic infiltration group showed a decrease in pain, with a visual analogue scale score of 0.7 versus 1.5 in the pectoral plane group ( p = 0.007). There was no difference in visual analogue scale score between the two groups at 1, 2, 6, or 12 hours after surgery. The duration of anesthesia was increased in the pectoral plane group, with 153 minutes versus 120 minutes in the local anesthetic infiltration group ( p < 0.001). There was no difference in rescue morphine consumption between the two groups. CONCLUSIONS: The authors found that local anesthetic infiltration had a superior analgesic effect at 24 hours after surgery for dual-plane breast implant augmentation compared with pectoral plane block. These findings are a good indication that the local anesthetic infiltration technique is at least as effective as pectoral plane block while being safe, fast, and easy to use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Laparoscopy-assisted immediate vaginal reconstruction with a vertical pedicled deep inferior epigastric perforator flap for primary melanoma of the vagina.

The vagina is a rare site for primary melanoma. Here, we report on a case of laparoscopy-assisted immediate vaginal reconstruction with vertical pedicled deep inferior epigastric perforator flap.

Does total wrist denervation give reliable long-term results? Survival curve with an average follow-up of 8.2 years.

INTRODUCTION: Pain is the main reason why patients consult for degenerative and posttraumatic wrist conditions. While the many surgical techniques make choosing the appropriate procedure difficult, total wrist denervation, which has an "analgesic" aim, remains an accessible therapeutic solution to treat this symptomatology. Nevertheless, long-term results remain controversial, and few studies have focused on the survival of this procedure. HYPOTHESIS: Total wrist denervation provides lasting pain relief. PATIENTS AND METHODS: This was a single center, single operator (DLN), retrospective observational study. We analyzed 63 wrists. The mean age at the time of the procedure was 53.7 years. We verified the primary endpoint for survival, which included no further analgesic procedures and no significant residual pain (NRS≤3). Patient satisfaction and the quality of the wrist function were also assessed. RESULTS: The mean follow-up was 8.2 years. Some of the patients (12.7%) did not respond to treatment. We reported 1 neuroma of the superficial sensory branch of the radial nerve, 2 CRPS and 11 revision surgeries. We observed that the treatment became less effective over time. The median survival was 8.8 years. The survival rate of the procedure fell to 13.5% at the last follow-up. The mean residual pain was 3.4 on a numerical rating scale and the mean DASH score was 23.5. The mean satisfaction level, on a scale from 0 to 10, was 7.3 and most patients (79.6%) would undergo this procedure again. DISCUSSION: Survival of the total wrist denervation at the last follow-up was low in our study. Even though the treatment became less effective over time, the quality of the wrist function remained satisfactory and similar to the different studies previously published on the subject. There were very few complications and revisions. CONCLUSION: Total wrist denervation therefore remains an interesting surgical solution for patients with chronic wrist pain as it preserves mobility. LEVEL OF EVIDENCE: IV; Single center, single operator retrospective observational study.

Flap Venous Congestion and Salvage Techniques: A Systematic Literature Review.

Venous congestion is a frequent problem in flap surgery. Other than surgical revision, there are a multitude of procedures in the literature to tackle this problem, but their effectiveness is not clear. Through a systematic review, we aimed to identify and evaluate the different interventions available for managing flap venous congestion. METHODS: The MEDLINE, PubMed central, Embase, and Cochrane databases were searched. The study selection process was adapted from the PRISMA statement. All English and French original articles describing or comparing a method for managing flap venous congestion were included. For each article, a level of evidence was assigned, as defined by the Oxford Centre for Evidence-based Medicine. Lastly, we specifically analyzed the effectiveness of postoperative non-surgical methods. No formal analysis was performed. RESULTS: Through literature searches carried out in various databases, we identified 224 articles. Finally, 72 articles were included. The majority of these studies had a low-level evidence. A total of 17 different methods (7 pre- and intraoperative, and 10 postoperative) were found. Concerning non-surgical methods, the most represented were leeches, local subcutaneous injection of heparin with scarification, venocutaneous catheterization, negative pressure therapy, and hyperbaric oxygen therapy. CONCLUSIONS: Risks of venous congestion of flaps must always be present in a surgeon's mind, at every stage of flap surgery. Apart from studies on the use of leeches, which have a significant follow-up and large enough patient numbers to support their efficacy, the low-level evidence associated with studies of other methods of venous congestion management does not allow us to draw a scientifically valid conclusion about their effectiveness.

Keratinocytes Communicate with Sensory Neurons via Synaptic-like Contacts.

OBJECTIVE: Pain, temperature, and itch are conventionally thought to be exclusively transduced by the intraepidermal nerve endings. Although recent studies have shown that epidermal keratinocytes also participate in sensory transduction, the mechanism underlying keratinocyte communication with intraepidermal nerve endings remains poorly understood. We sought to demonstrate the synaptic character of the contacts between keratinocytes and sensory neurons and their involvement in sensory communication between keratinocytes and sensory neurons. METHODS: Contacts were explored by morphological, molecular, and functional approaches in cocultures of epidermal keratinocytes and sensory neurons. To interrogate whether structures observed in vitro were also present in the human epidermis, in situ correlative light electron microscopy was performed on human skin biopsies. RESULTS: Epidermal keratinocytes dialogue with sensory neurons through en passant synaptic-like contacts. These contacts have the ultrastructural features and molecular hallmarks of chemical synaptic-like contacts: narrow intercellular cleft, keratinocyte synaptic vesicles expressing synaptophysin and synaptotagmin 1, and sensory information transmitted from keratinocytes to sensory neurons through SNARE-mediated (syntaxin1) vesicle release. INTERPRETATION: By providing selective communication between keratinocytes and sensory neurons, synaptic-like contacts are the hubs of a 2-site receptor. The permanent epidermal turnover, implying a specific en passant structure and high plasticity, may have delayed their identification, thereby contributing to the long-held concept of nerve endings passing freely between keratinocytes. The discovery of keratinocyte-sensory neuron synaptic-like contacts may call for a reassessment of basic assumptions in cutaneous sensory perception and sheds new light on the pathophysiology of pain and itch as well as the physiology of touch. ANN NEUROL 2020;88:1205-1219.

Medial Sural Artery Perforator Flap for Leg and Knee Coverage: Extended Skin Paddle With 2 Perforators.

BACKGROUND: For soft-tissue defect coverage in the lower leg and around the knee joint, the gastrocnemius muscle flap is the most commonly used. Having constant anatomy, a long pedicle, and decreased donor site morbidity, the medial sural artery perforator (MSAP) flap may represent a good reconstructive alternative. The aim of this report was to present the experience of using a dual perforator MSAP pedicled flap. METHODS: Nineteen patients underwent soft-tissue reconstruction by MSAP flap in the one third of the lower leg and around the knee joint. Eleven patients were injured in traffic accidents. Exposure of a knee prosthesis required flap coverage in 4 cases. The other defect etiologies were a gunshot wound, bone abscess due to a sickle cell anemia, bone exposure due to a full thickness burn, and sarcoma resection. Defect dimensions ranged from 7 × 5 cm to 15 × 8 cm. Seventeen flaps were harvested with 2 perforators. Donor sites were closed primary in 16 of the 19 cases. RESULTS: The sizes of the MSAP flaps ranged from 7 to 22 cm × 5 to 8 cm. The procedure was uneventful in 17 cases. The 2 unsuccessful flaps developed a distal necrosis, for which an excision with direct suture was made secondary. Complete healing was achieved in all cases. CONCLUSIONS: The pedicled MSAP flap represents a versatile option in soft-tissue defect coverage of the lower leg and around the knee joint. Inclusion of 2 perforators could render the flap safer and increase its skin paddle, making it suitable for larger defects.

Secondary Composite Breast Augmentation: Concept and Outcomes, Introduction to a Layered Approach.

BACKGROUND: Secondary procedures following breast augmentation are often more difficult than primary cases because the soft-tissue envelope changes over time. OBJECTIVES: This study was conducted to confirm the utility of a composite technique in breast revisional surgery. METHODS: This was a 9-year retrospective chart and photographic data study of one surgeon's experience with the combined use of fat and implants in revisional cases. The 148 patients had a follow-up at least 1 year after surgery. Our approach consists of a detailed analysis of the different layers covering the implant and yields a treatment plan addressing all issues involving the secondary breast. RESULTS: On average, revisional surgery was performed 8.66 years after the first augmentation. The mean age of the patients at revision surgery was 42 years (range, 22.2-70.7 years). The mean fat harvest was 600 mL (range, 100-3000 mL) and the mean volume of fat reinjected was 153 mL (range, 60-400 mL). The mean volume before and after revision was the same (288 mL vs 289 mL). At the original surgery, the breast implants were located in a subpectoral pocket in 78.7% of the patients and, at the revision surgery, in a subglandular pocket in 74.8% of the patients. Within the first 2 years, 13 patients (8.7%) underwent reoperation for additional fat grafting. Among 45 preoperative breast capsular contractures, there were 8 recurrences in the first 3 years resulting in 4 reoperations. CONCLUSIONS: Secondary breast augmentation cannot rely solely on implant exchange. Because the soft-tissue envelope also ages over time, fat grafting is mandatory in the vast majority of secondary cases. A rigorous preoperative analysis enables breast defects to be treated appropriately.

Use of the Propeller Lumbar Perforator Flap: A Series of 32 Cases.

Lumbosacral substance defect is a challenge in reconstructive surgery because few coverage solutions are available in this anatomical region. Lumbar artery perforator flaps (LAPs) have been progressively developed and make it possible to solve very complex situations. We report a multicenter study on LAP performed to treat medium and low lumbar defects of various etiologies, to highlight the versatility of this flap as well as its robustness and reproducibility. METHODS: Between 2012 and 2019, 32 LAPs were performed in the Toulouse and Strasbourg University hospitals. Etiologies of the defects encountered were diverse: chronic wounds following neurosurgery, oncodermatology, burn sequelae, and ballistic injury. All LAPs were used in their pedicled form, turned as propeller, and combined or not with other flaps. RESULTS: We treated 31 patients with 32 LAPs. Average flap size was 14.3 cm (range 8-26) × 6.5 cm (range 5-10), and average arc of rotation was 131.3 degrees (range 70-180 degrees). Only 4 patients (12.9%) presented partial necrosis, but required no other covering procedure because secondary healing was sufficient. No coverage failure was reported. Average follow-up duration was 9.7 months (range 1-18). CONCLUSIONS: In the case of lumbosacral defects of various etiologies, propeller LAP is a reliable and efficient surgical procedure, offering the advantage of low donor site morbidity. The reconstructive surgeon should propose this technique to patients as a first-line option where surgery is indicated.

Predicting epiphyseal screw length in anterior plating of distal radial fractures.

The purpose of this study was to determine whether optimal epiphyseal screw length could be predicted with reference to a given diaphyseal screw length when fixating a plate to the anterior surface of the distal radius. Computerized tomography scans of 40 wrists of 28 men and 12 women were semi-automatically segmented. A virtual anterior plate model was fixed to the distal radius. The mean maximal appropriate length of one diaphyseal screw and of the four distal epiphyseal screws were measured and linear regression analyses were performed. We found that the epiphyseal screw lengths were highly correlated to the diaphyseal screw length. Based on the data derived from measurements, we recommend epiphyseal screw lengths from ulnar to radial of 18, 18, 20 and 16 mm, respectively, if the diaphyseal screw is 14 mm or less. For diaphyseal screws longer than 14 mm we recommend epiphyseal screws of 20, 20, 22 and 18 mm. Using these recommended screw lengths as general guidelines may reduce the risk of intra-operative and postoperative extensor tendon injury.

The SCIP propeller flap: Versatility for reconstruction of locoregional defect✰.

INTRODUCTION: Abdominopelvic defect is frequently a challenge. Several local flaps exist for this anatomical region, but sequelae of the donor site, particularly with regard to morbidity on the anterior abdominal wall, are frequent. Although the utility of the superficial circumflex iliac artery flap is well established in its free form as well as its pedicled form described by McGregor, the superficial circumflex iliac artery perforator (SCIP) propeller flap is rarely reported. The purpose of this study is to highlight the possible range of locoregional coverage using the SCIP propeller flap. METHODS: Between 2012 and 2018, 72 SCIP flaps were made in the propeller version to cover locoregional defects of various etiologies in our units. RESULTS: The dimensions of SCIP flaps were on average 20.2 cm long (9-39) by 8.2 cm wide (5-18). The average rotation angle was 163.3° (range 130-180). In sixteen patients, SCIP flaps were bilateral. In five cases, the reconstruction was combined with a contralateral Tensor Fascia Lata (TFL) flap to cover a very large defect. Two SCIP flaps necrotized following global venous congestion and a TFL flap was performed in rescue. No complications appeared on the donor site and the patients did not have any functional complications related to the reconstruction. Particular care was taken to respect the lateral cutaneous nerve of the thigh. CONCLUSION: The SCIP propeller flap provides a reliable and versatile method for reconstructing abdominoperineal defect, including the thigh root region to the trochanters with low donor site morbidity.

Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations.

BACKGROUND: Covering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects. HYPOTHESIS: The posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot. MATERIAL AND METHOD: Patients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit. RESULTS: Thirteen patients with a mean age of 46.9 years (range: 25-73 years) were reviewed after a mean follow-up of 19.5 months (range: 16-63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients. DISCUSSION: The posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate. LEVEL OF EVIDENCE: IV, retrospective study.

Reconstruction of columellar defects: Which surgical technique to choose? A retrospective study of 18 patients.

The reconstruction of the columella is challenging and poorly evaluated in the literature. Our study aimed to evaluate retrospectively the different techniques used in our center and to propose an algorithm of reconstruction adapted to each patient. We report a retrospective cohort study included 18 patients (9 men and 9 women; 53 years-old in average) with columellar reconstruction treated from 1999 through 2014. Six different techniques were used: chondrocutaneous graft, nasolabial flap, paramedian forehead flap and scalping flap according to the Converse technique or the Raulo technique. Four independent plastic surgeons evaluated the aesthetic result on a 10 cm visual analogue scale comparing the patients' photographs before and after the reconstruction. Furthermore, we asked the patients to perform the same evaluation, and to evaluate their level of satisfaction. The mean follow-up was 4 years. Three chondrocutaneous grafts were performed to reconstruct partial defects (Surgical Evaluation (SE): 7.9, Patient Evaluation (PE): 8.3).Three bilateral nasolabial flaps (SE: 6.1, PE: 6.7), 5 paramedian forehead flap (SE: 6.9, PE: 7.3) 6 Converse scalping flap (SE: 4.9, PE: 5.4) and 1 Raulo scalping flap (SE: 6,1, PE: 6,3) were performed to reconstruct total defects exceeding the columella. The use of composite graft was the most satisfactory procedure for partial defects. Paramedian forehead flaps and Raulo scalping flap were the most satisfactory procedures for extended defects. Nasolabial flap was the most adapted procedure for patients with general anesthesia contraindication or for defects extended to the lip.

Major Role for TRPV1 and InsP3R in PAR2-Elicited Inflammatory Mediator Production in Differentiated Human Keratinocytes.

PAR2 activation in basal keratinocytes stimulates inflammation via the Ca2+-dependent production of mediators such as IL-1ß, TNF-α, and TSLP. In this study, we investigated PAR2 calcium signaling and the consequent production of inflammatory mediators in differentiated human primary keratinocytes (DhPKs). Stimulation with the PAR2-activating peptide SLIGKV promoted Ca2+ store depletion in both undifferentiated human primary keratinocytes and DhPKs. SLIGKV-evoked Ca2+ store depletion did not trigger the store-operated Ca2+ entry (i.e., SOCE) through ORAI1 in DhPKs compared with undifferentiated human primary keratinocytes. The inhibition of phospholipase C and the concomitant inhibition of TRPV1 and inositol triphosphate receptor in DhPKs abrogated the SLIGKV-evoked Ca2+ store depletion; NF-κB activity; and the production of inflammatory mediators such as IL-1ß, TNF-α, and TSLP. Taken together, these results indicate a key role for both InsP3R and TRPV1 in Ca2+ internal stores in the PAR2-evoked Ca2+ release and consequent skin inflammation in DhPKs. These findings may provide clues to understanding the pathological role of DhPKs in skin disorders in which PAR2 is known to be involved, such as atopic dermatitis, Netherton syndrome, and psoriasis.