Microvascular free flap coverage of complex soft tissue defects after revision total knee arthroplasty: a cross-sectional observation study.

BACKGROUND AND PURPOSE: Soft tissue defects after total knee arthroplasties (TKA) represent a major orthopedic challenge with amputation as a feared outcome. Microvascular free flap coverage (FFC) can increase limb salvage rates, but complications related to the procedure are yet to be explored further. We aimed to review a single-center experience with FFC for soft tissue defects related to revision total knee arthroplasty. METHODS: Through a retrospective chart review from 2006 to 2021, we identified all patients who had FFC of a knee with an existing TKA. Typically, patients underwent 2-stage revision arthroplasty. To identify areas of intervention, we divided the entire regimen into 2 phases divided by the free flap surgery (pre- and post-free flap). RESULTS: We identified 18 patients with a median age at free flap surgery of 69 years (range 39-85), who were followed for a median of 5.1 years (range 2 months to 10.6 years). The median duration from primary TKA to their final operation was 17.5 months (range 19 days to 7 years). Patients underwent a mean of 7.6 surgical procedures on their knee with 3.6 orthopedic revisions prior to the FFC and 0.6 after. Soft tissue coverage was achieved in all patients and no patients underwent amputation. One-third of patients experienced early complications at recipient site after free flap surgery. There were no donor site complications. CONCLUSION: Microvascular FFC of complex soft tissue defects after revision total knee arthroplasty proved achievable in all patients with successful limb salvage in all patients.

USP25 Inhibits Neuroinflammatory Responses After Cerebral Ischemic Stroke by Deubiquitinating TAB2.

Cerebral ischemic stroke is a leading cause of morbidity and mortality globally. However, the mechanisms underlying ischemic stroke injury remain poorly understood. Here, it is found that deficiency of the ubiquitin-specific protease USP25 significantly aggravate ischemic stroke injury in mice. USP25 has no impact on neuronal death under hypoxic conditions, but reduced ischemic stroke-induced neuronal loss and neurological deficits by inhibiting microglia-mediated neuroinflammation. Mechanistically, USP25 restricts the activation of NF-κB and MAPK signaling by regulating TAB2. As a deubiquitinating enzyme, USP25 removeds K63-specific polyubiquitin chains from TAB2. AAV9-mediated TAB2 knockdown ameliorates ischemic stroke injury and abolishes the effect of USP25 deletion. In both mouse and human brains, USP25 is markedly upregulated in microglia in the ischemic penumbra, implying a clinical relevance of USP25 in ischemic stroke. Collectively, USP25 is identified as a critical inhibitor of ischemic stroke injury and this data suggest USP25 may serve as a therapeutic target for ischemic stroke.

Efficacy of breast reconstruction in elderly women (>60 years) using deep inferior epigastric perforator flaps: A comparative study.

BACKGROUND: The indications for microsurgical breast reconstruction remain debated, particularly concerning the safety of deep inferior epigastric perforator (DIEP) flaps in elderly women. Free tissue transfer still carries a risk of perioperative morbidity and mortality in elderly patients. We conducted this comparative study to clarify this issue. METHODS: This retrospective cohort study included all unilateral DIEP breast reconstructions performed at a single institution. Patients were divided into two groups based on age: an elderly (60 years or older) and a non-elderly cohort (younger than 60 years). Demographic and comorbidity data were secondary predictor variables. The primary outcomes were complete flap loss, partial flap loss, and the need for flap re-exploration. The secondary outcomes included surgical site occurrences, such as wound healing-related complications, seroma, and others. RESULTS: We included 214 flaps, 177 in the non-elderly and 37 in the elderly cohort. Elderly women had slightly higher comorbidity rates than those of non-elderly women, although these differences were not statistically significant. BMI was significantly lower in elderly women than in non-elderly women. The incidence of total or partial flap loss did not differ significantly between the two cohorts (2.7% vs 1.1%, p = 0.459% and 0.0% vs 5.1%, p = 0.161), nor did the flap re-exploration (8.1% vs 10.1%, p = 0.937). Similarly, postoperative complication rates did not differ significantly between the two groups (45.9% vs 61.8%, p = 0.074). On logistic regression, being elderly was not a risk factor for complete flap loss, nor for any complications. The overall success rate for the non-elderly cohort was 98.7%, whereas that for the elderly cohort was 97.3%. CONCLUSIONS: Microsurgical breast reconstruction using DIEP is safe in elderly patients, as it achieves outcomes and complications rates comparable to those observed in a younger population. Patients should not be denied DIEP flaps because of their age alone.

Total calcaneal reconstruction using a massive bone allograft and a distally pedicled osteocutaneous fibula flap: A novel technique to prevent amputation after calcaneal malignancy.

In patients with primary calcaneal malignancies, such as Ewing's sarcoma, radical treatment with amputation of the foot can result in serious functional impairment and chronic pain. Total calcanectomy followed by the reconstruction of the calcaneal defect offers an alternative treatment to amputation. Capanna et al. described a technique for successfully reconstructing long limb segmental bone defects using a free fibula flap placed within the intramedullary canal of an allograft. We present both a review of the literature on calcaneal reconstruction and describe how the principles of Capanna can be adapted to reconstruct the calcaneus. Total calcanectomy due to Ewing's sarcoma and the subsequent application of this novel reconstructive technique was performed in two young patients aged 5 and 16 years. The reconstruction was achieved by inserting a distally pedicled osteocutaneous fibula flap within the reamed canal of an allograft and placing the composite in the calcaneal defect. Reconstruction was successful with complete bone union between the allograft and the adjacent bone. There were no fractures or infections and both flaps survived. Functional outcome was assessed with a physiotherapist at a follow-up period of 2 years postoperatively, showing near-normal ambulance. This novel technique proved excellent as a limb salvage procedure, avoiding amputation, and offering a satisfactory oncological and functional outcome.

Efficacy of mesenchymal stem cell-delivery using perpendicular multi-needle injections to the skin: Evaluation of post-ejection cellular health and dermal delivery.

AIM: Mesenchymal stem cell (MSC)-therapy is increasingly being evaluated in clinical trials. Dermal delivery is not only time consuming but also unreliable, potentially hampering the therapeutic result. Therefore, qualification of cell delivery protocols is essential. This study evaluated a clinically relevant automated multi-needle injection method for cutaneous MSC-therapy, allowing the skin to be readily and timely treated, by assessing both the cellular health post-ejection and dermal delivery. METHODS: Following dispensation through the injector (31 G needles: 9- or 5-pin) the cellular health and potency (perceived- and long-term (12 h) viability, recovery, metabolism, adherence, proliferation and IDO1-expression) of adipose-derived stem cells (10-20-50 ×106 cells/ml) were assessed in vitro in addition to dermal delivery of solution in human skin. RESULTS: No significant detrimental effect on the perceived cell viability, recovery, metabolism, adherence or IDO1-expression of either cell concentration was observed. However, the overall long-term viability and proliferation decreased significantly regardless of cell concentration, nonetheless marginally. An injection depth above 1.0 mm resulted in all needles piercing the skin with dermal delivery from up to 89% needles and minimal reflux to the skin surface, and the results were confirmed by ultrasound and histology. CONCLUSION: The automated injector is capable of delivering dermal cell-doses with an acceptable cell quality.

Enhanced recovery after microvascular reconstruction in head and neck cancer - A prospective study.

Objectives: Patients undergoing microvascular reconstruction after head and neck cancer typically have several comorbidities, and the procedures are often followed by complications and prolonged hospitalization. Consequently, the application of enhanced recovery after surgery (ERAS) for these patients undergoing microvascular reconstruction has gained attention in recent years. ERAS is a peri- and postoperative care concept that has repeatedly shown beneficial results for a wide variety of surgical procedures, including microvascular reconstruction. This study presents the results after the introduction of our ERAS protocol for head and neck cancer reconstruction. Methods: We prospectively treated 30 consecutive patients according to our ERAS protocol from June 2019 to December 2020 and compared the results of the treated patients with those of patients treated with our traditional recovery after surgery (TRAS) protocol. We are based on our ERAS protocol on the following core elements of recovery: improved patient information, goal-directed fluid therapy, minimally invasive surgery, opioid-sparing multimodal analgesia, early ambulation, and pre-defined functional discharge criteria. Results: The baseline characteristics of the groups were comparable. The ERAS group had a significantly shorter length of stay (13.1 vs. 20.3 days, p < 0.001), significantly shorter time to ambulation (3.0 days vs. 6.4 days, p < 0.001), shorter time to removal of nasogastric tube (13.3 days vs. 22.7 days, p = 0.05), and fewer tracheostomies performed (10% vs. 90%, p < 0.001). There were no differences in complications, flap survival, or 30-day re-admissions between the two groups. Conclusion: The introduction of ERAS in patients with head and neck cancer undergoing microvascular reconstruction seems safe and results in improved recovery. Level of evidence: 3.

Donor-site morbidity following breast reconstruction with a latissimus dorsi flap - A prospective study.

INTRODUCTION: Despite a trend toward the use of perforator-based flaps for autologous breast reconstruction, the m. latissimus dorsi (LD) flap remains a popular alternative. Several studies have sought to uncover the shoulder-related donor-site morbidity, but the results are inconclusive. This study aims at evaluating what impact breast reconstruction with an LD flap has on shoulder strength, range of motion (ROM), lymphedema, sensory disturbances, and patients' ability to perform activities of daily living (ADL). MATERIALS AND METHODS: In a prospective observational study, we examined 20 female patients undergoing delayed breast reconstruction with an LD flap. The primary outcome was a change in shoulder strength, measured with the Biodex System4 Pro-dynamometer. ROM was assessed using two-dimensional photogrammetry. Furthermore, the patients' self-reported pain, lymphedema, sensory disturbances, and ability to perform ADL were assessed using a questionnaire. Measurements were performed pre-operatively at 3 months and 12 months post-operatively. RESULTS: Of the 20 included patients, 17 completed the follow-up. At the 12 months follow-up, a significant loss of isometric shoulder strength of 17% was observed in shoulder adduction (P<0.001) and 21% in extension (P<0.001). Isometric strength and ability to perform ADL and ROM were unchanged. There was a decrease in the number of patients reporting problems with lymphedema (10 to 7) and an increase in the incidence of sensory disturbances (10 to 13). CONCLUSION: A loss of shoulder strength was observed following the transfer of the LD flap; however, the procedure did not hinder the post-operative performance of ADLs for the patients. LD reconstruction seems to be a safe procedure.

Long-term results of a standardized enhanced recovery protocol in unilateral, secondary autologous breast reconstructions using an abdominal free flap.

BACKGROUND: In 2015, we published one of the first reports using an enhanced recovery protocol (ERP) in microsurgery1, and in 2016, our final ERP setup in autologous breast reconstruction (ABR) using free abdominal flaps2. We showed that by adhering to a few simple, easy to measure, functional discharge criteria, it was possible to safely discharge the patients by the third postoperative day (POD). However, one of the challenges of interpreting studies using ERP in ABR is the often heterogenous patient populations and the need to clearly distinguish between primary and secondary and unilateral and bilateral reconstructions. MATERIALS AND METHODS: In the 5-year period from 2016-2020, the same surgical team, performed 147 unilateral, delayed breast reconstructions (135 DIEP, 9 MS-TRAM-2, and 3 SIEA flaps) according to our previous analgesic protocol and surgical strategy. Data were collected prospectively. RESULTS: Three flaps were lost (2%) and 82% of the patients(n=128) were discharged to home by POD 2 (n=8%) or 3 (74%). The remaining 18% (n=26) were discharged by POD 4 (12.5%) or 5 (5.5%). Ten patients (7%) were reoperated, and 17 patients (12%) had minor complications within POD 30 (infection, seroma, etc.) that did not necessitate hospital admission. CONCLUSION: Using our ERP, unproblematic discharge directly to home is possible on POD 3 in more than 80% of patients after ABR. ERP is no longer a research tool but considered standard of care in microsurgical breast reconstruction.

Human subcutaneous dirofilariasis: the 'migrating' skin tumor.

A 46-year-old woman presented with facial pain and discomfort. Diagnosis of subcutaneous dirofilariasis was reached after several months from symptom onset. Dirofilariasis should be suspected, also in non-endemic areas, in patients with a migrating subcutaneous nodule. Plastic surgery is preferred, as the face is often involved.

Enhanced recovery after breast reconstruction with a pedicled Latissimus Dorsi flap-A prospective clinical study.

INTRODUCTION: We have previously implemented and published an enhanced recovery after surgery (ERAS) program for autologous breast reconstruction using DIEP flaps. The latissimus dorsi (LD) flap is another commonly used flap for autologous breast reconstruction (ABR). The aim of the present study was to use our experience from the ERAS program in DIEP flap reconstruction to optimize our LD breast reconstruction program. MATERIAL AND METHODS: We examined our data for a 10-year period (n = 135) and compared this with two different surgical team approaches, within the same unit. One team implemented an ERAS program (n = 18), the other did not (n = 12). Data were collected prospectively. In the ERAS group, patient information was revised, multimodal analgesia was introduced, drain handling was optimised and functional discharge criteria was introduced. Fulfilment of functional discharge criteria were assessed twice daily and specified reasons for not allowing discharge registered. RESULTS: All patients had a breast reconstruction using a unilateral LD flap. Patient and surgical parameters were comparable. Length of stay was significantly shorter in the ERAS group (3.2 days) compared to the historical (6.9) and non-ERAS (TRAS) group (6.3) (p<0.0001). Drains were removed significantly faster in the ERAS group (day 3.9) vs day 6.3 (historical) and day 7.0 (TRAS) (p<0.0001). Time to drain removal was the main reason for extended LOS. There were no differences in reoperations, readmissions or complications between the three groups. All patients in the ERP group were ambulating, pain free, had abdominal function, were eating and managing personal hygiene on POD 1. CONCLUSIONS: LOS was safely reduced to 3 days for LD breast reconstruction in the ERAS group. By discharging patients with drains, it should theoretically be possible to reduce LOS to 1 day, as all other discharge criteria have then been fulfilled.

Mesenchymal stem cell therapy of acute thermal burns: A systematic review of the effect on inflammation and wound healing.

AIM: Mesenchymal stem cell (MSC) therapies are emerging as a promising strategy to promote tissue repair, and may extend their utility to burn care. This comprehensive review of the extant literature, evaluated all in vivo studies, to elucidate the potential protective and therapeutic effect of MSCs in acute thermal skin burns. METHODS: PubMed was systematically searched, according to PRISMA guidelines, and all relevant preclinical and clinical studies were included according to pre-specified eligibility criteria. RESULTS: Forty-two studies were included in a qualitative synthesis, of which three were human and 39 were animal studies. The preclinical studies showed that MSCs can significantly reduce inflammation, burn wound progression and accelerate healing rate of acute burns. The underlying mechanisms are complex and not fully understood but paracrine modulators, such as immunomodulatory, antioxidative and trophic factors, seem to play important roles. Allogeneic MSC therapy has proved feasible in humans, and could allow for prompt treatment of acute burns in a clinical setting. CONCLUSION: MSC therapy show positive results, regarding improved burn wound healing and immunologic response. However, most findings are based on small animal studies. Randomized clinical trials are warranted to investigate the regenerative effects in human burns before translating the findings into clinical practice.

Microvascular reconstruction in head and neck cancer - basis for the development of an enhanced recovery protocol.

INTRODUCTION: Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. Postoperative complications are common, which often leads to prolonged hospital stay. Enhanced recovery after surgery (ERAS) is a peri- and postoperative care concept with the aim of achieving pain- and risk-free surgery. It has been previously established as superior to conventional care for a wide variety of procedures, including microsurgical procedures such as reconstructions of the breast. Several ERAS protocols for microvascular head and neck cancer reconstructions have been proposed, although most of these are based on extrapolated evidence from different surgical specialties. Results from the implementation of ERAS for these procedures are inconsistent. METHODS: The current study investigates our clinical experience of head and neck cancer reconstruction for the period of 2014-2016 with the aim of establishing a list of functional discharge criteria. By combining these with the current published knowledge on the subject, we developed an ERAS protocol. RESULTS: We performed 89 microvascular procedures in the study period, of which 58 were in the oral cavity/sinuses and 31 were laryngopharyngeal. Most cases were squamous cell carcinoma (89%). The average LOS was 20.3 days in both groups. Postoperative complications included infection (37%), 30-days re-operations (19%), and re-admissions (17%). Furthermore, we identified the following discharge criteria: adequate pain relief, ambulation, sufficient nutritional intake, normal infection-related blood parameter results and absence of fever, bowel function, and closure of tracheostomy. CONCLUSION: Based on our retrospective analysis and identified discharge criteria, we present an approach to develop an ERAS protocol for microvascular reconstruction after head and neck cancer.

[Treatmentof rhinophyma with laser and surgery].

Rhinophyma is a disfiguring skin condition characterised by progressive hyperplasia of the nasal sebaceous glands and proliferation of blood vessels and connective tissue. It is considered the end stage of rosacea and affects primarily older males of Northern European descent. Several surgical and laser treatment options are available. None of these has been compared in randomised, controlled prospective trials. In this review, we provide an overview of the different treatment modalities and account for their respective strengths and limitations.

Use of Cerebrospinal Fluid Biomarkers in Diagnosis and Monitoring of Rheumatoid Meningitis.

Rheumatoid meningitis is a rare extra-articular manifestation of rheumatoid arthritis, often with non-specific symptoms. In most cases brain MRI shows a patchy lepto- and pachymeningeal enhancement, but the diagnosis currently relies on examination of a meningeal biopsy with presence of plasma cells and rheumatoid noduli. Presence of IgM rheumatic factor (RF) has been found in several cases and recently four cases have shown high titer anti-cyclic citrullinated peptide (anti-CCP) in CSF, suggesting this as a potential marker for rheumatoid meningitis. We present a 62 year-old woman with sero-positive (IgM RF and anti-CCP) rheumatoid arthritis, presenting with headache and gait impairment. Brain MRI revealed the classical patchy meningeal enhancement and the diagnosis of rheumatoid meningitis was confirmed by neuropathological examination of a meningeal biopsy. Analysis of the CSF revealed positive IgM RF (92.7 IU/mL) and strongly positive anti-CCP (19,600 IU/mL) and CXCL-13 (>500 ng/L). After treatment with high-dose steroid and Rituximab the clinical symptoms resolved. A 6 month follow-up analysis of CSF showed a dramatic decrease in all these markers with negative IgM RF and a decrease in both anti-CCP (64 IU/mL) and CXCL-13 (<10 ng/L). Our case further underlines the potential use of CSF anti-CCP and IgM RF in the diagnosis of RM and the use of these markers and CXCL-13 in evaluation of treatment response. A case review of 48 cases of rheumatoid meningitis published since 2010, including, symptoms, serum, and CSF findings, treatment, and outcome is provided.

Delayed two-stage breast reconstruction: The impact of radiotherapy.

BACKGROUND: Despite a trend towards immediate breast reconstruction in recent years, delayed breast reconstruction using a tissue expander remains a common procedure. Radiotherapy after mastectomy but before reconstruction is a risk factor, although studies examining the effect of this are limited. The aim of this retrospective cohort study is to evaluate the impact of pre-reconstructive radiotherapy (PRT) in patients undergoing breast reconstruction using an expander/implant. MATERIALS AND METHODS: Two hundred twenty-three consecutive patients underwent unilateral mastectomy followed by expander-based reconstruction over a 10-year period (2004-2013). Fifty patients (22%) received radiotherapy before reconstruction (PRT group), and 173 patients (78%) did not (non-PRT group). Descriptive patient data as well as data regarding the operations, hospitalisation and complications were collected. Statistical analyses such as logistic regression, Fisher exact test and multivariate analysis were performed using R-statistics. RESULTS: PRT was a significant predictor of loss of reconstruction, and when adjusted for smoking and body mass index (BMI), it showed an odds ratio (OR) of 17.8 [95% confidence interval (CI): 5.7-70.6; p<0.01] for loss of reconstruction, with 15 (30%) in the PRT group and 7 (4%) in the non-PRT group. We found no difference in short-term reoperations or infections at either stage of reconstruction. CONCLUSION: In patients undergoing delayed breast reconstruction using an expander/implant, radiotherapy is a significant risk factor for loss of reconstruction. It should be considered a relative contraindication for this reconstructive modality, and careful selection and advisement of the patient about the risks of complications and potential need for additional corrective surgery or later autologous breast reconstruction should be discussed.

[Treating scars with lipofilling].

Hypertrophic, keloidal and contracted scars can be cosmetically and functionally debilitating, and by patients this is often perceived as traumatising. Psychological and social impairments are common in these types of scars. Currently, autologous lipofilling, with or without enrichment with stem cells, is performed to improve scar quality. In this review, we evaluate the evidence on lipofilling as a treatment of scars. The literature mainly consists of studies of low-level evidence, i.e. they lack controls and randomisation. Nevertheless, all studies indicate, that lipofilling may improve the quality of scars.

[Metformin and surgery before general anaesthesia].

Danish national guidelines recommend discontinuation of metformin 48 h prior to general anaesthesia due to the presumed increased risk of lactic acidosis. By reviewing recent studies concerning the risk of metformin-associated lactic acidosis it is found, that studies indicate, that metformin does not increase the risk of lactic acidosis. However, comorbidities such as cardiovascular insufficiency, sepsis, dehydration and impaired kidney function are risk factors. New guidelines propose discontinuation of metformin on the day of surgery. Patients with Type 2 diabetes and comorbidities should have the levels of arterial pH and lactate monitored.