Factors Associated with Prolonged RT-PCR SARS-CoV-2 Positive Testing in Patients with Mild and Moderate Forms of COVID-19: A Retrospective Study.

Background and objectives: This article aims to evaluate the number of days necessary for patients with mild and moderate forms of COVID-19 to reach undetectable levels of SARS-CoV-2 RNA in the upper respiratory tract specimens. As a secondary objective, we sought to establish a correlation between different conditions associated with longer viral load as this could result in a longer period of contagion and infectivity. Materials and Methods: It is a retrospective study. A total of 70 patients with confirmed mild and moderate forms of COVID-19 were enrolled in our study. Results: Number of days with traceable viral load was 25.93 (±6.02) days in patients with mild COVID-19 and 26.97 (±8.30) in moderate form (p = 0.72). Age, male gender, and obesity, along with several chronic conditions (cardiac, liver, renal, and neurological disease), were associated with prolonged positive RT-PCR test from the nasal swab (therefore prolonged viral load). These are in general, risk factors for severe forms of COVID-19. Conclusions: There are several conditions associated with prolonged positive RT-PCR in mild and moderate forms of COVID-19. As to why and what is the significance of it remains to be studied.

Treatment and Prevention of Periprosthetic Capsular Contracture in Breast Surgery With Prosthesis Using Leukotriene Receptor Antagonists: A Meta-Analysis.

BACKGROUND: Capsular contracture (CC) is the most common long-term complication of breast surgery with prosthesis. Leukotriene receptor antagonists (LRAs) have been tested as a potential treatment; however, mixed results have been observed. OBJECTIVES: The aim of this study was to undertake a meta-analysis to clarify the treatment and prophylactic capabilities of LRAs in the management of CC. METHODS: A systematic literature search of the most popular English-language databases was performed to identify relevant primary publications. We included all studies that used the Baker scale to evaluate the treatment and preventive capabilities of LRAs. RESULTS: Six eligible studies were included based on predefined inclusion and exclusion criteria, totalling 2276 breasts, of which 775 did not receive LRAs and 1501 did. Final pooled results showed that LRAs could help manage CC with a risk difference (RD) of -0.38 with a corresponding 95% CI of -0.69 to -0.08, showing statistical significance at a Z value of 2.48, P = 0.01. Subgroup analysis based on the type of drug showed that only montelukast yielded statistical significance (RD = -0.27, 95% CI = -0.51 to -0.03, Z = 2.20, P = 0.03). Zafirlukast did not seem to influence CC. Further subgroup analysis based on treatment timing showed that prophylaxis was ineffective and only treatment for ongoing CC yielded statistically significant improvements. CONCLUSIONS: The current meta-analysis proved that LRAs could be used in the management of CC. Only treatment for ongoing CC showed statistically significant improvements. Montelukast seemed to be more efficient with a safer profile for adverse effects, whereas zafirlukast yielded no statistically significant results.

High Division of the Median Nerve with Unusually High Origin of the 3rd Space Common Digital Nerve.

BACKGROUND: Median nerve (MN) variation in the carpal tunnel has been well documented by Lanz. Encountering rarely documented variants, that do not fit into existing classifications, increases the risk of iatrogenic injury. METHODS: The random occurrence of two unclassifiable anatomical variants of the MN in the carpal tunnel gives motivation to search the literature for similar and identical cases. CASE REPORTS: This article presents two cases of very rare anatomical variants of high division of the MN. First case is a pure high branching of the 3rd space common digital nerve (CDN). The second case is a high division of the MN to a thicker lateral component and a thinner medial component. The lateral component of the MN gives off the palmar cutaneous branch (PCB), the thenar motor branch (TMB), the 1st and 2nd space CDN's and contributes medially with a branch to the 3rd space CDN. The medial component of the MN bifurcates distally into a medial and lateral branch. The lateral branch from the medial component of the MN distally unites with the medial branch of the lateral component of the MN to form the 3rd space CDN. The medial branch from the medial component of the MN has a major contribution to the 4th space CDN from the ulnar nerve. In both cases, the medial component of the MN has a transmuscular course through the flexor digitorum superficialis (FDS) muscle. DISCUSSION: Finding similar case reports from worldwide suggests the need to improve current classification of the MN variants in the carpal tunnel. CONCLUSIONS: One cannot rely entirely on the existing anatomical classifications of the MN in the carpal tunnel. There is an underappreciated risk of iatrogenic injury, especially in endoscopic carpal tunnel release, and a chance of missing out on repair of important anatomical structures in trauma cases. There is a possibility of augmenting group 3 of Lanz's classification by adding subgroup "3D High division of the MN with the medial component having a transmuscular course through the FDS muscle", stating the different distal branching patterns.

Lower limb replantation: 27 years follow up.

Replantation of lower extremity is a very complex and difficult procedure. There are still a lot of controversies about indications, even numerous scoring systems are now available that can facilitate the surgeon's decision. We present the functional results of a replanted below-knee amputation in an elderly patient, 27 years after the injury and discuss the indication for replantation.

Repair of urethral injury associated with penile fracture using buccal mucosa graft: A novel therapeutic approach for complex cases.

Penile fracture is a rare urological emergency caused by blunt trauma to the erect penis and it may be accompanied by urethral injury. Complete urethral rupture is very uncommon and is usually managed by primary anastomosis. However, these patients are more likely to develop post-operative complications such as urethral strictures. Buccal mucosa graft is commonly used for substitution urethroplasty in management of urethral strictures, but its use has not been reported for immediate treatment in the setting of penile fracture. We report a patient with rupture of both corpora cavernosa, as well as the rupture of the urethra, after sexual intercourse. Buccal mucosa graft was used for surgical repair of urethral injury. At 36-month follow-up patient did not experience erectile or voiding problems. The application of this technique could possibly reduce the incidence of urethral strictures in these patients and further prospective studies with larger samples should be conducted.

Surgical management of hidradenitis suppurativa with keystone perforator island flap.

INTRODUCTION: Hidradenitis suppurativa is a chronic, relapsing disease of the skin, characterized by apocrine gland and pilosebaceous complex infections, causing recurrent superficial nodules and abscesses, fistula formation, scarring and fibrosis. It is accepted that wide local excision and local coverage is the crucial treatment to prevent recurrence of the disease. MATERIALS AND METHODS: All patients presenting for surgical treatment of hidradenitis suppurativa between 2014 and 2019 were identified from the hospital database. Only patients with hidradenitis suppurativa confined to the axillary, inguinal or sacrococcygeal regions in Hurley grade II and III were included. A total of 21 patients (11 male, 10 female) aged between 21 and 76 years were evaluated retrospectively. All of the 22 defects were reconstructed with keystone perforator island flap following wide local excision. We performed descriptive analysis of demographic data, comorbidities, topographic distribution of lesions, Hurley scoring, size of defect, specific type of reconstruction, complications, follow-up period, recurrences. RESULTS: 21 patients with localized axillary, inguinal or sacrococcygeal hidradenitis suppurativa were identified, and 22 keystone perforator island flaps were performed. All keystone perforator island flaps survived giving a durable cover to the affected regions. There were no complications. Functional and aesthetic results were satisfactory and there were no recurrences. CONCLUSION: These findings confirm that the keystone perforator island flap procedure can be effective for immediate defect reconstruction after wide local excision of advanced hidradenitis suppurativa of the axillary, inguinal and sacrococcygeal regions and provides excellent aesthetic results.

Giant keystone type III perforator flaps for dermatofibrosarcoma protuberans defect reconstruction.

INTRODUCTION: Dermatofibrosarcoma protuberans (DFSP) is a relatively rare malignant tumor, with important local aggressiveness. CASE REPORT: We present a case of a 59-years-old man with a history of Psoriasis and viral hepatitis C presented in our department with a giant lesion on the posterior trunk, of 24/36 cm, with pus and local bleeding, causing important anemia. The tumor was excised, creating an elliptical defect of around 34 × 42 cm down to fascial level, which was covered by two lateral flaps - modified Keystone type III. RESULTS: The flaps were completely viable and integrated with small dehiscence, which were assisted to heal secondarily. CONCLUSION: Our paper presents a reliable alternative to skin grafting for a very large defect on the posterior trunk, the modified type III keystone flap, to our knowledge, for the first time presented for such a wide defect and on adult.

Emergency toe-to-hand transfer for post-traumatic finger reconstruction: A multicenter case series.

BACKGROUND: The aim of this paper was to evaluate the outcomes of a homogenous series of emergency with a toe-to-hand transfer reconstructions with a different timing: immediate (same surgical step with the debridement), primary (in the first 24 h), early (24-72 h after the debridement) or delayed (72 h-7 days). MATERIALS AND METHODS: Between 2001 and 2011, 31 patients received an immediate reconstruction with a toe-to-hand transfer. Data on indications, timing, type of surgery, complications and outcomes (sensory and motor recovery, patient satisfaction) were extrapolated and recorded. RESULTS: Most of the procedures in our series (71%) were performed in the first 24 h. Survival rate was 100%. The only complications were 3 venous thrombosis (10%), solved with surgical re-exploration. Only 1 patient required secondary surgery for web deepening. No functional problems were recorded at the donor site. Sensibility recovery was acceptable in all patients; toe mobility was higher for the reconstructed thumb (85%) than for other digits (77%). Patient satisfaction was high with regard to functional results and lower but acceptable with regard to the aesthetic outcome. There was no difference in satisfaction rate of patients treated within 24 h or within 7 days. CONCLUSION: No conclusive evidence exists in favor of an immediate versus a primary, early or delayed emergency reconstruction. Emergency toe transfer for finger reconstruction is a safe procedure and its outcomes are comparable to those reported in the literature for secondary reconstruction. Immediate reconstruction has the advantage of an easier dissection, but early or delayed reconstruction gives more time to discuss with the patient and to plan surgery.

What microsurgeon, orthopaedic and plastic surgeon should know about bionic hand.

Hand loss is a catastrophic event that generates significant demands for orthopedics and prosthetics. In the course of history, prostheses evolved from passive esthetic replacements to sophisticated robotic hands. Yet, their actuation and particularly, their capacity to provide patients with sensations, remain an unsolved problem. Sensations associated with the hand, such as touch, pain, pressure and temperature detection are very important, since they enable humans to gather information from the environment. Recently, through a synergistic multidisciplinary effort, medical doctors and engineers have attempted to address these issues by developing bionic limbs. The aim of the bionic hands is to replace the amputated hands while restoring sensation and reintroducing hand-motor control. Recently, several different approaches have been made to interface this sophisticated prosthesis with residual neuro-muscular structures. Different types of implants, such as intramuscular, epineural and intraneural, each have their own complementary advantages and disadvantages, which are discussed in this paper. After initial trials with percutaneous leads, present research is aimed at making long-term implantable electrodes that give rich, natural feedback and allow for effortless control. Finally, a pivotal part in the development of this technology is the surgical technique which will be described in this paper. The surgeons' insights into this procedure are given. These kinds of prostheses compared with the classic one, hold a promise of dramatic health and quality of life increase, together with the decrease the rejection rate.

Why, when and how propeller perforator flaps in reconstructive surgery.

PURPOSE: The aim of this paper was to evaluate the outcomes of propeller perforator flaps used all over the body, and to appreciate their advantages and/or disadvantages over the free perforator flaps. METHOD: Patients that required propeller perforator flaps used all over the body were eligible to participate in this study. A preoperative Doppler examination was performed for all the flaps in the trunk and thigh, but not regularly in the face, lower leg, foot, forearm and hand. We evaluated the most important technical aspects of harvesting the flaps, the main indications and advantages of using propeller perforator flaps, their disadvantages and complications. For post-excisional face and trunk defects after cancer or decubitus ulcers were performed approximately 25% of flaps. RESULTS: We had very good results in approximately 70% of cases. In the remaining cases, excepting 3 cases in which the flaps were completely lost, we registered only minor complications due to venous congestion, which were solved spontaneously or by skin grafting. CONCLUSION: The main advantages of propeller perforator flaps, i.e. no need of microvascular anastomoses, replacing like-with-like, faster functional rehabilitation, can reduce in well selected cases the indication for free flaps. The rate of complications is not higher than by using other methods. The single real disadvantage of propeller perforator flaps is the location of the perforator close to the defect, what can be an impediment in trauma cases.

Finger defect coverage with digital artery perforator flaps.

AIM: The aim of this paper is to demonstrate the advantages of using local resources in the coverage of such defects. Our approach in fingers' defects is the use of local perforator flaps, both as propeller flaps or bi-lobed pedicled flaps. PATIENTS AND METHODS: After performing an anatomical study on cadaver segments injected with latex followed by transparentation, 81 local perforator flaps in 80 patients during a period of 10 years (2007-2016), i.e. 47 digital artery propeller perforator flaps (DAPP), 10 island transposition perforator flaps (DATP), and 24 bi-lobed pedicled perforator flaps (BLP) were performed in our department. The patients were evaluated regarding finger mobility (ROM), two-points discrimination (TPD), and degree of satisfaction (DS) from cosmetic point of view. RESULTS: The mean interval for social and professional reintegration was 12 days. As complications, we registered only venous congestion in 7 cases followed by epidermolysis in 4 cases and superficial necrosis in 3 cases, which healed by reepithelialization. The range of motion (ROM) of the reconstructed fingers was normal in all the patients. All the flaps regain a satisfactory degree of sensibility (TPD between 4 mm and 14 mm). The DS was relatively high, with 67 patients very satisfied, 11 satisfied, and 2 unsatisfied. CONCLUSIONS: This fast and less invasive method, which replaces like-with-like, allows an early and good reinervation and a rapid social and professional reintegration, proves to be a very reliable alternative in digital defects coverage.

Free-flap breast reconstruction on experimental porcine model.

INTRODUCTION: Free flaps require mastering microsurgical technique. In addition, breast reconstruction implies accuracy not only in flap survival, but also satisfying aesthetic outcome. Thus, such complex abilities can be acquired by creating experimental models for surgical training. MATERIALS AND METHODS: In accordance with relevant anatomy data found in literature, we chose a porcine model and performed a flap similar to the human deep inferior epigastric perforator (DIEP). Furthermore we developed a surgical protocol for a free flap transfer similar to a double-pedicle DIEP flap. The adipo-cutaneous flap was harvested as a free flap based on the superior abdominal vascularization and microsurgical anastomoses were performed to both the internal thoracic and thoracodorsal vessels. RESULTS: We were able to harvest a superior epigastric double-perforator free flap with increased similarity to the human DIEP flap. Microsurgical anastomoses were possible to both to the internal thoracic vessels and thoracodorsal vessels, which both proved to have optimal caliber for termino-terminal anastomosis. CONCLUSION: Although there are several differences when comparing a swine experimental model with human anatomy, our protocol enhances the possibilities for training in breast reconstruction.

"Close-open-close free-flap technique" for the cover of severely injured limbs.

The treatment of severely injured extremities still presents a very difficult task for trauma orthopaedic surgeons. Despite improvements in technology and surgical/microsurgical techniques, sometimes a limb must be amputated, otherwise severe and potentially fatal complications may develop. There is a well-established belief that severe open fractures should be left open. However, Godina proved wound coverage in the first 72 h (after an injury) to be safe and to bring good final results. So early wound cover (no later than one week after an injury) with well vascularized free flaps became the gold standard. Yet for many patients (some of whom have serious health problems), operative treatment needs to be postponed when they arrive to specialized microsurgical departments for microsurgical reconstruction much later than one week after incurring an injury.  As the definite wound cover period from one week to 3 months seems to be hazardous, especially due to the potential of infection, we developed a safe, original flap technique that prevents infection and covers important structures such as exposed bones, tendons, nerves and vessels. We named this technique the "close-open-close free flap technique". It enables difficult wound cover in any biological phase of the wound, by combining complete flap cover first, with the removal of stitches from one side of the flap after 6-12 h. This technique works very well for borderline cases as well; where even after a complete debridement, dead tissue still remains in the wound - making wound cover very dangerous. Closing completely severe open fractures with free (or pedicled) flaps and removing the stitches on one side after 6-12 h, enables orthopaedic surgeons to safely cover any kind of wound in any biological phase of the wound. Additional debridements, lavages and reconstructions can easily be performed under the flap and after the danger of a serious infection has disappeared, definitive wound closure can be carried out.

Zone II Flexor Tendon Repair by Modified Brunelli Pullout Technique and Very Early Active Mobilization.

Numerous surgical methods and hand therapy protocols have been described in attempts to improve the functional outcome after flexor tendons repair in zone II. It is generally accepted that the best functional results can be obtained by combining a surgical technique, which provides enough strength of the repair, with very early postoperative mobilization. One of the methods to achieve these goals seems to be the Brunelli pullout technique, which moves the tension from the suture level to the finger pulp. We describe here our modifications to the original Brunelli technique, which, by moving the tension from the suture level and by diminishing the gap, allows immediate postoperative mobilization.

Propeller perforator flaps in forearm and hand reconstruction.

After a long history in flaps' surgery, the perforator flaps became the most used flaps nowadays. From the beginning, their use as free flaps diminished substantially the donor site morbidity. In the attempt to not only diminish the donor site morbidity, but also to achieve more similar reconstructions, a new concept appeared 20 years ago: local perforator flaps. The local perforator flaps offer as main advantages the absence of microsurgical sutures ("microsurgical non-microvascular flaps"), same surgical field, the sparing of muscles and main vascular pedicles, and shorter hospitalization time. They can be used as V-Y advancement flaps, transposition flaps, propeller flaps, and keystone flaps (multiperforator flaps). The present study will refer to the use of local perforator flaps in forearm and hand reconstruction, and will point on the most important technical aspects of their harvesting, the main indications, advantages and disadvantages, and possible complications.

Functional salvage of a hand after unsuccessfull attempt of replantation.

Amputation by crush injuries generally represents a contraindication for replantation, and especially when the lesion is caused by the summation of multiple concomitant traumatic mechanisms. We present the case of a 22 year- old female who arrived in our service with a crush/torsion amputation of all long fingers at the metacarpo-phalangeal level of the right hand. After the unsuccessful attempt of replantation, the functional reconstruction of the hand was achieved by using a double free flap transfer: anterolateral thigh perforator flap (ALT) and digital block transfer of second and third toes.

Elbow defects reconstruction using pedicled perforator flaps.

Soft tissue defects around the elbow are a real challenge in the field of reconstructive surgery. This anatomical region is passed by superficial noble anatomical structures (arteries, veins, nerves) that are often exposed in post-traumatic or post-excisional defects. The elbow joint has a high tendency to stiffness or ankylosis even after short immobilization. The pedicled perforator flaps, based on source vessels from the anastomotic arcades of the elbow seem to be an efficient and reliable reconstructive choice. The flap offers a good local coverage, replacing "like with like", has minor donor site morbidity and contrary to the free flaps, allows the very early beginning of physical therapy starting with the first postoperative day. This paper represents a review of the literature concerning this problem.

Plantar flaps based on perforators of the plantar metatarsal/common digital arteries.

INTRODUCTION: Because of the unique characteristics of its integument, the affirmation "replacing like with like" becomes more than evident in the reconstruction of defects of the ultraspecialized plantar skin. But, the paucity of local resources, and especially in the forefoot, transforms this attempt in a very challenging problem. Many techniques, including skin grafts and various types of flaps were used in the management of defects in the forefoot. We present a new useful flap in the reconstruction of skin defects in the forefoot, based on small perforator vessels originating either from the plantar metatarsal arteries or plantar common digital arteries. MATERIALS AND METHODS: Starting with June 2011, this flap was performed, as plantar transposition perforator flap, plantar propeller flap, or plantar propeller perforator plus flap, in seven patients with ulcers over the plantar forefoot. During a follow-up of 7 to 17 months (mean, 9.8 months), the local evolution regarding flap integration, pain, relapse, sensitive recovery, donor site, and footwear quality was analyzed. RESULTS: We registered a 100% survival rate of the flaps, with delayed healing in only one case. The gait resumption was possible after 6 weeks in all cases. CONCLUSION: This new flap, based on small perforator vessels from the plantar metatarsal or common digital arteries, and which provides a good, stable, and sensory recovery, seems to be a promising method in the reconstruction of plantar skin defects over the metatarsal heads.

A new surgical treatment for mallet finger deformity: deepithelialised pedicled skin flap technique.

INTRODUCTION: Mallet finger, well-known also as drop finger or baseball finger, is a frequent deformity after extensor tendons injury in the fingers. Although numerous nonoperative or operative techniques have been used in managing this deformity, the treatment still remains a debated subject. PATIENTS AND METHODS: Starting from 1996, 121 fingers in 118 patients with neglected deformity or unsuccessful splinting older than 10 days underwent surgical treatment. In 101 patients a tendinous mallet finger was present, and in 20 patients a bony mallet finger. After immobilising the distal interphalangeal (DIP) joint at 0° extension with a Kirschner wire, the extensor tendon was repaired by using a dorsal deepithelialised skin flap reinserted transosseous. The DIP joint was immobilised for 6 weeks in a thermoplastic splint, and after that it was gradually weaned from the immobilisation. An overnight splint was used for 4-6 weeks after starting the mobilisation. RESULTS: The mean follow-up period was 10 months (range: 3-120 months). An excellent result in 89 fingers and a good result in 32 fingers were obtained, according to Crawford's evaluation criteria. CONCLUSION: This method seems to be a new reliable alternative in the treatment of chronic mallet finger.

The use of propeller perforator flaps for diabetic limb salvage: a retrospective review of 25 cases.

BACKGROUND: Peripheral vascular disease and/or diabetic neuropathy represent one of the main etiologies for the development of lower leg and/or diabetic foot ulcerations, and especially after acute trauma or chronic mechanical stress. The reconstruction of such wounds is challenging due to the paucity of soft tissue resources in this region. Various procedures including orthobiologics, skin grafting (SG) with or without negative pressure wound therapy and local random flaps have been used with varying degrees of success to cover diabetic lower leg or foot ulcerations. Other methods include: local or regional muscle and fasciocutaneous flaps, free muscle and fasciocutaneous, or perforator flaps, which also have varying degrees of success. PATIENTS AND METHODS: This article reviews 25 propeller perforator flaps (PPF) which were performed in 24 diabetic patients with acute and chronic wounds involving the foot and/or lower leg. These patients were admitted beween 2008 and 2011. Fifteen PPF were based on perforators from the peroneal artery, nine from the posterior tibial artery, and one from the anterior tibial artery. RESULTS: A primary healing rate (96%) was obtained in 18 (72%) cases. Revisional surgery and SG for skin necrosis was performed in six (24%) cases with one complete loss of the flap (4%) which led to a lower extremity amputation. CONCLUSIONS: The purpose of this article is to review the use of PPF as an effective method for soft tissue coverage of the diabetic lower extremity and/or foot. In well-controlled diabetic patients that present with at least one permeable artery in the affected lower leg, the use of PPF may provide an alternative option for soft tissue reconstruction of acute and chronic diabetic wounds.