Wound exudate reduction from retroperitoneum with facilitation of healing by triamcinolone injection: A case report.

RATIONALE: Maintaining a moderately moist environment is important in the treatment of chronic skin ulcers. Excessive exudate inhibits wound healing, although it may be difficult to control. We report a case of successful treatment with triamcinolone to suppress retroperitoneal exudates and facilitate wound healing. PATIENT CONCERNS: A 78-year-old man presented to our department with excessive exudative oozing from a chronic ulcer in the gluteal region. The retroperitoneum was exposed for a prolonged period after colon cancer surgery and developed chronic granulation. DIAGNOSES: The exposed retroperitoneum was covered using an island flap, with the left superior gluteal artery perforator providing the feeding vessels and skin graft, which covered part of the flap harvesting area. The flap and lower bed did not adhere because of the presence of an excessive retroperitoneal exudate. Skin grafts to the flap harvesting area were not accepted, and secondary healing did not proceed because of exudate leakage. INTERVENTION: A single dose of 2.5-mg triamcinolone was injected inferiorly to the flap. OUTCOMES: After injection of triamcinolone, the exudate decreased, and secondary healing in the residual ulcer progressed satisfactorily. CONCLUSION: Injection of triamcinolone might be an option for controlling exudates to heal skin ulcers.

Improving Metacarpophalangeal Joint Instability by Joint Implantation in Parallel From a Supernumerary Thumb in Severely Hypoplastic Duplicated Thumbs.

ABSTRACT: Here, we present 2 cases of a severely hypoplastic duplicated thumb classified as Wassel types 5 and 6 and discuss whole-joint implantation from a supernumerary thumb as an alternative to stabilize the hypoplastic metacarpophalangeal (MCP) joint. The aim of the surgical treatment of thumb polydactyly is to reconstruct a functional and aesthetically pleasing thumb. Hypoplasia of joint components and abnormal tendon alignment lead to unpleasing results with angular deformity of the reconstructed thumb. In 2 cases, the MCP joint of the dominant digit was hypoplastic and unstable in all directions. The main problem was underdevelopment of the affected MCP joint, and it was reasonable to attempt to stabilize the unstable joint by adding another redundant joint in parallel. Whole-joint implantation with a flap on a vascular pedicle is useful to repair both joint instability and soft tissue hypoplasia, as in case 1. The vascularized joint can maintain balanced growth potential. However, nonvascularized interphalangeal (IP) joint implantation is a simple solution for repairing MCP joint instability, as in case 2. These joints have no tendon insertions, so we believe they are acting as a splint supporting the hypoplastic joint for a long period. The transfer of composite tissues from the foot has been reported for reconstruction of finger and thumb hypoplasia. Duplicated thumb operation is usually recommended at 1 year old. Similarly, nonvascularized joint implantation in parallel may be a promising choice to overcome MCP joint instability and to maintain range of motion in hypoplastic cases with a duplicated thumb.In conclusion, joint implantation in parallel from a supernumerary thumb could prevent angular deformity and is an alternative to overcome MCP joint instability in cases of a severely hypoplastic duplicated thumb without any donor morbidity.

Which plantar region can predict peripheral arterial disease by using laser speckleflowgraphy?

Laser speckle flowgraphy (LSFG) is a new device that can measure skin blood flow and capture the movement of erythrocytes. However, there are a few reports on the use of LSFG to estimate skin blood flow, especially in the lower extremities. We aimed to compare plantar skin blood flow between patients with and without peripheral arterial disease (PAD) to discern the extent to which LSFG could accurately predict PAD. We prospectively measured the plantar skin blood flow in 28 patients with PAD and 37 participants without PAD at two hospitals from 2017 to 2021, using the ankle-brachial index (ABI) and LSFG. We partitioned the plantar into 12 parts: digits 1-5, medial metatarsal, middle metatarsal, lateral metatarsal, medial arch, middle arch, lateral arch, and heel, and compared the difference between the two groups and the area under the curve (AUC) of each point. Statistical analyses were performed to determine the sensitivity, specificity, false-positive rate, and false-negative rate at high accuracy points of AUC and ABI. There was a significant difference among the 12 points between the two groups, and the ratio using toe 1 and toe 5 was highly accurate. The ratio using toe 1 indicated higher sensitivity (89 vs. 82%), higher false-positive rate (22 vs. 4%), lower specificity (81 vs. 97%), and an equivalent false-negative rate (9 vs. 12%) to that of the ABI. These findings could facilitate the use of LSFG to estimate the skin blood flow condition in the plantar skin. Our results indicate that measuring toe 1 using LSFG could be used to somewhat assess PAD.

Hallucal thenar index: A new index to detect peripheral arterial disease using laser speckle flowgraphy.

OBJECTIVES: Laser speckle flowgraphy is a technology using reflected scattered light for visualization of blood distribution, which can be used to measure relative velocity of blood flow easily without contact with the skin within a short time. It was hypothesized that laser speckle flowgraphy may be able to identify foot ischemia. This study was performed to determine whether laser speckle flowgraphy could distinguish between subjects with and without peripheral arterial disease. MATERIALS AND METHODS: All subjects were classified based on clinical observations using the Rutherford classification: non-peripheral arterial disease, class 0; peripheral arterial disease group, class 2-5. Rutherford class 6 was one of the exclusion criteria. Laser speckle flowgraphy measured the beat strength of skin perfusion as an indicator of average dynamic cutaneous blood flow change synchronized with the heartbeat. The beat strength of skin perfusion indicates the strength of the heartbeat on the skin, and the heartbeat strength calculator in laser speckle flowgraphy uses the blood flow data to perform a Fourier transform to convert the temporal changes in blood flow to a power spectrum. A total of 33 subjects with peripheral arterial disease and 40 subjects without peripheral arterial disease at a single center were prospectively examined. Laser speckle flowgraphy was used to measure hallucal and thenar cutaneous blood flow, and the measurements were repeated three times. The hallucal and thenar index was defined as the ratio of beat strength of skin perfusion value on hallux/beat strength of skin perfusion value on ipsilateral thenar eminence. The Mann-Whitney U-test was used to compare the median values of hallucal and thenar index and ankle brachial index between the two groups. A receiver operating characteristic curve for hallucal and thenar index of beat strength of skin perfusion was plotted, and a cutoff point was set. The correlation between hallucal and thenar index of beat strength of skin perfusion and ankle brachial index was explored in all subjects, the hemodialysis group, and the non-hemodialysis (non-hemodialysis) group. RESULTS: The median value of the hallucal and thenar index of beat strength of skin perfusion was significantly different between subjects with and without peripheral arterial disease (0.27 vs. 0.87, respectively; P < 0.001). The median value of ankle brachial index was significantly different between subjects with and without peripheral arterial disease (0.8 vs. 1.1, respectively; P < 0.001). Based on the receiver operating characteristic of hallucal and thenar index, the cutoff was 0.4416 and the sensitivity, specificity, positive predictive value, and negative predictive value were 68.7%, 95%, 91.7%, and 77.6%, respectively. The correlation coefficients of all subjects, the hemodialysis group, and the non-hemodialysis group were 0.486, 0.102, and 0.743, respectively. CONCLUSIONS: Laser speckle flowgraphy is a noninvasive, rapid, and widely applicable method. Laser speckle flowgraphy using hallucal and thenar index would be helpful to determine the differences between subjects with and without peripheral arterial disease. The correlation between hallucal and thenar index of beat strength of skin perfusion and ankle brachial index indicated that this index was especially useful in the non-hemodialysis group.

Aesthetic outcomes following adipose flap versus fillet flap technique for radial polydactyly: a comparison study.

We performed a comparative study looking at the aesthetic outcomes of using a digital artery vascularized adipose flap (DAAF) for treatment of Wassel type IV radial polydactyly versus a fillet flap technique. Clinical charts and pictures of patients between 2002 and 2017 were reviewed to evaluate the appearance of 16 reconstructed thumbs using a visual analogue scale. Our results showed that the DAAF technique resulted in better outcomes with regard to contour of the thumb than the fillet flap group, with significantly less conspicuous scarring in the DAAF group. We conclude that the DAAF can produce better aesthetic outcomes in the reconstruction of radial polydactyly than conventional fillet flaps.Level of evidence: III.

Intertendinous epidermoid cyst of the forearm.

As epidermoid cysts generally originate from hair follicle infundibulum, they appear as intradermal or subcutaneous tumors and are very rare in locations away from the skin. Here, we report a rare case of intertendinous epidermoid cyst of the forearm in a 68-year-old man that was treated surgically.

Free serratus anterior fascial flap combined with vascularized scapular bone for reconstruction of dorsal hand and finger defects.

We present two cases of serratus anterior free fascial flap combined with vascularized scapular bone graft for reconstruction of traumatized dorsal hand and phalangeal bone defects. Composite flaps with single vascular pedicles allowed conservation of severely injured fingers and provided good functional and cosmetic outcomes.

Peripheral sympathetic nerve dysfunction in adolescent Japanese girls following immunization with the human papillomavirus vaccine.

OBJECTIVE: To investigate the causes of neurological manifestations in girls immunized with the human papillomavirus (HPV) vaccine. METHODS: During the past nine months, 44 girls visited us complaining of several symptoms after HPV vaccination. Four patients with other proven disorders were excluded, and the remaining forty subjects were enrolled in this study. RESULTS: The age at initial vaccination ranged from 11 to 17 years, and the average incubation period after the first dose of the vaccine was 5.47±5.00 months. Frequent manifestations included headaches, general fatigue, coldness of the legs, limb pain and weakness. The skin temperature examined in 28 girls with limb symptoms exhibited a slight decrease in the fingers (30.4±2.6 °C) and a moderate decrease in the toes (27.1±3.7 °C). Digital plethysmograms revealed a reduced height of the waves, especially in the toes. The limb symptoms of four girls were compatible with the Japanese clinical diagnostic criteria for complex regional pain syndrome (CRPS), while those in the other 14 girls were consistent with foreign diagnostic criteria for CRPS. The Schellong test identified eight patients with orthostatic hypotension and four patients with postural orthostatic tachycardia syndrome. The girls with orthostatic intolerance and CRPS commonly experienced transient violent tremors and persistent asthenia. Electron-microscopic examinations of the intradermal nerves showed an abnormal pathology in the unmyelinated fibers in two of the three girls examined. CONCLUSION: The symptoms observed in this study can be explained by abnormal peripheral sympathetic responses. The most common previous diagnosis in the studied girls was psychosomatic disease. The social problems of the study participants remained unresolved in that the severely disabled girls stopped going to school.

CASE REPORT Penetrating Injury of the Orbit by a Needlefish.

OBJECTIVE: We present a very rare case of penetrating injury into the orbit by a needlefish. The patient underwent extirpation twice at another hospital. METHODS: We performed foreign body removal from a right subbrow incision under general anesthesia. RESULTS: The foreign body was successfully removed and the patient's diplopia recovered gradually after surgery. CONCLUSIONS: Treatment was similar to that used for penetrating injury. As there is a risk of secondary infection, it is important to completely remove the fish body, followed by vigorous irrigation and debridement.