Treatment of Thyroid Eye Disease-Associated Ophthalmopathy and Myopathy With Intraorbital Injection of 5-Fluorouracil and Triamcinolone Acetonide.

PURPOSE: The authors report a technique of local application of anti-metabolite and corticosteroid mixture in the orbit for treatment of thyroid orbitopathy with moderate-severe inflammation and muscle involvement. METHODS: Patients of one orbital surgeon seen between March 2019 and May 2020 with active thyroid eye disease and restrictive strabismus were considered for local treatment of the myopathic component of the disease. A mixture of 1 ml 5-FU 50 mg/ml, 0.25 ml triamcinolone 40 mg/ml, and 1 ml lidocaine 2% is injected through the skin using a 25-gauge, 1.5-inch needle into the orbit adjacent to the affected extraocular muscle. Six patients were treated in the outpatient setting and 3 patients have been treated with this intervention intraoperatively at the time of orbital decompression. One was treated with the mixture reconstituted with hyaluronic acid (Healon GV) to address postoperative medial rectus fibrosis to the medial wall, this mixture was applied topically in the operative field and not injected. RESULTS: All patients had subjective improvement in the eye movement limitation and 2 patients had a change in motility on exam that was temporally correlated to injections. One patient did not disclose high-dose aspirin intake before injection and experienced a retrobulbar hemorrhage immediately following injection which was successfully treated. No complications were noted as a result of the medication itself. DISCUSSION: The combination of 5-fluorouracil and triamcinolone acetonide for orbital treatment may be a useful adjunct in treating patients with ongoing inflammatory activity, both in the office and in the operating room. The novel combination may optimize ophthalmic outcomes, modifying disease course in some patients.

Decrement Evoked Potential (DEEP) Mapping of the Atria: Unmasking Atrial Fibrillation Substrate.

BACKGROUND: Atrial myopathy may underlie the progression of atrial fibrillation (AF) from a treatable disease to an irreversible condition with poor ablation outcomes. Electrophysiological methods to unmask areas prone to re-entry initiation could be key to defining latent atrial myopathy. METHODS: Consecutive patients referred for AF ablation were prospectively included at four institutions. Decrement evoked potential mapping (DEEP) was performed in eight left atrial sites and five right atrial sites, from two different pacing locations (endocardially from the left atrial appendage, epicardially from the proximal coronary sinus). The electrograms (EGMs) during S1 600 ms drive and after an extra stimulus (S2 at +30 ms above atrial refractoriness) were studied at each location and assessed for decremental properties. Follow-up was 12 months. RESULTS: Seventy-four patients were included and 85% had persistent AF. A total of 17,614 EGMs were individually analysed and measured. Nine percent of the EGMs showed DEEP properties (local delay of >10 ms after S2) with a mean decrement of 33±26 ms. DEEPs were more frequent in the left atrium than the right atrium (9.4% vs 8.0%; p<0.001) and more prevalent in persistent AF patients than paroxysmal AF patients (9.8% vs 4.6% p=0.001). Atrial DEEPs were more frequently unmasked in normal bipolar voltage areas and by epicardial pacing than endocardial pacing (9.6% vs 8.4%, respectively; p=0.004). Within the left atrium, the roof had the highest prevalence of DEEP EGMs. CONCLUSIONS: DEEP mapping of both atria is useful for highlighting areas with a tendency for unidirectional block and re-entry initiation. Those areas are more easily unmasked by epicardial pacing from the coronary sinus and more prevalent in persistent AF patients than in paroxysmal AF patients.

Transosseous tunnels versus suture anchors for the repair of acute quadriceps and patellar tendon ruptures: A systematic review and meta-analysis of biomechanical studies.

BACKGROUND: Multiple techniques have been developed for the repair of acute quadriceps and patellar tendon ruptures with the goal of optimizing clinical outcomes while minimizing complications and costs. The purpose of this study was to evaluate the biomechanical properties of transosseous tunnels and suture anchors for the repair of quadriceps and patellar tendon ruptures. METHODS: A systematic review of the PubMed and Embase databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using specific search terms and eligibility criteria. Meta-analysis was performed by fixed-effects models for studies of low heterogeneity (I2 <25%) and random-effects models for studies of moderate to high heterogeneity (I2 ≥25%). RESULTS: A total of 392 studies were identified from the initial literature search with 7 studies meeting the eligibility criteria for quadriceps tendon repair and 8 studies meeting the eligibility criteria for patellar tendon repair. Based on the random-effects model for total gap formation and load to failure for quadriceps tendon repair, the mean difference was 8.88 mm (95% CI, -8.31 mm to 26.06 mm; p = 0.31) in favor of a larger gap with transosseous tunnels and -117.25N (95%CI, -242.73N to 8.23N; p = 0.07) in favor of a larger load to failure with suture anchors. A similar analysis for patellar tendon repair demonstrated a mean difference of 2.86 mm (95% CI, 1.08 mm to 4.64 mm; p = 0.002) in favor of a larger gap with transosseous tunnels and -56.34N (95% CI, -226.75 to 114.07N; p = 0.52) in favor of a larger load to failure with suture anchor repair. CONCLUSIONS: Transosseous tunnels are biomechanically similar to suture anchors for quadriceps tendon repair. Patellar tendon repair may benefit from reduced gap formation after cycling with suture anchor repair, but the load to failure for both techniques is biomechanically similar. Additional studies are necessary to evaluate these and alternative repair techniques. LEVEL OF EVIDENCE: Systematic review and meta-analysis of biomechanical studies, Level V.

Diaphragmatic endometriosis: robotic approaches and techniques.

OBJECTIVE: To present different approaches used in the surgical management of diaphragmatic endometriosis using the Davinci Robotic system. DESIGN: A video article presenting patient positioning, port placement, and surgical techniques used in robotic excision of diaphragmatic endometriosis with concomitant pelvic disease. SETTING: Endometriosis center. PATIENT(S): Patients undergoing excision of diaphragmatic endometriosis. INTERVENTION(S): Systematic robotic approach to excise diaphragmatic lesions depending on the depth of invasion. MAIN OUTCOME MEASURES(S): The advantages and disadvantages of the lithotomy and the lateral decubitus approach were reviewed. Ports placements are illustrated according to the chosen approach. Diaphragmatic peritoneal stripping, diaphragmatic shaving, and diaphragmatic excision are different techniques used according to the depth of invasion. RESULTS(S): N/A. CONCLUSION(S): The choice of approach between the lithotomy position and the left lateral decubitus position depend on the extent of the diaphragmatic disease and the presence of concomitant pelvic lesions. Despite the lack of high-quality evidence, the advantages of the robotic system may improve the outcomes in such difficult cases in comparison with conventional laparoscopy.

Extrapelvic endometriosis located individually in the rectus abdominis muscle: a rare cause of chronic pelvic pain (a case report).

Endometriosis of the rectus abdominis muscle is an extremely rare form of extrapelvic localization of the disease. It is usually iatrogenic and develops after caesarean section or gynecological surgery. Preoperative diagnosis is very difficult and a challenge for gynecologists and surgeons; thus, the diagnosis is histological. The treatment of choice consists of wide local excision of the lesion on healthy margins. We cite a case of isolated endometriosis in the rectus abdominis muscles in a 46-year-old patient with a previous caesarean section, the diagnosis of which was made randomly when performing abdominal total hysterectomy for the treatment of chronic pelvic pain. Histological examination of the surgical specimen confirmed the diagnosis. Simultaneously, the surgical specimen of the uterus and ovaries was free of endometriosis. Postoperatively, the patient mentioned discharge of her symptoms. No further therapeutic intervention was deemed necessary, as it was considered that a complete resection of the endometrial tissue implantation from the muscles of abdominal wall was performed. The present case report lay emphasis on the significant difficulties involved in the preoperative diagnosis of endometriosis of the rectus abdominis muscle. Concurrently, it is pointed out that, despite its rarity, individual extrapelvic endometriosis located in the rectus abdominis muscle should be included among other pathological entities in the differential diagnosis of chronic pelvic pain in women of reproductive age, who gave birth by caesarean section or underwent gynecological surgery with abdominal or laparoscopic access.

Thoracic and diaphragmatic endometriosis: an overview of diagnosis and surgical treatment.

PURPOSE OF REVIEW: Thoracic endometriosis is a rare disease that can lead to a variety of clinical manifestations. There are currently no guidelines for optimal diagnosis and management of the disease. The purpose of this review is to provide an overview of the diagnosis and surgical treatment of thoracic endometriosis. RECENT FINDINGS: Various imaging modalities, including computed tomography (CT), MRI and ultrasound, have been reported in the detection of thoracic endometriosis. MRI is the most sensitive imaging study and may aid in preoperative planning. Histopathology of a biopsied lesion remains the gold standard for diagnosis. Surgical management of thoracic endometriosis may involve laparoscopy and/or thoracoscopy, and surgical planning should include preparation for single ventilation capability. A multidisciplinary approach involving a gynaecologic surgeon and thoracic surgeon may be considered. Repairing diaphragm defects and pleurodesis are shown to decrease recurrent symptoms. SUMMARY: Although optimal diagnostic testing remains uncertain, a high clinical suspicion for thoracic endometriosis is critical to ensure prompt diagnosis and treatment in order to prevent recurrent symptoms and progression to more serious sequalae. Minimally invasive surgical techniques are becoming increasingly utilized and allow for thorough evaluation and treatment of thoracic endometriosis.

Spinal surgery for a late-onset axial myopathy.

Axial myopathies with paraspinal predominance usually present with dropped head, abnormal posture or rigidity of the spine. Management of axial myopathy can be difficult and there is little data in the literature about surgical treatment. We discuss a case of axial myopathy with late-onset scoliosis and dropped head, focusing on the surgical management of the case.

Attenuation of Muscle Mass and Density Is Associated With Poor Outcomes Among Patients Undergoing Major Gynecologic Surgery: A Retrospective Cohort Study.

BACKGROUND: The aim of this study was to explore the associations of preoperative sarcopenia (muscle mass depletion) and myosteatosis (muscle quality attenuation) with the incidence of postinduction hypotension (PIH) and postoperative complications among patients undergoing major gynecologic surgery. METHODS: Based on a previous prospective surgical registry of gynecologic patients, we included patients with an available preoperative abdominal computed tomography (CT) scan performed within 3 months before surgery. The cross-sectional muscle mass and density at the third lumbar vertebra (L3) level were measured from the CT scan. The primary outcome was PIH, which was defined as a blood pressure reduction >30% from baseline. The secondary outcome was postoperative complications based on the Clavien-Dindo classification. Multivariable logistic regression analyses were performed to identify the associations between the muscle parameters and outcomes. RESULTS: Of the 167 gynecologic surgical patients included in this study, the mean (standard deviation [SD]) age was 53.0 (12.2) years. Sarcopenia was present in 86 (51.5%) patients. Fifty-six (33.5%) patients experienced PIH, and 89 (53.3%) patients experienced different degrees of postoperative complications. Multivariable analysis showed that myosteatosis was significantly associated with an increased risk of PIH (odds ratio [OR] = 2.95, 95% confidence interval [CI], 1.24-7.04; P = .015), and sarcopenia was associated with an increased risk of postoperative complications (OR = 2.30; 95% CI, 1.16-4.57; P = .018). CONCLUSIONS: Muscle assessments using preoperative CT scans may help identify high-risk patients and determine perioperative management strategies among gynecologic patients.

[Surgical repair of a thigh muscle herniation with synthetic mesh].

We present the case of a 14-year-old female patient with a big muscle hernia in the thigh after extraction of a fascia lata strip to repair bilateral congenital ptosis. After three weeks, a progressive emergence of a large bulge between the two thigh incisions in a standing position was noticeable, with local discomfort, dull pain on exertion and unsightly ap-pearance that worried the patient. On surgery three months later, a large tear in the fascia lata and muscle herniation was revealed. The fascial tear was debrided and a synthetic mesh was applied. Ten years later, the patient confirmed her continued asymptomatic condition. Muscular hernia of significant size as a consequence of a fascia lata strip harvest is extremely infrequent in adoles-cents. Surgical repair of big muscular hernias in extremities with synthetic mesh, usually used in groin hernia repair, is an infrequent orthopaedic tool but is safe, easy to apply and inexpensive.

Tonsillectomy Improved Therapeutic Response in Anti-SRP Myopathy With Chronic Tonsillitis.

Chronic tonsillitis has been attracted attention as a source of abnormal immune responses and a possible trigger of autoimmune diseases such as IgA nephritis, IgA vasculitis, palmoplantar pustulosis, psoriasis, rheumatoid arthritis, Behçet's disease, and myositis. Here we present the first report of anti-signal recognition particle antibody-associated necrotizing myopathy (anti-SRP myopathy) with IgA nephropathy and chronic tonsillitis in which the therapeutic response to intravenous immunoglobulin (IVIG) treatment was dramatically improved after tonsillectomy and accompanied by a rapid increase in ΔIgG, defined as the change in serum IgG levels 2 weeks after the start of IVIG treatment relative to pre-treatment levels. Moreover, serum anti-SRP antibody titers became undetectable after tonsillectomy even though the resected tonsils did not produce anti-SRP antibodies. Tonsillectomy should be considered when chronic tonsillitis is observed in patients with autoimmune diseases showing poor response to treatment, including anti-SRP myopathy.

Surgical repair of a thigh muscle herniation with synthetic mesh / Reparación quirúrgica de hernia muscular en muslo con malla sintética

We present the case of a 14-year-old female patient with a big muscle hernia in the thigh after extraction of a fascia lata strip to repair bilateral congenital ptosis. After three weeks, a progressive emergence of a large bulge between the two thigh incisions in a standing position was noticeable, with local discomfort, dull pain on exertion and unsightly appearance that worried the patient. On surgery three months later, a large tear in the fascia lata and muscle herniation was revealed. The fascial tear was debrided and a synthetic mesh was applied. Ten years later, the patient confirmed her continued asymptomatic condition. Muscular hernia of significant size as a consequence of a fascia lata strip harvest is extremely infrequent in adolescents. Surgical repair of big muscular hernias in extremities with synthetic mesh, usually used in groin hernia repair, is an infrequent orthopaedic tool but is safe, easy to apply and inexpensive

Presentamos el caso de una chica de 14 años con una gran hernia muscular en muslo tras extracción de una tira de fascia lata para ser utilizada en cirugía oftalmológica. Tres semanas más tarde era muy evidente en bipedestación un abultamiento entre ambas incisiones, con molestias locales, dolorimiento y preocupación por el aspecto estético. Tres meses más tarde se realizó intervención quirúrgica evidenciándose herniación de parte del músculo vasto externo con gran defecto fascial, que fue desbridado, aplicándose malla no reabsobible de polipropileno. Diez años más tarde la paciente confirmó que permanece asintomática. La aparición de una hernia muscular de gran tamaño en extremidades de adolescentes como consecuencia de extracción de fascia lata es extremadamente infrecuente. La reparación de hernias musculares de gran tamaño en extremidades mediante malla sintética, utilizada habitualmente en reparación de hernias inguinales, es una técnica rápida, segura y barata a tener en cuenta en cirugía ortopédica

Reliability of pre-operative diffusion tensor imaging parameter measurements of the cervical spine in patients with cervical spondylotic myelopathy.

The present study assessed test-retest and inter-observer reliability of diffusion tensor imaging (DTI) in cervical spondylotic myelopathy (CSM), as well as the agreement among measurement methods. A total 34 patients (12 men, 22 women; mean age, 58.7 [range 45-79] years) who underwent surgical decompression for CSM, with pre-operative DTI scans available, were retrospectively enrolled. Four observers independently measured fractional anisotropy (FA) values twice, using three different measurement methods. Test-retest and inter-observer reliability was assessed using intraclass correlation coefficients (ICCs). Overall, inter-observer agreements varied according to spinal cord level and the measurement methods used, and ranged from poor to excellent agreement (ICC = 0.374-0.821), with relatively less agreement for the sagittal region of interest (ROI) method. The radiology resident and neuro-radiologist group showed excellent test-retest reliability at almost every spinal cord level (ICC = 0.887-0.997), but inter-observer agreements varied from fair to good (ICC = 0.404-0.747). Despite excellent test-retest reliability of the ROI measurements, FA measurements in patients with CSM varied widely in terms of inter-observer reliability. Therefore, DTI parameter data should be interpreted carefully when applied clinically.

A tissue engineering approach for repairing craniofacial volumetric muscle loss in a sheep following a 2, 4, and 6-month recovery.

Volumetric muscle loss (VML) is the loss of skeletal muscle that results in significant and persistent impairment of function. The unique characteristics of craniofacial muscle compared trunk and limb skeletal muscle, including differences in gene expression, satellite cell phenotype, and regenerative capacity, suggest that VML injuries may affect craniofacial muscle more severely. However, despite these notable differences, there are currently no animal models of craniofacial VML. In a previous sheep hindlimb VML study, we showed that our lab's tissue engineered skeletal muscle units (SMUs) were able to restore muscle force production to a level that was statistically indistinguishable from the uninjured contralateral muscle. Thus, the goals of this study were to: 1) develop a model of craniofacial VML in a large animal model and 2) to evaluate the efficacy of our SMUs in repairing a 30% VML in the ovine zygomaticus major muscle. Overall, there was no significant difference in functional recovery between the SMU-treated group and the unrepaired control. Despite the use of the same injury and repair model used in our previous study, results showed differences in pathophysiology between craniofacial and hindlimb VML. Specifically, the craniofacial model was affected by concomitant denervation and ischemia injuries that were not exhibited in the hindlimb model. While clinically realistic, the additional ischemia and denervation likely created an injury that was too severe for our SMUs to repair. This study highlights the importance of balancing the use of a clinically realistic model while also maintaining control over variables related to the severity of the injury. These variables include the volume of muscle removed, the location of the VML injury, and the geometry of the injury, as these affect both the muscle's ability to self-regenerate as well as the probability of success of the treatment.

Persisting Muscle Dysfunction in Cushing's Syndrome Despite Biochemical Remission.

CONTEXT: Glucocorticoid-induced myopathy is a characteristic symptom of endogenous Cushing's syndrome (CS). Its long-term outcome is largely unknown. OBJECTIVE: To evaluate long-term muscle function following the remission of endogenous CS. STUDY DESIGN: Observational longitudinal cohort study. SETTING: Tertiary care hospitals and a specialized outpatient clinic. PATIENTS: As part of the prospective multicenter German Cushing's Registry, we assessed muscle strength in patients with overt endogenous CS. We studied the patients at the time of diagnosis (n = 88), after 6 months (n = 69), and thereafter annually, following surgical remission over a period of up to 4 years (1 year: n = 55; 2 years: n = 34; 3 years: n = 29; 4 years: n = 22). Muscle function was evaluated by hand grip strength and by chair rising test. RESULTS: Grip strength was decreased to 83% of normal controls (100%) at the time of diagnosis. It further decreased to 71% after 6 months in remission (P ≤ 0.001) and showed no improvement during further follow-up compared with baseline. Chair rising test performance improved initially (8 seconds at baseline vs 7 seconds after 6 months, P = 0.004) but remained at this reduced level thereafter (7 seconds after 3 years vs 5 seconds in controls, P = 0.038). In multivariate analysis, we identified, as predictors for long-term muscle dysfunction, age, waist-to-hip ratio, and hemoglobin A1c at baseline. Furthermore, muscle strength during follow-up was strongly correlated with quality of life. CONCLUSION: This study shows that CS-associated myopathy does not spontaneously resolve during remission. This calls for action to identify effective interventions to improve muscle dysfunction in this setting.

Percutaneous endoscopic gastrostomy in small infants unable to swallow safely.

BACKGROUND: Data about percutaneous endoscopic gastrostomy (PEG) insertions in small infants are limited, and most studies include older children. We aimed to evaluate the safety of PEG placement in infants weighing ≤5 kg together with their follow-up results. METHODS: A retrospective evaluation was made of records between January 2005 and December 2019. RESULTS: A total of 43 infants were ≤5 kg at the time of PEG insertion. The mean age was 5 ± 3 (19 days-16 months) months and the mean weight was 4.3 ± 0.6 (2.7-5.0) kg. The primary diagnoses were neurological disorders in 25, metabolic disorders in nine, cleft palates in four, muscular disorders in four, and a cardiac disorder in one. All procedures were completed successfully. A self-resolving pneumoperitoneum developed in one (2.3%). The tube was extruded in six (14%) patients postoperatively which required suture-approximation of the skin and subcuticular tissues. The tube was removed in four (9%) patients with achievement of oral feeds on the long-term. Eighteen (42%) died of primary diseases. The tubes were in situ for a median of 12.4 (17 days-73 months) months in these patients. A total of 20 (46.5%) patients are currently being followed up and their tubes are in situ for a median of 50.3 (4.7 month-9.8 years) months. CONCLUSIONS: Percutaneous endoscopic gastrostomy placement is safe in small infants with associated morbidities. Complications related to the procedure are within acceptable limits. The accidental extrusion of the tube was a special consideration in this patient group. The overall mortality was high because of underlying primary diseases.

Minimally Invasive Method for Correcting Reducible Cryptotia.

Various surgical methods have been used to treat cryptotia; however, there is a drawback of these methods in that they leave a permanent scar. The authors describe a 7-year-old child who missed the optimal corrective time for cryptotia. Minimally invasive surgery was planned as a 3rd alternative to external splinting or invasive surgery by taking advantage of 2 methods. Silly putty was prefabricated as an auricular sulcus retainer, and fixation sutures between the deep dermis and temporal fascia were placed through small incisions along the future auricular sulcus. Then the prefabricated auricular sulcus retainer was maintained for 2 months. After 6 months, the corrected ear shape remained stable with the inconspicuous scar. With minimally invasive correction, a successful treatment effect can be expected while minimizing scarring in patients who are not expected to have a therapeutic effect with a simple reduction.

Risk factors for surgery due to rotator cuff disease in a population-based cohort.

AIMS: Few risk factors for rotator cuff disease (RCD) and corresponding treatment have been firmly established. The aim of this study was to evaluate the relationship between numerous risk factors and the incidence of surgery for RCD in a large cohort. METHODS: A population-based cohort of people aged between 40 and 69 years in the UK (the UK Biobank) was studied. People who underwent surgery for RCD were identified through a link with NHS inpatient records covering a mean of eight years after enrolment. Multivariate Cox proportional hazards regression was used to calculate hazard ratios (HRs) as estimates of associations with surgery for RCD accounting for confounders. The risk factors which were considered included age, sex, race, education, Townsend deprivation index, body mass index (BMI), occupational demands, and exposure to smoking. RESULTS: Of the 421,894 people who were included, 47% were male. The mean age at the time of enrolment was 56 years (40 to 69). A total of 2,156 people were identified who underwent surgery for RCD. Each decade increase in age was associated with a 55% increase in the incidence of RCD surgery (95% confidence interval (CI) 46% to 64%). Male sex, non-white race, lower deprivation score, and higher BMI were significantly associated with a higher risk of surgery for RCD (all p < 0.050). Greater occupational physical demands were significantly associated with higher rates of RCD surgery (HR = 2.1, 1.8, and 1.4 for 'always', 'usually', and 'sometimes' doing heavy manual labour vs 'never', all p < 0.001). Former smokers had significantly higher rates of RCD surgery than those who had never smoked (HR 1.23 (95% CI 1.12 to 1.35), p < 0.001), while current smokers had similar rates to those who had never smoked (HR 0.94 (95% CI 0.80 to 1.11)). Among those who had never smoked, the risk of surgery was higher among those with more than one household member who smoked (HR 1.78 (95% CI 1.08 to 2.92)). The risk of RCD surgery was not significantly related to other measurements of secondhand smoking. CONCLUSION: Many factors were independently associated with surgery for RCD, including older age, male sex, higher BMI, lower deprivation score, and higher occupational physical demands. Several of the risk factors which were identified are modifiable, suggesting that the healthcare burden of RCD might be reduced through the pursuit of public health goals, such as reducing obesity and modifying occupational demands. Cite this article: Bone Joint J 2020;102-B(3):352-359.

Primary hydatid disease of the transverse abdominal muscle A case report.

INTRODUCTION: Echinococcus is a parasitic disease that affects all organs and tissues. The most commonly affected are liver (70-80%) and lungs (10-25%), while very rarely, in about 5% of cases, it can be found in the spleen, kidneys, brain, heart, pancreas, muscles and skeleton. CASE REPORT: Although localization of hydatid cyst in muscle is rare, it is important to consideredPORT it in the differential diagnosis of a cystic mass in the muscle. Clinical diagnosis of cystic echinococcosis is based on general ultrasound imaging, CT, MRI, differentiation of Echinococcus-Ag, ELISA testing, immunoelectrophoresis (IEP), counterimmunoelectrophoresis (CIE). DISCUSSION: Surgery is the primary treatment for muscle hydatidosis. We present our experience in treating the case of an infected hydatid cyst on transverse abdominal muscle, with infection extending to the right diaphragm and subcutaneous tissue of abdomen and thorax between the transverse abdominal and internal sternal abdominal muscles. CONCLUSION: The goal of the surgical treatment is total evacuation of the parasite, "sterilization" of the residual cavity and handling of intraoperartive complications. The post-operative course was normal and the patient was discharged to home care ten days after surgery in good general and local condition. KEY WORDS: Abscess, Echinococcus, Infection, Muscle.

Surgical Management of Fibroadipose Vascular Anomaly of the Lower Extremities.

BACKGROUND: Fibroadipose vascular anomaly (FAVA) is a recently-defined vascular malformation often involving the extremities and presenting in childhood. Patients may present to orthopaedic surgeons with pain, swelling, joint contractures, and leg length discrepancy. There is no established therapy or treatment paradigm. We report on outcomes following surgical excision for patients with this condition. METHODS: Between 2007 and 2016, all 35 patients that underwent excision of lower-extremity FAVA were retrospectively reviewed using a combination of medical records, radiologic findings, and telemedicine reviews. RESULTS: Mean age at initial presentation was 12.3±6.8 years. Mean follow-up from time of definitive diagnosis at our institution was 66 months (range: 12 to 161 mo). Mean follow-up after surgery was 35 months (range: 6 to 138 mo). Females were affected more than males (71% vs. 29%). The most common location of FAVA was in the calf (49%), followed by the thigh (40%). The most commonly involved muscle was gastrocnemius (29%), followed by the quadriceps (26%). At latest follow-up after surgery, there was an improvement in the proportion of patients with pain at rest (63% vs. 29%), pain with activity (100% vs. 60%), as well as analgesia use (94% vs. 37%). Fourteen patients (40%) had symptomatic residual disease or recurrence of FAVA requiring further treatment. Six patients (17%) required further surgery and 6 (17%) required further interventional radiologic procedures. Three patients (9%) required eventual amputation for intractable pain and loss of function. Lesions with direct nerve involvement were associated with persistent neuropathic symptoms at latest follow-up (P=0.002) as well as symptomatic residual disease and/or recurrence requiring further treatment (P=0.01). Seventeen patients (49%) had 19 preoperative joint contractures. Eighteen of the 19 contractures (95%) had sustained improvement at latest follow-up. CONCLUSIONS: In carefully selected patients, surgical excision of FAVA results in improvement of symptoms. However, symptomatic residual disease and/or recurrence are not uncommon. Direct nerve involvement is associated with a worse outcome. LEVEL OF EVIDENCE: Level IV-case series.