Risk of recurrence of nail unit melanoma after functional surgery versus amputation.

BACKGROUND: Minimally invasive nail unit melanoma (NUM) can be treated with functional surgery (FS) instead of amputation. OBJECTIVE: To determine risk factors associated with recurrence in NUM. METHODS: We retrospectively reviewed patients with NUM between 2008 and 2022 at a tertiary referral center. Multivariable Cox regression models adjusted for male sex and Breslow thickness (BT) were generated. Receiver operating characteristic analysis was performed to determine optimal cut-off points of the BT for stratifying recurrence risk. RESULTS: We evaluated 140 NUM cases (33 amputation and 107 FS). The mean BT values were 3.14 ± 2.62 mm (amputation) and 0.70 ± 1.36 mm (FS). Recurrence occurred in 10 (30.30%) patients with amputation and 23 (21.5%) with FS. Distant disease occurred in 10 (30.30%) patients with amputation and 8 (7.48%) with FS. Male sex, greater BT, amelanotic color, ulcers, and nodules were associated with greater risk for recurrence or distant disease. A BT of 0.8 mm was deemed the optimal cut-off for stratifying recurrence risk after surgery (odds ratio, 5.32; 95% CI, 2.04-13.85). LIMITATIONS: Small sample. CONCLUSION: FS can be considered for NUM with a BT < 0.8 mm, providing an amputation-sparing benefit. However, NUM with risk factors for recurrence requires patient counselling and close follow-ups.

Long-term walking ability and patient satisfaction after lower limb functional surgery in patients affected by Charcot-Marie-Tooth disease: A retrospective study.

Structural foot deformities consequent to Charcot Marie Tooth (CMT) can be treated by functional surgery (FS). This study aims to evaluate both long-term walking ability and patients' satisfaction in CMT subjects who underwent FS during their lifetime. We conducted a retrospective observational study. Age, sex, CMT type, comprehensive surgical history, current walking ability assessed by the Walking Handicap Scale (WHS) and patients' global impression of change (pGIC) were retrieved from a custom database managed at our institution. WHS and pGIC were assessed between mid-2018 and mid-2019. Data from 79 patients were screened and 63 were included, 35W-28M, mean age 42 (15), with demyelinating (75%), axonal (20%), and other types (5%) of CMT, who underwent FS between 1967 and 2018. FS evolved significantly over the years from bone-related procedures (e.g., arthrodesis) to both bone and soft tissues-related procedures. The re-intervention rate decreased from 70% before 2000 to 32% in the last decade. Complications arose in five cases. FS was mainly performed on adults (73%). WHS was ≥ 5 in three-quarters of the sample (range 1-6) and was significantly affected by age groups in patients with demyelinating CMT (n=47, p<0.01, non-parametric ANOVA). Nearly 80% of patients were satisfied with FS (pGIC ≥ 4). In conclusion, CMT subjects who underwent FS surgery maintained a high gait efficiency in the long-term period, with middle to high levels of satisfaction in the majority of the cases. This confirms the validity of FS in the management of acquired foot deformities in CMT patients.

Functional surgery versus amputation for in situ or minimally invasive nail melanoma: A meta-analysis.

BACKGROUND: Evidence on whether functional surgery is not inferior to amputation for the treatment of in situ or minimally invasive (Breslow thickness ≤0.5 mm) nail melanoma is limited. OBJECTIVE: To investigate the difference in local recurrence between the 2 interventions for in situ or minimally invasive nail melanoma using available published studies. METHODS: We performed systematic search on PubMed, Embase, Cochrane Library, trial registers, and grey literature databases from inception to June 28, 2018. We included observational studies with at least 5 patients with in situ or minimally invasive nail melanoma. Main outcome was local recurrence. RESULTS: The odds ratio synthesized from 5 studies including 109 patients (88 functional operations and 21 amputations) was 1.57 (95% confidence interval, 0.31-8.00). LIMITATIONS: Small sample size and possible interstudy heterogeneity. CONCLUSIONS: Our meta-analysis revealed no difference in local recurrence between the 2 interventions. Considering the functional deficit after amputation, conservative surgery should be the treatment of choice for in situ or minimally invasive nail melanoma.

Ultrasonographic evaluation of nail matrix topography for preservative nail surgery of nail unit melanoma.

Recently, functional or preservative surgery has been preferred for nail unit melanoma; however, complete resection of the nail unit, particularly the matrix, is challenging because of its complex structure. This study aims to measure the distance of important nail structures through ultrasonography. Herein, 14 patients without nail deformity were included. The length from the nail cuticle to the distal interphalangeal joint (distance X), to the attachment part of the extensor muscle (distance A), to the median proximal end of the nail matrix (distance B), and to the lateral proximal end of the nail matrix (distance C) were measured. In the axial plane, the length from the highest point of the nail plate to the bottom of the distal phalanx (distance Y) and to the lateral tip of the nail plate (distance D) were measured. On the first fingernail, third fingernail, first toenail, and third toenail, the mean ratio A:X, ratio B:X, ratio C:X, and ratio D:Y were 78.6%, 44.3%, 57.2%, 40.1%, and 84.6%; 55.9%, 64.9%, 40.2%, and 66.4%; 35.6%, 50.8%, 34.3%, and 81.9%; and 57.2%, 59.6%, and 31.7%, respectively. Nail units are often invisible to the naked eye; thus, this study will help identify the approximate scope of excision.

Stair-stepped mandibulotomy: Clinical indication, surgery program design, and operation points.

For radical treatment of malignancies in the posterior region of the oral cavity and oropharynx, surgical exposure of the tumor by mandibulotomy is often required. Midline or paramedian vertical mandibulotomies are commonly performed in clinical practice, but these can damage the suprahyoid musculature and genioglossus, and weaken the swallowing and speech function of patients. Stair-stepped mandibulotomy is a new procedure, developed on the principles of functional surgery, that preserves the structure and function of the mandible whilst providing a clear field and avoiding damage to critical muscle attachments. Stair-stepped mandibulotomy is suitable for patients whose primary tumor is located in the middle and posterior part of the tongue or oropharynx, especially if the lesion involves extrinsic tongue muscles. In this case report, we draw on 2 cases of typical patients in our center to elaborate the surgery program design, operation points, advantages and disadvantages of stair-stepped mandibulotomy.

Recurrence rates after functional surgery versus amputation for nail squamous cell carcinoma not involving the bone: A systematic review.

Background Nail unit squamous cell carcinoma (nSCC) is a malignant subungual tumour. Although it has a low risk of metastasis and mortality, the tumour has a significant local recurrence rate. There is insufficient data to determine whether functional surgery is less effective than amputation for nSCC that does not involve the bone. Objectives We aimed to investigate existing data on the outcomes of functional surgery and amputation for nSCC without bone invasion. Materials and Methods We carried out an extensive search in PubMed, Embase, Cochrane Library, Web of Science, and Scopus for appropriate English-language academic papers, starting with the creation of individual resources until February 23, 2023. The main outcome was local recurrence. Initially, 2191 studies related to nSCC were selected. Information from every research study was retrieved and subdivided, comprising the year of publication, period, number of patients, age, gender distribution, tumour stage, type of intervention, number of recurrences, and follow-up period. Results Ten independent studies (319 lesions) were finally selected. Mohs micrographic surgery was the most reported surgical modality, followed by wide surgical excision and amputation. Local recurrence rates between Mohs micrographic surgery, wide surgical excision and amputation treatment were nearly identical. Other surgical methods included limited surgical excision, partial ablation, and limited excision until the clearing of margins, with recurrence rates up to 50%. Conclusions Given the functional impairment and psychological distress associated with phalanx amputation, functional surgery, including Mohs micrographic surgery and wide surgical excision , should be the preferred therapy for nSCC without bone involvement. Amputation should remain the preferred therapy for nSCC that involves the bone. Partial excision should be avoided. Further studies on whether Mohs micrographic surgery or wide surgical excision is a better option for nSCC not involving the bone are required.

Lateral Pectoral Nerve Identification through Ultrasound-Guided Methylene Blue Injection during Selective Peripheral Neurectomy for Shoulder Spasticity: Proposal for a New Procedure.

Internally rotated and adducted shoulder is a common posture in upper limb spasticity. Selective peripheral neurectomy is a useful and viable surgical technique to ameliorate spasticity, and the lateral pectoral nerve (LPN) could be a potential good target to manage shoulder spasticity presenting with internal rotation. However, there are some limitations related to this procedure, such as potential anatomical variability and the necessity of intraoperative surgical exploration to identify the target nerve requiring wide surgical incisions. This could result in higher post-surgical discomfort for the patient. Therefore, the aim of our study was to describe a modification of the traditional selective peripheral neurectomy procedure of the LPN through the perioperative ultrasound-guided marking of the target nerve with methylene blue. The details of the localization and marking procedure are described, as well as the surgical technique of peripheral selective neurectomy and the potential advantages in terms of nerve localization, surgical precision and patients' post-surgical discomfort. We suggest that the proposed modified procedure could be a valid technique to address some current limitations and move the surgical treatment of spasticity toward increasingly tailored management due to the ease of nerve identification, the possibility of handling potential anatomical variability and the resulting smaller surgical incisions.

Current Neurosurgery.

Neurosurgery is based on neuroscience, physiology and medical physics. Therefore, neurosurgery has also developed along with discoveries and innovations in these fields. The present article outlines the areas of neurosurgery and their development until 2022. Technology for the preservation of the central nervous system and cranial nerve function has made remarkable progress through the integration of diagnostic imaging and functional evaluation capabilities. Endovascular treatment strategies of cerebrovascular disorders have also progressed. The procedures have not only shifted from craniotomy to endovascular catheterization, but the devices used in these procedures have also changed. In addition to these traditional disease treatment strategies/techniques, neurosurgical techniques have recently been used in surgical procedures to improve quality of life. Epilepsy, is one of the diseases that does not significantly have a direct impact on life outcomes. However, epilepsy patients find it difficult to reintegrate into society. In epilepsy, seizure management is important, and some subgroups of patients can be better treated using surgical intervention than by using pharmacotherapy. In addition, the treatment of dementia due to idiopathic normal pressure hydrocephalus can be improved by surgical management of the cerebrospinal fluid. Neurosurgical intervention can help diseased patients reintegrate into society, which is difficult without treatment. Even in these disease groups, surgical intervention may have irreversible consequences. Therefore, its implications should be decided based on universal scientific evidence.

Individualized Functional Decompression Options for Adult Chiari Malformation With Syringomyelia and A Novel Scale for Syringomyelia Resolution: A Single-Center Experience.

OBJECTIVE: To compare outcomes of posterior fossa bony decompression alone (PFD) versus PFD with duraplasty (PFDD) versus PFDD with additional obex exploration (PFDDO) in patients with Chiari malformation type I (CMI) combining syringomyelia. METHODS: Clinical records of adult patients who underwent decompressions from 2014 to 2022 were retrospectively analyzed. The decompression procedure was individualized based on the cerebrospinal fluid pulse in the surgical field. The Chicago Chiari Outcome Scale (CCOS) was used to assess the prognosis of the patients and a novel syringomyelia resolution scale, based on 3-dimensional volume, was introduced. The percentage change in the cervical syrinx volume was classified as follows by resolution: ≥ 70%, 30%-70%, and < 30%. RESULTS: Seventy-eight individuals were enrolled, of which 22, 20, and 36 underwent PFD, PFDD, and PFDDO, respectively. The three decompression groups had no significant difference in the preoperative characteristics and postoperative prognosis. Multivariate analyses revealed that better CCOS was significantly correlated with younger age at surgery (p = 0.018), syrinx originated from lower cervical levels (p = 0.037), narrower preoperative cerebral aqueduct (p = 0.005), and better syrinx volume resolution (p = 0.004). Additionally, a better cervical syrinx volume resolution was significantly correlated with higher CCOS (p = 0.017), narrower cerebral aqueduct (p = 0.035), and better tonsillar descent resolution (p = 0.007). CONCLUSION: Individualized functional decompression induced an equal effect on CCOS and syrinx volume resolution for all CMI patients with syringomyelia. Our syringomyelia resolution scale facilitates communication and prediction of CMI prognosis.

Functional outcomes after robot-assisted pyeloplasty for ureteropelvic junction obstruction: A bi-centre experience.

BACKGROUND: Robot-assisted pyeloplasty (RALP) for patients with clinically symptomatic ureteropelvic junction obstruction (UPJO) is increasing and needs assessment. METHODS: Patients who underwent RALP for UPJO in two academic centres were included. Demographic and perioperative data were collected retrospectively. UPJO was evaluated by imaging pre- and post-surgery. Patients had follow-up consultations 3,6 and 12 months post-surgery. Global success was defined as a clinical response plus radiographic evidence of no further obstruction 3-months post-surgery. RESULTS: Overall 214 patients (median age: 40 years [interquartile range:30.3-54.0]) were included. Fourteen patients (6.5%) had undergone previous surgery for UPJO. Thirty patients (14%) suffered complication: urinoma (n = 13; 6.1%), pyelonephritis (n = 15; 7%) and retroperitoneal haematomas (n = 2; 0.9%). Repeated early surgery was necessary in eight patients (3.6%). Seven patients had a recurrence of UPJO and six (2.9%) underwent repeated surgery. Radiological success rate was 96.7% whereas global success rate was 91%. CONCLUSIONS: RALP was a reliable, effective and safe treatment for UPJO with a high global and radiologic success rate.

Management of Nail Unit Melanoma.

Nail unit melanoma is an uncommon form of melanoma with worse prognosis compared with nonacral cutaneous melanoma. Nail unit melanoma is often diagnosed at a late stage. Clinical and dermoscopic features may suggest a diagnosis of nail unit melanoma, but confirmation requires histologic analysis. Like the clinical diagnosis, histopathologic diagnosis of nail unit melanoma is also difficult. The surgical management of nail unit melanoma has evolved from aggressive amputations to digit-sparing approaches. This article reviews the clinical presentation, diagnosis, and surgical treatment of nail unit melanoma to promote early diagnosis and rational surgery.

Lower Extremity Amputations in At-Risk Patients: A Focus on Tissue Viability and Function in the Compromised Limb.

Amputations distal to the ankle joint are commonly performed in efforts to preserve a limb. Thorough examination of lower extremity biomechanics, patient functional status, and patient goals must be used to help prevent reulceration and further amputation. Once infection is resolved in the acute setting, musculotendon balancing should be considered at the time of amputation closure to maintain functionality of the limb. Patients should be closely followed postoperatively and monitored for biomechanical deformity that needs to be addressed. Careful attention to detail and adherence to surgical principles can help keep patients active and prevent further amputation.

Long-term effects on body functions, activity and participation of hemiplegic patients in equino varus foot deformity surgical correction followed by immediate rehabilitation. A prospective observational study.

Background: Functional surgery is an effective approach in the treatment of the rigid equinovarus foot deformity (EVFD). This must be associated with early rehabilitation treatments (ERTs) to prevent muscle rearrangements due to immobilization. Objectives: To assess the effects of EVFD surgical correction in adult stroke patients, when assessed according to the ICF domains. Methods: Variables from 24 adult chronic stroke survivors with EVFD surgical correction followed by ERT, age 55 ± 13 years, affected side 12L/12R, time from lesion 5 ± 4 years were analyzed. Body function domain: pain (NPRS), walking speed, clinical global impression of change (cGIC). Activity domain: Rivermead Mobility Index (RMI), FAC, and 6 min walking test (6MWT). Participation domain: Walking Handicap Scale (WHS). Patients were assessed before (T0), one (T1), three (T2) and twelve (T3) months after surgery by a single assessor. Results: All variables but the 6MWT significantly improved (Wilcoxon test, p < .05) at T1 or T2 and this remained until the 12-months mark. Since T1, all patients reached and maintained a supervised independent walking (FAC≥3) and all those wearing an AFO stopped using it. The median cGCI was "much improved" at T1, with a "further minimal improvement" at T3. This was not associated with the improvement measured by both FAC, and WHS (Chi-square test, p = .20 and p = .36, respectively). Conclusions: Functional surgery combined with ERT is effective in improving the patients' condition according to all ICF domains. Both subjective and objective assessments have to be used when assessing these patients.

[Functional parotid surgery for removal of benign parotid tumors].

Objective: To evaluate the effect of the application of functional parotid surgery for removal of benign parotid tumors and the prevention of Frey syndrome. Method: One hundred and fifty-six cases with benign tumor were underwent functional regional parotidectomy. All tumors were smaller than 4 cm in diameter. The safe surgical margin was 5 mm when the tumors were less than 2 cm in diameter, while the safety margin was 1 cm for the tumors diameter between 2-4 cm. 156 cases were assigned to two groups(A and B). The absorbable hemostatic sponge was placed between the surface of parotid gland and skin flap after tumor resection in group A，while no sponge was placed in group B. Postoperative followup was 12-24 months. Result: No compression bandage was performed. No patient had recurrence or salivary fistula. There were 3 cases of temporary facial paralysis, of which 2 cases recovered from the mandibular marginal branch injury within 1 month and 1 case recovered from the facial nerve trunk injury within 6 months. Compared with group B 15.38%(12/78)，the incidence of Frey syndrome was significantly decreased in group A 3.85%（3/78）.χ2=5.728, P<0.05. Conclusion: The removal of benign parotid tumors by functional parotid surgery can effectively preserve the function of residual gland and reduce complication. Intraoperative implantation of absorbable hemostatic sponge between parotid gland and skin flap can reduce the incidence of Frey syndrome.

Anterolateral thigh perforator flap made by customized 3D-printing fabrication of fixed positioning guide for oromaxillofacial reconstruction: a preliminary study

Background: Oromaxillofacial carcinomas frequently result in serious tissue defect due to enlarged resection for treating their extensive invasion, which require challenging reconstruction. Three-dimensional (3D) printing is an advanced technology which has greatly promoted the progress of craniomaxillofacial reconstructive surgery. This present study aimed to investigate the advantages of anterolateral thigh (ALT) perforator flap manufactured by 3D printing fixed positioning guide template in curing oromaxillofacial defect.Material and methods: Twenty patients with oromaxillofacial defects resulted from severe primary malignant tumors were divided into experimental group assisted by digital technique (n=8) and controlled group conventionally aided by ultrasound (n=12). The therapeutic effectiveness, flap preparation time, amount of bleeding, deviation of perforator vessel location, aesthetic satisfaction of donor site, postoperative complications, adverse symptom of flap, and LEFS scores were compared.Results: For experimental group, flap preparation time was significantly shorter; and it has obviously less bleeding, minor deviation of perforator vessel location, and better aesthetic satisfaction of donor site (P<.001). There was no statistical difference in postoperative complications and LEFS scores between two groups (P>.05).Conclusions: The study suggests 3D printing template of fixed positioning guide provides a brand-new method for orienting perforated vessels of ALT flap, which is more accurate in clinical application. It can improve the operative efficacy, and increase the successful rate of operation as well. (AU)

Functional Surgery for Malignant Subungual Tumors: A Case Series and Literature Review. / Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura.

BACKGROUND AND OBJECTIVES: Amputation is the conventional treatment for malignant subungual tumors (MSUTs), namely, subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM). Functional surgery consisting of wide local excision (WLE) of the nail unit can preserve function without modifying prognosis in such cases. We present a series of MSUTs treated with WLE of the nail unit, describe the technique, and review its indications. MATERIAL AND METHODS: Retrospective observational study of MSUTs treated with WLE of the nail unit between 2008 and 2017. The technique consisted of en bloc supraperiosteal excision of the nail unit with a margin of 5mm followed by repair with a full-thickness graft. RESULTS: Eleven MSUTs were treated in the study period: 7 SUMs (4 in situ; mean thickness, 1.17mm; range, 0-4mm) and 4 SUSCCs (mean thickness, 3.4mm; range, 1.6-6mm). WLE of the nail unit was performed in 9 patients and amputation in 2 patients with invasive SUM. Mean follow-up was 39 months (range, 12-96 months) and no local or regional recurrences were detected. One of the 2 patients who underwent amputation developed metastasis to the brain and died. In our review of the literature, we identified 5 series of patients with SUSCC treated with WLE of the nail unit (105 patients) and 14 series of patients with SUM (243 patients). Based on an analysis of these cases and ours, it would appear that WLE of the nail unit is associated with a very low rate of local recurrence (<7%) and offers better functional and cosmetic outcomes than amputation. CONCLUSIONS: WLE of the nail unit is the treatment of choice for SUSCC without bone involvement and for thin noninvasive SUM (Breslow depth <1mm). It is also feasible in intermediate-thickness SUMs when detailed histologic examination of the margins confirms complete resection. Amputation, by contrast, is the treatment of choice for SUSCCs with bone involvement, very thick SUMs (>4mm), and recurrent tumors.

Transmanubrial Approach for Removing a Head and Neck Tumor Located at the Upper Lateral Mediastinum.

BACKGROUND: When a head and neck tumor invades the upper lateral mediastinum, the transmanubrial approach (TMA), in which the sternoclavicular joint is temporary mobilized and replaced back to the physiological position, appears to be an excellent method. However, there have been only a few reports about the application of this approach to head and neck tumors. MATERIALS AND METHODS: We recently adopted this technique for the removal of 2 head and neck tumors that required handling of the subclavian and innominate veins around the venus angle. RESULTS: We could safely remove the tumors under good surgical view and obtained excellent cosmetic and functional results. CONCLUSIONS: TMA is a useful technique for the removal of head and neck tumors, which invade the upper lateral mediastinum. More frequent applications of this method are encouraged in combination with head and neck tumor surgery.

Essential Subcortical Tracts in Language and Reading. 3D-Tractography for Clinical Practice and Anatomic Correlation with Intraoperative Subcortical Electrostimulation.

Diffusion tensor imaging (DTI) and tractography provide the neurosurgeon with a valid 3D view of the white matter tracts of the brain for the presurgical planning of the treatment of lesions close to eloquent areas, this being one of the principal clinical applications of this technique. In this article, we describe through practical cases the anatomic relationships of white matter tracts that are essential for language and reading, based on DTI studies and the excellent anatomic correlation with the intraoperative subcortical map.

Sedation During Surgery for Movement Disorders and Perioperative Neurologic Complications: An Observational Study Comparing Local Anesthesia, Remifentanil, and Dexmedetomidine.

BACKGROUND: The anesthetic management of patients requiring surgery for movement disorders needs to balance microrecording quality and patient cooperation with safety and comfort. Anesthetics can alter microrecording, although the effect on outcome is debatable. They also provide a rested and cooperative patient and minimize complications such as intracranial hemorrhage by providing better hemodynamic control. Most teams use local anesthesia with monitored anesthesia care or conscious sedation with propofol. Recently, dexmedetomidine has emerged as an alternative that, at low doses, does not affect microrecording, and that does not impair respiratory drive. METHODS: In the past 15 years, we have used in our institution local anesthesia, remifentanil, or dexmedetomidine sedation. We compared functional outcome and rate of complications in a group of 145 patients with similar characteristics. RESULTS: We found 5 (3.4%) intracranial hemorrhages. Two (1.4%) were symptomatic. The remifentanil group had the highest risk of having systolic blood pressure >160 mm Hg during surgery (odds ratio [OR], 2.8; 95% confidence interval [CI], 0.9-9.9), whereas the dexmedetomidine group had the lowest (OR, 0.7; 95% CI, 0.2-1.8), compared with the local anesthesia group. Surgical time was shortest with dexmedetomidine (mean, 283 minutes) and longest with local anesthesia only (mean, 328 minutes). Functional outcome (Unified Parkinson's Disease Rating Scale, Part III motor component scale) was similar among groups. The dexmedetomidine group had a statistically significant lower risk of perioperative neurologic events compared with the local anesthesia group (OR, 0.09; 95% CI, 0.002-0.68). CONCLUSIONS: Sedation can be used safely without affecting outcome, and dexmedetomidine provides better hemodynamic management. Clinical significance remains unclear and larger studies need to be undertaken.

Upper Eyelid Blepharoplasty: Evaluation, Treatment, and Complication Minimization.

Upper eyelid blepharoplasty is one of the most common procedures performed worldwide for both functional and cosmetic indications. There is a high rate of patient satisfaction; however, in this era of social media, patient expectations are higher than ever. Today's digitally savvy patients expect perfect outcomes with no complications and rapid recovery. To achieve optimal results, a careful preoperative evaluation and sound surgical technique is essential for minimizing complications. Here the authors review their approach to the management of the blepharoplasty patient.