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Annals of Plastic Surgery Jan 2023Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap....
BACKGROUND
Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap. The first description of the soleus muscle as an island flap supplied by one distal perforator was reported by Yajima et al (Plast Reconstr Surg. 1995;96:1162-1168). However, its use as a propeller flap supplied by the distal perforators and rotated for more than 90 degrees was not described yet.
OBEJECTIVES
The aims of the study are to study the detailed vascular anatomy of the distal perforators of the soleus muscle flap and to demonstrate the applicability of using it as a propeller flap.
PATIENTS AND METHODS
A total number of 42 patients were included in this study. These patients had various distal leg and foot defects. All patients were assessed preoperatively by Doppler study and computed tomography angiography to define the vascular status of the leg. The muscle was raised as a reversed flow flap, based on 1 or more distal perforators and its feeding vessel (posterior tibial artery) after being dissected and divided proximally. The muscle was rotated for more than 90 degrees to reach distal leg defects and approximately 180 degrees to reach the foot defects.
RESULTS
All flaps survived completely with good and durable coverage. The vascularity of the limb was not affected in all patients. There was no functional donor site morbidity.
CONCLUSIONS
The reversed flow hemisoleus muscle flap supplied by the distal perforators and the posterior tibial artery has a great arc of rotation that can cover all distal leg, ankle, and foot defects. Therefore, it can be used as alternative to free flap in lower extremity reconstruction. A new nomenclature is suggested for this flap which is the propeller hemisoleus muscle flap.
Topics: Humans; Plastic Surgery Procedures; Foot; Muscle, Skeletal; Tibial Arteries; Free Tissue Flaps; Perforator Flap; Soft Tissue Injuries
PubMed: 36534105
DOI: 10.1097/SAP.0000000000003365 -
Analysing debranching techniques in Frozen Elephant Trunk procedures: a narrative literature review.Cardiovascular Diagnosis and Therapy Apr 2023Since 2003, the Frozen Elephant Trunk (FET) technique has attained rising popularity for treating extensive aortic arch pathologies such as acute and chronic aortic... (Review)
Review
BACKGROUND AND OBJECTIVE
Since 2003, the Frozen Elephant Trunk (FET) technique has attained rising popularity for treating extensive aortic arch pathologies such as acute and chronic aortic dissection, as well as thoracic aortic aneurysm. Conventionally, the FET procedure included a complete resection of the aortic arch and, subsequently, a distal aortic anastomosis of the prosthetic part of the hybrid graft in arch zone 3. Simultaneous to the introduction of the FET technique, the traditional Elephant Trunk technique was simplified by adding debranching techniques which allows for proximalization of the distal aortic anastomosis. Nowadays, modern concepts of aortic arch surgery combine the FET technique with proximalization of the distal anastomosis in arch zone 2 or further proximal, achieved by using different debranching techniques. This review describes different debranching techniques to facilitate arch reconstruction, and aims to critically assess the outcomes and potential clinical advantages of proximalization using debranching in FET surgery.
METHODS
We conducted a search using the PubMed and Google Scholar electronic databases to evaluate published outcomes of different debranching techniques. An overview of the data synthesis of 21 included studies is reported.
KEY CONTENT AND FINDINGS
Most studies report numeric, but not statistically significant improved outcomes after debranching in FET surgery for mortality, neurological complications, spinal cord injury, kidney failure, bowel ischemia and recurrent nerve palsy. Some studies report statistically significant improved results in isolated endpoints such as neurological, bowel ischemia, and recurrent nerve palsy. Most studies report debranching to be technically easier, but this is difficult to objectively assess and measure.
CONCLUSIONS
There is an improved numeric outcome of different debranching techniques with proximalization of the distal anastomosis, but without reaching statistical significance. This review shows marked heterogeneity across included studies and highlights the scarce use of existing guidelines in clinical research of open aortic arch surgery as proposed by the International Aortic Arch Surgery Study Group. Furthermore, this review demonstrates the urgent need for multicenter registries or studies to be able to compare the outcome of different surgical techniques for various aortic arch pathologies.
PubMed: 37583690
DOI: 10.21037/cdt-22-502 -
Differentiation; Research in Biological... 2020Development of the human prepuce was studied over the course of 9-17 weeks of gestation in 30 specimens. Scanning electron microscopy revealed subtle surface features...
Development of the human prepuce was studied over the course of 9-17 weeks of gestation in 30 specimens. Scanning electron microscopy revealed subtle surface features that were associated with preputial development, namely the appearance of epidermal aggregates that appeared to be associated with formation of the preputial fold. Transverse and sagittal sections revealed that the epidermis of the glans is considerably thicker than that of the penile shaft. We described a novel morphogenetic mechanism of formation of the preputial lamina, namely the splitting of the thick epidermis of the glans into the preputial lamina and the epidermis via the intrusion of mesenchyme containing red blood cells and CD31-positive blood vessels. This process begins at 10-11 weeks of gestation in the proximal aspect of the glans and extends distally. The process is likely to be androgen-dependent and mediated via androgen receptors strategically localized to the morphogenetic process, but signaling through estrogen receptor may play a role. Estrogen receptor alpha (ESR1) has a very limited expression in the developing human glans and prepuce, while estrogen receptor beta (ESR2) is expressed more broadly in the developing preputial lamina, epidermis and urethra. Examination of the ontogeny of innervation of the glans penis and prepuce reveals the presence of the dorsal nerve of the penis as early as 9 weeks of gestation. Nerve fibers enter the glans penis proximally and extend distally over several weeks to eventually reach the distal aspect of the glans and prepuce by 14-16 weeks of gestation.
Topics: Humans; Male; Microscopy, Electron, Scanning; Morphogenesis; Penis; Receptors, Androgen; Receptors, Estrogen; Urethra
PubMed: 31654825
DOI: 10.1016/j.diff.2019.10.002 -
PloS One 2024Predating Darwin's theory of evolution, the holotype of Saurodesmus robertsoni is a long-standing enigma. Found at the beginning of 1840s, the specimen is a damaged...
Predating Darwin's theory of evolution, the holotype of Saurodesmus robertsoni is a long-standing enigma. Found at the beginning of 1840s, the specimen is a damaged stylopodial bone over decades variably assigned to turtles, archosaurs, parareptiles, or synapsids, and currently nearly forgotten. We redescribe and re-assess that curious specimen as a femur and consider Saurodesmus robertsoni as a valid taxon of a derived cynodont (?Tritylodontidae). It shares with probainognathians more derived than Prozostrodon a mainly medially oriented lesser trochanter and with the clade reuniting tritylodontids, brasilodontids, and mammaliaforms (but excluding tritheledontids) the presence of a projected femoral head, offset from the long axis of the femoral shaft; a thin, plate-like greater trochanter; a distinct dorsal eminence proximal to the medial (tibial) condyle located close to the level of the long axis of the femoral shaft and almost in the middle of the width of the distal expansion; and a pocket-like fossa proximally to the medial (tibial) condyle. Saurodesmus robertsoni is most similar to tritylodontids, sharing at least with some forms: the relative mediolateral expansion of the proximal and distal regions of the femur, the general shape and development of the greater trochanter, the presence of a faint intertrochanteric crest separating the shallow intertrochanteric and adductor fossae, and the general outline of the distal region as observed dorsally and distally. This makes Saurodesmus robertsoni the first Triassic cynodont from Scotland and, possibly, one of the earliest representatives of tritylodontids and one of the latest non-mammaliaform cynodonts worldwide. Moreover, it highlights the need for revisiting historical problematic specimens, the identification of which could have been previously hampered by the lack of adequate comparative materials in the past.
Topics: Animals; Fossils; Femur; Scotland; Biological Evolution; Phylogeny
PubMed: 38809839
DOI: 10.1371/journal.pone.0303973 -
Journal of Clinical Orthopaedics and... 2020Calcaneus malunion is a common sequela to calcaneal fractures and is a cause of pain and discomfort. Multiple approaches have been described to address the subtalar... (Review)
Review
Calcaneus malunion is a common sequela to calcaneal fractures and is a cause of pain and discomfort. Multiple approaches have been described to address the subtalar joint and the lateral wall. Type 2 malunion is the most commonly encountered problem, and is usually addressed by the sinus tarsi approach. This has some limitations, as exposure for lateral wall excision beneath the peroneal tendons maybe a problem. We have slightly modified the sinus tarsi approach by a more horizontal skin incision, which may even be extended proximally by 1-2 cm; this allows access to the lateral wall on either side of the peroneal tendons. The approach is described in detail.
PubMed: 32405217
DOI: 10.1016/j.jcot.2020.03.011 -
Journal of Hand and Microsurgery Sep 2023Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is...
Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is essential to maximize their hand function. Multiple procedures, including proximal row carpectomy (PRC) and wrist arthrodesis (WA), are considered among the different surgical alternatives. However, the biomechanical consequences of these two procedures have not been well described in current literature. Hence, the objective of our study is to assess the change in the extrinsic digit flexor tendon resting length after proximal row carpectomy and wrist arthrodesis. Six fresh-frozen cadaver upper extremities (four females and two males) with no obvious deformity underwent dissection, PRC, and WA. All the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor pollicis longus (FPL) tendons were marked proximally 1-cm distal to their respective myotendinous junction and cut distally at the marked point. The overlapping segment of each distal flexor tendon from its proximal mark was considered the amount of flexor tendon resting length change after PRC and WA. A descriptive evaluation was performed to assess the increment in tendon resting length. Additionally, a regression analysis was performed to evaluate the relation between the tendon resting length and the proximal carpal row height. Following PRC and WA, the mean digit flexor tendon resting length increment achieved across all tendons was 1.88 cm (standard deviation [SD] = 0.45; range: 1.00-3.00 cm). A weak direct relationship ( = 0.0334) between the increment in tendon resting length and proximal carpal row height was initially suggested, although no statistical significance was demonstrated ( = 0.811). This study provides an anatomic description of the increased extrinsic digit flexor tendon resting length after PRC and WA in cadaveric specimens. Findings provide a useful framework to estimate the amount of extrinsic digit flexor resting length increment achieved after wrist fusion and the proximal carpal row removal.
PubMed: 37701311
DOI: 10.1055/s-0042-1742458 -
North American Spine Society Journal Sep 2022Proximal junctional fractures (PJFr) can be a catastrophic complication associated with adult spinal deformity surgery. Osteoporosis can be a major risk factor for the...
BACKGROUND
Proximal junctional fractures (PJFr) can be a catastrophic complication associated with adult spinal deformity surgery. Osteoporosis can be a major risk factor for the cause of PJFr. Recent studies suggest using surrogate computed tomography (CT) scans in place of spinal dual-energy x-ray absorptiometry (DEXA) scores for bone mineral density (BMD). Investigate the feasibility of using preoperative CT based bone mineral density at upper instrumented vertebrae (UIV) and one level proximally (UIV+1) and distally (UIV-1) to predict the possibility of PJFr risk.
METHODS
Retrospective two-academic center case-controlled study, reviewed consecutive adult spinal deformity surgeries; included constructs encompassing at least five fusion levels and fusions to pelvis. Examined demographic, surgical, and radiographic data preoperatively, postoperatively, and final follow-up. Formed groups based on type of proximal junctional deformity (PJD): Control (no PJD), proximal junctional kyphosis (PJK) and PJFr. Preoperative CT BMD values measured in Hounsfield units (HU) for sagittal and axial planes at UIV, UIV+1, and UIV-1 and compared between groups.
RESULTS
N=92 patients. Preoperative CT scan BMD values were significantly lower in PJFr vs. control at: UIV+1 in sagittal (p=0.007), axial (p=0.02) planes; UIV sagittal (p=0.04) and axial (p=0.03) planes; and UIV-1 sagittal (p=0.05) plane. Similarly, lower CT scan BMD values noted in PJFr vs. PJK at: UIV+1 in sagittal (p=0.04) and axial (p=0.03) planes. Trend seen with lower CT scan BMD values at UIV+1 level in PJFr vs. PJK in sagittal (p=0.12) and axial (p=0.10) planes. Preoperative global sagittal imbalance measurements significantly lower in control, but comparable between PJK and PJFr.
CONCLUSIONS
Higher preoperative global sagittal imbalance with lower preoperative CT BMD values at UIV and UIV+1 vertebral body may increase the risk of proximal junctional fractures after adult spine deformity surgery. Proximal junctional hooks may supplement the pathogenesis. Readers should note the small sample size. 3.
PubMed: 35783005
DOI: 10.1016/j.xnsj.2022.100130 -
Clinical Epidemiology 2019We conducted a systematic review and meta-analysis aimed at evaluating the differences of diagnostic performance of fecal occult blood tests (FOBTs) in detecting... (Review)
Review
OBJECTIVE
We conducted a systematic review and meta-analysis aimed at evaluating the differences of diagnostic performance of fecal occult blood tests (FOBTs) in detecting advanced colorectal neoplasms located in the proximal versus distal colorectum.
METHODS
PubMed, Embase, Cochrane Library, and Web of Science were searched for eligible articles published before August 17, 2018. Two independent reviewers conducted study assessment and data extraction. Diagnosis-related indicators of FOBT for detecting proximal and distal colorectal neoplasms were summarized, and further stratified by the type of FOBT (guaiac-based FOBT (gFOBT) and immunochemical FOBT (iFOBT)). Pooled sensitivities and specificities were calculated using a random effect model. Summary receiver operating characteristic curves were plotted and area under the curves were calculated.
RESULTS
Overall, 31 studies meeting the inclusion criteria were included in this review. For gFOBT, we found no site-specific difference (proximally vs distally located) of pooled sensitivities observed in the colorectal cancer (CRC), advanced adenomas, and advanced neoplasms groups. As for iFOBT, pooled sensitivities for detecting CRC located in the distal colon/rectum were comparable with that in the proximal colon (proximal vs distal, 0.67, 95% CI 0.62-0.72 vs 0.72, 95% CI 0.68-0.75), while higher pooled sensitivities for detecting advanced adenomas and advanced neoplasms located in the distal colon/rectum than for detecting those in the proximal colon were observed for iFOBT with the values of 0.24 (95% CI 0.22-0.25) vs 0.32 (95% CI 0.30-0.34) and 0.25 (95% CI 0.23-0.28) vs 0.38 (95% CI 0.36-0.40), respectively. Summary receiver operating characteristic curve analyses showed similar patterns for both types of FOBT regarding the diagnostic accuracy for detecting colorectal neoplasms according to the anatomical sites of the colorectum.
CONCLUSION
iFOBT had higher sensitivity for detecting advanced adenomas and advanced neoplasia located in the distal colon/rectum than that for those in the proximal colon.
PubMed: 31695506
DOI: 10.2147/CLEP.S213677 -
Journal of Clinical Medicine Nov 2023Lower instrumented vertebra (LIV) selection is critical to avoid complications like adding-on. This study aims to determine the usefulness of the traction test (TR) in...
Lower instrumented vertebra (LIV) selection is critical to avoid complications like adding-on. This study aims to determine the usefulness of the traction test (TR) in selecting the LIV during surgery for adolescent idiopathic scoliosis (AIS). We analyzed 42 AIS patients with Lenke 1 curves who had preoperative, postoperative, and at least 12-month follow-up X-rays, as well as preoperative side bending (SB) and TR radiograms. Neutral vertebra (NV), stable vertebra (SV), lower instrumented vertebra (LIV), and Cobb angles were identified and compared on all radiographic images. In 23 cases, the TR resulted in SV proximalization compared to the preoperative X-rays, while in 8 cases, SV-TR was more distal. This distalization occurred in 50% of Lenke 1C curves, where a greater correction of the distal curve was found. NV-TR was proximal to NV-preop in 9 cases, while NV-SB was proximal in 22 cases. LIV was proximal to SV-TR in 8 cases, while it was proximal to SV-preop in 22. One patient with LIV proximal to SV-TR developed adding-on. In conclusion, the TR is crucial in AIS preoperative planning as it provides information distinct from that of standard X-rays and SB: (1) it better assesses gravitational stability than rotational stability; and (2) choosing LIV equal to or proximal to SV-TR may prevent adding-on, except in 'flexible' Lenke 1C curves where LIV should be equal or distal to SV-preop.
PubMed: 38002604
DOI: 10.3390/jcm12226986 -
Plastic and Reconstructive Surgery.... Jul 2023The A2 and A4 pulleys are fibro-osseous structures that support the flexor tendon function. Injury to these pulleys can result in bowstringing and limited tendon...
UNLABELLED
The A2 and A4 pulleys are fibro-osseous structures that support the flexor tendon function. Injury to these pulleys can result in bowstringing and limited tendon excursion. Thus, having an understanding of the skin surface landmark of the A2 pulley is crucial to safeguard it during hand surgery.
METHODS
We performed cadaveric dissection of 62 hands. For 248 fingers, the measurement of distance A, which is half the distance between the palmar digital crease and proximal interphalangeal crease reflected in the palm, and distance B, which is the distance between the A2 pulley's starting point and the palmar digital crease, were taken by a caliber. Statistical analysis was performed using the paired sample test to determine whether there was a significant difference between distances A and B.
RESULTS
Our study revealed that there was no significant difference (p>0.05) between the measured starting point of the A2 pulley and its proposed surface landmark for the index, middle, and small fingers. Conversely, the ring finger showed a statistically significant difference of 1 mm more proximal.
CONCLUSIONS
By measuring the distance between the palmar digital crease and proximal interphalangeal crease and reflecting it proximally in the palms, one can anticipate the location of the A2 pulley's starting point for each digit, except for the ring finger. The ring finger's starting point is 1 mm more proximal than the other digits. Knowing the starting point of the A2 pulley will help hand surgeons limit incisions and avoid accidental injury during hand surgery.
PubMed: 37496981
DOI: 10.1097/GOX.0000000000005138