Reconstruction of a Neglected, Extensor Hallucis Longus Tendon Rupture Using Interposed Scar Tissue: A Case Report and Literature Review

Injury of the extensor hallucis longus (EHL) tendon is relatively rare, but surgical repair is necessary to prevent deformity and gait disturbance. Primary suturing is possible if the condition is acute, but not when it is chronic. The scar tissue between the ruptured ends is a proliferative tissue composed of fibroblasts and collagen fibers. Given the histological similarity to normal tendons, several studies have reported tendon reconstruction using scar tissue. Here, we report a reconstruction of a neglected EHL rupture using interposed scar tissue. A 54-year-old female visited our clinic with a weak extension of a big toe. She had dropped a knife on her foot a month prior, but did not go to hospital. The wound had healed, but she noted dysfunctional extension of the toe and increasing pain. Magnetic resonance imaging (MRI) revealed that EHL continuity was lost and that the proximal tendon stump was displaced toward the midfoot. Scar tissue running in the direction of the original ligament was observed between the ruptured ends. In the surgical field, the scar tissue formed a shape similar to the extensor tendon. Therefore, we performed tendon reconstruction using the interposed scar tissue. For the first 2 postoperative weeks, the ankle and foot were immobilized to protect the repair. Six weeks after surgery, the patient commenced full weight-bearing. At the 3-month follow-up, active extension of the hallux was possible, with a full range of motion. The patient did not feel any discomfort during daily life. Postoperative MRI performed at 1 year revealed that the reconstructed EHL exhibited homogeneously low signal intensity, and was continuous. The AOFAS Hallux Metatarsophalangeal-Interphalangeal scale improved from 57 to 90 points and the FAAM scores improved from 74% to 95% (the Activities of Daily Living subscale) and from 64% to 94% (the Sports subscale). Scar tissue reconstruction is as effective as tendon autografting or allografting, eliminates the risk of donor site morbidity and infection, and requires only a small incision and a short operative time.

Free thoracodorsal artery polyfoliate perforator flaps for repairing multiple soft tissue defects in the hand

Background Hand injury is commonly associated with multiple soft tissue defects. Polyfoliate flaps grafting is the optimal approach for multiple wounds.The feasibility of clinical using of free thoracodorsal artery polyfoliate perforator flaps for repairing multiple soft tissue defects in the hand needs to be confirmed in clinical practice. Methods Fifteen patients with hand soft tissue defects that were repaired using free thoracodorsal artery polyfoliate perforator flaps from January 2015 to February 2018 was retrospectively analysed. The survival rate, the operative time, the appearance and sensory recovery of the flaps, and hand function were evaluated. Results The flaps of all 15 patients survived. Vascular crisis occurred in one patient, and the flap was saved after exploratory operation. The 15 patients were followed up for 12–26 months. Sensation in the flaps was partially recovered in all 15 patients. The wound in the donor area was closed directly with sutures. Mean score of scars at the donor site were assessed using the modified Vancouver scar scale (VSS) was 2.7. A puffed appearance in the recipient area was noted in four patients. To obtain a more satisfactory appearance, revision of the flap was performed once in these four patients. The Total Active Movement (TAM) evaluation system was used to assess the results, which were considered excellent in seven patients, good in six patients, fair in two patients, and poor in none of the patients. Ten of the 15 patients returned to their primary jobs. Conclusion Free thoracodorsal artery polyfoliate perforator flaps are appropriate for repairing multiple soft tissue defects in the hand, offer a satisfactory appearance, require a short operative time, and have little impact on the function and aesthetics of the donor site.

Efficacy Analysis of Day Surgery A1 Pulley Release for Pediatric Trigger Thumb

Objective: To investigate clinical application of day surgery A1 pulley release for pediatric trigger thumb.Methods: We retrospectively analyzed the clinical data of 1,642 children with trigger thumb who were treated with day surgery A1 pulley release at our hospital, including satisfaction surveys, functional recovery, and complications.Results: The operative time for unilateral and bilateral tenolysis was 4.8 ± 3.1 and 9.2 ± 3.8 min, respectively. Three children had postoperative fever and were discharged on the 2nd day after surgery. The rest of the children were discharged on the day of surgery. All incisions healed primarily, and no complications of vascular and nerve injury were reported. The patients' degree of satisfaction with the medical treatment process, diagnosis and treatment workflow, treatment effectiveness, length of hospital stay and hospitalization cost, and discharge guidance were 97.9, 96.1, 99.3, 91.1, and 98.5%, respectively. The follow-up period was between 5 months and 3 years and 1 month. Four children experienced symptom relapse after the operation, and re-tenolysis was performed in one of them. At the final follow-up, the appearance and function of the thumb had recovered well in all cases.Conclusion: Day surgery A1 pulley release can effectively release tendon sheaths and has a short operative time, no complications of vascular and nerve injury, and good recovery of thumb function. It is a safe and reliable procedure with high patient satisfaction, and it is worthy of clinical promotion.

Comparison of the outcomes of nasal bone reduction using serial imaging

Background: Nasal bone fractures are frequently encountered in clinical practice. Although fracture reduction is simple and correction requires a short operative time, low patient satisfaction and relatively high complication rates remain issues for many surgeons. These challenges may result from inaccuracies in fracture recognition and assessment or inappropriate surgical planning. Findings from immediate postoperative computed tomography (CT) scans and those performed at 4 to 6 weeks postoperatively were compared to evaluate the accuracy and outcomes of nasal fracture reduction.Methods: This retrospective study included patients diagnosed with nasal bone fractures at our department who underwent closed reduction surgery. Patients who did not undergo additional CT scans were excluded from the study. Clinical examinations, patient records, and radiographic images were evaluated in 20 patients with nasal bone fractures.Results: CT findings from immediately after surgery and a 1month follow-up were compared in 20 patients. Satisfactory nasal projection and aesthetically acceptable results were observed in patients with accurate correction or mild overcorrection, while undercorrection was associated with unfavorable results.Conclusion: Closed reduction surgery for correcting nasal bone fractures usually provides acceptable outcomes with relatively few complications. If available, immediate postoperative CT scans are recommended to guide surgeons in the choice of whether to perform secondary adjustments if the initial results are unsatisfactory. Based on photogrammetric data, nasal bone reduction with accurate correction or mild overcorrection achieved acceptable and stable outcomes at 1 month postoperatively. Therefore, when upward dislocation is observed on postoperative CT, one can simply observe without a subsequent intervention.

Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A “Good-Fast-Cheap” Technique for Any Etiology of Velopharyngeal Incompetence

Objective: To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication. Design: Retrospective review. Setting: Tertiary care center. Patients: Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded. Intervention: Modified pharyngeal flap with through-and-through dissection of the soft palate. Main Outcome Measure(s): Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale. Results: The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours. Conclusions: This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.

Free Thoracodorsal Artery Polyfoliate Perforator Flaps for Repairing Multiple Soft Tissue Defects in the Hand

Background: Hand injury is commonly associated with multiple soft tissue defects. Polyfoliate flaps grafting is the optimal approach for multiple wounds.To confirm the feasibility of clinical using of free thoracodorsal artery polyfoliate perforator flaps for repairing multiple soft tissue defects in the hand. Methods: Fifteen patients with hand soft tissue defects that were repaired using free thoracodorsal artery polyfoliate perforator flaps from January 2015 to February 2018 was retrospectively analysed. The survival rate, the operative time, the appearance and sensory recovery of the flaps, and hand function were evaluated. Results: The flaps of all 15 patients survived. Vascular crisis occurred in one patient, and the flap was saved after exploratory operation. The 15 patients were followed up for 12-26 months. Sensation in the flaps was partially recovered in all 15 patients. The wound in the donor area was closed directly with sutures. Obvious scar hyperplasia was noted in three patients. A puffed appearance in the recipient area was noted in four patients.To obtain a more satisfactory appearance, revision of the flap was performed once in these four patients. The Total Active Movement (TAM) evaluation system was used to assess the results, which were considered excellent in seven patients, good in six patients, fair in two patients, and poor in none of the patients. Ten of the 15 patients returned to their primary jobs. Conclusion: Free thoracodorsal artery polyfoliate perforator flaps are appropriate for repairing multiple soft tissue defects in the hand, offer a satisfactory appearance, require a short operative time, and have little impact on the function and aesthetics of the donor site.

Suture Suspension Arthroplasty for Thumb Carpometacarpal Arthritis Reconstruction: 12 to 14-Year Follow-up

Background Many surgical procedures have been described for the treatment of thumb carpometacarpal (CMC) joint osteoarthritis, with significant variation. To date, none has proven to be superior. The purpose of this study was to report long-term follow-up results of suture suspension arthroplasty (SSA). Methods The SSA technique uses a single incision, trapeziectomy, and an intra-articular suture suspension sling anchored into the insertions of the flexor carpi radialis (FCR) and abductor pollicis longus (APL), which serves to stabilize the base of the thumb metacarpal, correct subluxation deformity, and maintain arthroplasty space. Ninety of 153 SSA reconstructions (59% recall) were evaluated at long-term follow-up (mean, 12.6 years). Data were analyzed for functional outcomes, including preoperative and postoperative grip and pinch strength, radiographs, complications, and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. Results The mean age at date of surgery was 61.7 ± 7.6 years (82% women). Significant improvement was noted in grip strength (preoperative mean, 25.0 kg; postoperative mean, 28.0 kg; P < .0001), key pinch (preoperative, 4.2 kg; postoperative, 5.1 kg; P < .0001), and tip pinch (preoperative, 2.9 kg; postoperative, 3.6 kg; P < .0001). Radiographic subsidence averaged 35% (0-90). Postoperative QuickDASH scores (mean, 6.6; range, 0-50) revealed good to excellent pain relief and function. One revision was performed, and postoperative FCR rupture occurred in 3 reconstructions. Conclusions The SSA technique for thumb CMC arthritis reconstruction yields good to excellent long-term clinical outcomes. Potential advantages of the SSA include short operative time, a single incision, minimal cost, and no need for tendon harvesting, pin fixation, or implantable hardware.

Risk factors for postoperative complications after surgery in complicated Crohn’s disease

Aim: to improve results of the surgical treatment of Crohn’s disease. Patients and Methods: 162 patients were included. 69 (42,6 %) — received preoperative conservative treatment. Ileocecal resection was performed in 148 (91,4 %), in 5 (3,1 %) cases — part of jejunum resection, ileum resection — in 3 (1,8 %) patients and right hemicolectomy — 6 (3,7 %). Stoma formation was in 104 (64,2 %) patients. Complications were registered in 25 (15,4 %) cases. Results: in univariant analysis it was found that young age up to 40 years, male gender and short operative time ( 150 min) are the predictors (р = 0,03, р = 0,03 и р = 0,02, respectively) to noncomplicated postoperative period (reduce risk in 10, 5 и 10 fold, respectively). The absence of conservative treatment before surgery increased the complications’ rate more than 3 times comparing to patients who received therapy (OR 3,2 CI 95 % 0,1–11,45; р = 0,06), but we failed to get significance, that is why multivariant analysis was carried out to see the influence of all clinical factors on non-treated patients. Significance was found in all models. Conclusion: male gender (OR 0,2 CI 95 % 0,01–2,02; р = 0,02), the age younger than 40 (OR 0,1 CI 95 % 0,02–0,9; р = 0,03) and the duration of the operation less than 150 minutes (OR 0,1 CI 95 % 0,01–2,02; р = 0,03) is associated with the reduction of complications in the postoperative period. Preoperative conservative treatment during 3 months allows to decrease the rate of complications to 3,5 times (OR 3,5 CI 95 % 1,2–9,8; р = 0,01) and risk of the stoma formation — to 7 times (χ2 = 7,56; р = 0,006).

Surgical outcome of radioguided parathyroidectomy in primary hyperparathyroidism

Background: Focused parathyroidectomy is the adequate treatment for primary hyperparathyroidism for localised disease. Adequacy of resection is confirmed by the availability of intraoperative parathormone assay (iOPTH). In the absence of availability of iOPTH assay, the radio guided surgery is an option. The aim of this study was to evaluate the feasibility of radioguided parathyroidectomy in tertiary care centre in India and to compare the overall success rate, operative time, hospital stay and postoperative outcome between focused open and radioguided parathyroidectomy.Methods: This was a prospective study which included 30 primary hyperparathyroidism patients with a single gland disease localised on Tc99m Sesta MIBI scan. Patients were randomized into two equal groups, and they underwent focused open or radioguided parathyroidectomy. Patients were followed up for three months.Results: All patients achieved biochemical cure as evident by the normalization of serum calcium and parathormone levels after surgery. The mean incision length, and operative time in this study was significantly better for radioguided parathyroidectomy (p=0.0001, <0.0001 respectively). There was no perioperative complications like recurrent laryngeal nerve injury, gland rupture, or bleeding in either group. However, there seems to be higher grade of pain experience by the patients who underwent open focused parathyroidectomy (p<0.0001).Conclusions: Radioguided parathyroidectomy has excellent cure rate for PHPT with an added advantage of short operative time & incision length and less post-operative pain. Radioguided parathyroidectomy seems to be a good alternative in the absence of availability of iOPTH assay and frozen section.

Intrasellar cysticercosis cyst treated with a transciliary supraorbital keyhole approach – A case report

Background: Neurocysticercosis is the most common parasitic disease affecting the central nervous system. Isolated sellar cysticercosis cysts are rare and can mimic other sellar lesion as cystic pituitary adenoma, arachnoid cyst, Rathke cleft cyst, or craniopharyngioma. The surgical resection is mandatory because the cysticidal drugs are ineffective, however, new microsurgical approaches are emerging to reduce complications and need to test in this condition. We present a patient with a sellar cysticercosis cyst treated by transciliar supraorbital keyhole approach. Case Description: A 45-year-old female with presented with chronic severe headaches, progressive deterioration of 6 months in visual acuity and bitemporal hemianopia. The pituitary hormonal levels were normal. Magnetic resonance findings showed a sellar and suprasellar cyst and underwent a microsurgical supraorbital transciliar keyhole approach for lesion resection. Pathologically, the lesion demonstrated a parasitic wall characterized by wavy, dense cuticle, and focal globular structure, surrounding inflammatory reaction with plasma cells. Postoperatively, the patient recovery fully neurologically. Conclusion: Intrasellar cysticercosis cyst causes significant neurological deficits due to its proximity to the chiasm, optic nerves, pituitary stalk, and the pituitary gland. Surgical section is an effective treatment. The supraorbital keyhole craniotomy offers satisfactory exposure, possibility of total resection with dissection of the supra and parasellar structures, short operative time, less blood loss, short hospital stay, and good overall surgical outcome.