Distal Leg Research Articles

Autosomal recessive VWA1-related disorder: comprehensive analysis of phenotypic variability and genetic mutations.

A newly identified subtype of hereditary axonal motor neuropathy, characterized by early proximal limb involvement, has been discovered in a cohort of 34 individuals with biallelic variants in von Willebrand factor A domain-containing 1 (VWA1). This study further delineates the disease characteristics in a cohort of 20 individuals diagnosed through genome or exome sequencing, incorporating neurophysiological, laboratory and imaging data, along with data from previously reported cases across three different studies. Newly reported clinical features include hypermobility/hyperlaxity, axial weakness, dysmorphic signs, asymmetric presentation, dystonic features and, notably, upper motor neuron signs. Foot drop, foot deformities and distal leg weakness followed by early proximal leg weakness are confirmed to be initial manifestations. Additionally, this study identified 11 novel VWA1 variants, reaffirming the 10 bp insertion-induced p.Gly25ArgfsTer74 as the most prevalent disease-causing allele, with a carrier frequency of ∼1 in 441 in the UK and Western European population. Importantly, VWA1-related pathology may mimic various neuromuscular conditions, advocating for its inclusion in diverse gene panels spanning hereditary neuropathies to muscular dystrophies. The study highlights the potential of lower quality control filters in exome analysis to enhance diagnostic yield of VWA1 disease that may account for up to 1% of unexplained hereditary neuropathies.

Cross-leg flap, alternative surgery for post traumatic soft tissue defect of ankle and foot

BackgroundSoft tissue defects that afflict the ankle and foot are mostly the result of trauma. Large wounds with soft tissue defects, especially in the ankle and foot, are a reconstructive challenge due to the lack of availability of local tissues and recipient vessels. Case PresentationWe report a female with a crush injury of the right foot and a Lisfranc injury due to a motor vehicle accident. The patient had a soft tissue defect 20 × 10 cm2 with bone and tendon exposed. The patient had a fasciocutaneous flap from the posteromedial of the distal contralateral leg for soft tissue reconstruction. Both legs were stabilized with a cast. The cross-leg flap was separated from the donor site three weeks later, and K-Wire was removed. Flap evaluation was good, and the patient resumed normal gait and activity without any stiffness of joints related to the flap or cast. DiscussionReconstruction of soft tissue defects in the ankle and foot is a challenge for surgeons due to the paucity of local and regional tissues and associated vessel injuries. Cross-leg flap can be suitable alternative option. In this case, we use medially based fasciocutaneous perforator cross-leg flap, based on the posterior tibial artery perforators. Cross-leg flaps are less technically demanding, and the probability of reexploration is lower than in free flaps. The cross-leg flap has the disadvantage of prolonged immobilization and uncomfortable resting positions. ConclusionCross-leg flap can be alternative solution for covering large soft tissue defects in ankle and foot with its advantages and disadvantages.

Comparison of intraepidermal nerve fiber density and confocal corneal microscopy for neuropathy.

Compare the diagnostic characteristics of intraepidermal nerve fiber density (IENFD) and confocal corneal microscopy (CCM) for distal symmetric polyneuropathy (DSP) and small fiber neuropathy (SFN). Participants with obesity were recruited from bariatric surgery clinics and testing was performed prior to surgery. DSP and SFN were determined using the Toronto consensus definitions of probable neuropathy. IENFD was assessed from 3 mm punch biopsies of the distal leg and proximal thigh. CCM was performed on both eyes with manual and automated counting. The Michigan Neuropathy Screening Instrument questionnaire (MNSIq) was also completed. Diagnostic capability was determined using areas under the receiver operating characteristics curve (AUC) from logistic regression. We enrolled 140 participants (mean [standard deviation [SD]] age: 50.3 years [7.1], 77.1% female, BMI: 44.4 kg/m2 [6.7]). In this population, 22.9% had DSP and 14.3% had SFN. Distal leg IENFD had the largest AUC (95% confidence interval) for DSP (0.78, 0.68-0.89) and SFN (0.85, 0.75-0.96). Proximal thigh IENFD (DSP: AUC: 0.59, 0.48-0.69, SFN: AUC: 0.59, 0.46-0.73) and CCM metrics (DSP: AUC range: 0.55-0.60, SFN: AUC range: 0.45-0.62) had poorer diagnostic capability than distal leg IENFD for DSP/SFN (P < 0.05). MNSIq had similar diagnostic capability to distal leg IENFD for both DSP/SFN (DSP: AUC: 0.76, 0.68-0.85, SFN: AUC: 0.81, 0.73-0.88). More participants (52%) preferred skin biopsies to CCM. Distal leg IENFD was the best quantitative measure of DSP/SFN. CCM had poor diagnostic characteristics and fewer patients preferred this test to IENFD. The MNSIq had similar diagnostic characteristics to distal leg IENFD, indicating its value as a diagnostic tool in the clinical setting. clinicaltrials.gov: NCT03617185.

7140 Assessing Bone Mineral Density and Cortical Geometry Using High-resolution Peripheral Quantitative Computed Tomography and Dual Energy X-ray Absorptiometry in Pediatric Survivors of High-risk Neuroblastoma with Growth Failure

Abstract Disclosure: S. Gera: None. M. Guo: None. N. Pollock: None. I. Hampton: None. M. Song: None. D. Weber: None. M. Denburg: None. S. Mostoufi-Moab: None. Introduction: Survival of children with high-risk neuroblastoma (HR-NBL) has increased with multimodal therapy. Cis-retinoic acid (cis-RA), cornerstone of HR-NBL therapy, can cause osteoporosis and premature physeal closure, posing a threat to skeletal structure. HR-NBL survivors demonstrate profound growth failure. DXA measures areal bone mineral density (aBMD). DXA is confounded by short stature and fails to distinguish between trabecular and cortical bone. We previously reported no significant difference in height-per-age adjusted aBMD-Z in HR-NBL survivors compared to healthy controls[1]. However, aBMD-Z in severe short stature may attenuate bone density deficits. High-resolution peripheral quantitative computed tomography (HRpQCT) yields 3D measures of volumetric BMD and bone architecture. Objectives: Assess volumetric BMD (vBMD) and cortical structure using distal tibia HRpQCT and leg lean mass by DXA in HR-NBL survivors compared to healthy controls in a cross-sectional study. Methods: We prospectively enrolled 20 HR-NBL survivors (median age 12.2 yrs, range 9.5 to 15.8, 7 female) treated with cis-RA (median age 2.6 yrs at start of therapy, range 0.3-9.1), and 20 age-, sex-, and race-matched healthy controls. We assessed leg lean mass adjusted for leg length by DXA. For HRpQCT, we compared tibia length (cm), cortical and trabecular vBMD (mg HA/cm3), geometry parameters (cortical and trabecular area [mm2]), and structural parameters (cortical thickness [μm] and porosity, trabecular number [mm-[1]] and separation [μm]). Outcomes were compared using Student’s t-test or Mann-Whitney U test. Linear regression models assessed difference in outcomes of bone microarchitecture and leg lean mass between both groups. Results: Compared to controls, tibia length was significantly shorter in HR-NBL survivors (32.3 ± 0.8 vs. 35.7 ± 0.6, P&amp;lt;0.005). HR-NBL survivors demonstrated lower cortical area (187.6 ± 43.8 vs. 218.7 ± 42.3, P&amp;lt;0.05), cortical perimeter (62.4 ± 7.71 vs. 69.5 ± 8.1, P&amp;lt;0.01), and leg lean mass Z-score (-1.47 ± 1.34 vs. -0.20 ± 0.84, P&amp;lt;0.001) compared to controls. Cortical geometry deficits were explained by muscle deficits (P&amp;lt;0.001). Trabecular area, BMC, areal and volumetric BMD, and measures of bone structure were not significantly different in HR-NBL survivors compared to controls. IGF-1 and 25-OH D levels had no significant effects on DXA or HRpQCT parameters. Conclusion: Bone density is not severely impacted in HR-NBL survivors. Muscle deficits persist years after treatment and explain cortical geometry deficits. HRpQCT substantiates prior DXA evaluation in HR-NBL survivors with significant short stature, demonstrating preserved bone density and structure. 1.Guo et al. Sarcopenia and preserved bone mineral density in pediatric survivors of high-risk neuroblastoma with growth failure. J Cachexia Sarcopenia Muscle. 2021 Aug;12(4):1024-1033. Presentation: 6/3/2024

Osteochondroma of the Distal Tibia in an Adolescent: A Case Report

A 17-year-old male presented with a painful left ankle that had been worsening over the preceding 1 year. Clinical and radiographic inspection revealed marked bowing with a deformation of the fibula secondary to the laterally outgrowing bone lesion from the distal tibia proximal to the growth plate. MRI appearance suggestive of an osteochondroma of the lower extremity of the left tibia with signs of degeneration, It is surrounded by a cartilaginous cap, thickened in places, measuring 22 mm in maximum thickness. Although the radiographic characteristics of the lesion were indicative of osteochondroma, a typically asymptomatic and benign tumor that is usually identified as an incidental finding, the large size and symptoms associated with the lesion described in this article make it rather unusual. In this particular case, excessive bony outgrowth, pain, joint malposition, necessitated surgical intervention. The patient was successfully treated with resection of the tumor, after which gradual restoration of the alignment of the distal leg ensued without the need for fibular osteotomy. After more than 1 year of postoperative follow-up, neither radiographic nor clinical evidence of recurrence had been observed and the patient displayed a pain-free range of ankle motion without any physical limitations.

Insights into phenotypic variability caused by GARS1 pathogenic variants.

Pathogenic variants of the glycyl-tRNA synthetase 1 (GARS1) gene have been described as a cause of Charcot-Marie-Tooth disease type 2D, motor axonal neuropathy with upper limb predominance (distal hereditary motor neuropathy [dHMN] type V), and infantile spinal muscular atrophy. This cross-sectional, retrospective, observational study was carried out on 12 patients harboring the c.794C>T (p.Ser265Phe) missense pathogenic variant in GARS1. The patients' clinical data, nerve conduction studies, magnetic resonance imaging (MRI), and intraepidermal nerve fiber density in skin biopsies were reviewed. The mean age at onset was 9.5 years; the intrinsic hand muscles were affected before or at the same time as the distal leg musculature. The clinical examination revealed greater weakness of the distal muscles, with a more pronounced involvement of the thenar complex and the first dorsal interosseous in upper limbs. Electrophysiological studies were concordant with an exclusively motor axonal neuropathy. A pathologic split hand index was found in six patients. Muscle MRI showed predominant fatty infiltration and atrophy of the anterolateral and superficial posterior compartment of the legs. Most patients reported distal pinprick sensory loss. A reduced intraepidermal nerve fiber density was evident in skin biopsies from proximal and distal sites in nine patients. GARS1 variants may produce a dHMN phenotype with "split hand" and sensory disturbances, even when sensory nerve conduction studies are normal. This could be explained by a dysfunction of sensory neurons in the dorsal ganglion that is reflected as a reduction of dermal nerve endings in skin biopsies without a distal gradient.

Use of reverse sural artery flap for reconstruction of defects of distal leg, ankle and foot

Use of reverse sural artery flap for reconstruction of defects of distal leg, ankle and foot

Simultaneous correction of leg length discrepancy and angular deformity of the distal femur with retrograde Precice nails: a retrospective analysis of 45 patients.

Magnetically controlled motorized intramedullary lengthening nails (ILNs) can be employed for simultaneous correction of angular deformities of the distal femur and leg length discrepancy. This spares typical complications of external fixators but requires precise preoperative planning and exact intraoperative execution. To date, its results are insufficiently reported. We aimed to elucidate the following questions: (i) Is acute angular deformity correction and gradual femoral lengthening via a retrograde ILN a reliable and precise treatment option? (ii) What are the most common complications of treatment? Acute angular deformity correction and subsequent gradual lengthening of the distal femur with retrograde ILN was retrospectively analyzed in 45 patients (median patient age: 15 years, interquartile range [IQR] 13-19 and median follow-up: 40 months, IQR 31-50). Outcome parameters were accuracy, precision, reliability, bone healing, and complications of treatment. The median distraction was 46 mm (IQR 29-49), median distraction and consolidation index 0.9 mm/day (IQR 0.7-1.0) and 29 days/cm (IQR 24-43), respectively. The median preoperative mechanical axis deviation (MAD) was 30 mm (IQR 23-39) in the varus cohort and -25 mm (IQR -29 to -15) in the valgus cohort and reduced to a mean of 8 mm (standard deviation [SD] 8) and -3 (SD 10), respectively. Accuracy, precision, and reliability of lengthening were 94%, 95% and 96%, respectively. Accuracy and precision of deformity correction were 92% and 89%, respectively. In total, 40/45 of patients achieved distraction with a difference of less than 1 cm from the initial plan and a postoperative MAD ranging from -10 mm to +15 mm. In 13/45 patients unplanned additional surgeries were conducted to achieve treatment goal with nonunion being the most frequent (4/45) and knee subluxation (3/45) the most severe complication. Acute deformity correction and subsequent lengthening of the distal femur with retrograde ILN is a reliable and accurate treatment achieving treatment goal in 89% but unplanned additional surgeries in 29% of patients should be anticipated.

Excess Dally-like Induces Malformation of Drosophila Legs.

Glypicans are closely associated with organ development and tumorigenesis in animals. Dally-like (Dlp), a membrane-bound glypican, plays pivotal roles in various biological processes in Drosophila. In this study, we observed that an excess of Dlp led to the malformation of legs, particularly affecting the distal part. Accordingly, the leg disc was shrunken and frequently exhibited aberrant morphology. In addition, elevated Dlp levels induced ectopic cell death with no apparent cell proliferation changes. Furthermore, Dlp overexpression in the posterior compartment significantly altered Wingless (Wg) distribution. We observed a marked expansion of Wg distribution within the posterior compartment, accompanied by a corresponding decrease in the anterior compartment. It appears that excess Dlp guides Wg to diffuse to cells with higher Dlp levels. In addition, the distal-less (dll) gene, which is crucial for leg patterning, was up-regulated significantly. Notably, dachshund (dac) and homothorax (hth) expression, also essential for leg patterning and development, only appeared to be negligibly affected. Based on these findings, we speculate that excess Dlp may contribute to malformations of the distal leg region of Drosophila, possibly through its influence on Wg distribution, dll expression and induced cell death. Our research advances the understanding of Dlp function in Drosophila leg development.

Posterior Tibial Artery Perforator Based Propeller Flap for Reconstruction of 143 Skin and Soft Tissue Defect Around Ankle Joint

Background: Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this needs facility of microsurgery, may lead to donor site morbidity and is time consuming. With the introduction of perforator flap, management of small and medium size defects of distal leg and ankle region is easier, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180-degree, donor site can be closed primarily and increases the distance crossed by flap, thus increasing versatility. Objectives: To observe the outcome of soft tissue coverage of defects around ankle joint by posterior tibial artery perforator based propeller flaps. Methods: This was a prospective type of observational study carried out on 20 patients with skin and soft tissue defects in and around ankle joint for a period of 14 months in the Department of Burn and Plastic Surgery, Dhaka Medical College and Hospital. Results: Among 20 cases 17 were male and 3 females; age ranged from 11 to 60 years. Post operative outcome of flap were excellent in 11 cases, good in 6 cases, poor in 3 cases as per defined criteria. Uneventful outcome was observed in 14 cases and minor complications were observed in 5 cases; and total flap loss occurred in 1 case which required revision surgery. Conclusions: Perforator flap provides adequate soft tissue coverage for small &amp; medium size wound around ankle. It is an easy, reliable &amp; effective procedure with reasonable outcome. J Dhaka Med Coll. 2022; 31(2) : 243-250

Outcome of Delayed Distally Based Sural Flap for Distal Tibial and Foot Defects

Abstract: Background: Lower limb defects can be tricky to repair. We have limited options for reconstruction in the leg and foot region. Sural flap is considered as the workhorse for reconstruction of these defects. We present our case series of delayed reverse sural flap. Objective: To determine the outcome of Delayed Distally based sural flaps for distal tibial and foot defects. Materials and Methods: Study was carried out at plastic and reconstructive unit HMC and MMC. Over a period of 10 years from January, 2009 to December, 2018. This is a cross sectional study, presenting with soft tissue defects of foot. Patients presented in the emergency, as an outpatient or as referrals from another center. All patients were admitted and operated as elective cases. Result: In 24 patients, there were no complications. Two patients (6%) had partial flap loss and required revision surgeries. Two patients had marginal flap necrosis and were treated conservatively. Conclusion: This study presents our experience with use of reverse sural flap. It provides a reliable option for foot and distal leg defects. It is relatively easy to do and easy to learn. It can be attempted in centers where expertise or facilities for microvascular surgery are not available and in patients who are not ideal candidates for a free flap. Keywords: Sural flap, Foot and leg defects, Delayed reverse sural flap, Peroneal perforators, Fasciocutaneous flap, Sural angiosome.

Morphological changes in plasma-exposed poultry red mites (Dermanyssus gallinae) using high-resolution video camera and optical coherence tomography (OCT)

Dermanyssus gallinae, the poultry red mite (PRM), is a hematophagous temporary ectoparasite that causes serious economic losses and animal health impairment on laying hen farms worldwide. Control is limited by the parasite’s hidden lifestyle, restrictions on the use of chemical acaricides and the development of resistance against certain drug classes. As a result, research was conducted to explore alternative control methods. In recent years, atmospheric pressure plasma has been increasingly reported as an alternative to chemical acaricides for pest control. This physical method has also shown promising against PRM under laboratory conditions. However, the detailed mechanisms of action have not yet been elucidated. In the present study, the effects of cold atmospheric pressure plasma on PRM were investigated using digital videography and optical coherence tomography (OCT), an imaging technique that visualizes the topography of surfaces and internal structures. Digital videography showed that a redistribution of the contents of the intestinal tract and excretory organs (Malpighian tubules) occurred immediately after plasma exposure. The body fluids reached the distal leg segments of PRM and parts of the haemocoel showed whiter and denser clumps, indicating a coagulation of the haemocoel components. OCT showed a loss of the boundaries of the hollow organs in transverse and sagittal sectional images as well as in the three-dimensional image reconstruction. In addition, a dorso-ventral shrinkage of the idiosoma was observed in plasma-exposed mites, which had shrunk to 44.0% of its original height six minutes after plasma exposure.

A Novel Video-Based Methodology for Automated Classification of Dystonia and Choreoathetosis in Dyskinetic Cerebral Palsy During a Lower Extremity Task.

Movement disorders in children and adolescents with dyskinetic cerebral palsy (CP) are commonly assessed from video recordings, however scoring is time-consuming and expert knowledge is required for an appropriate assessment. To explore a machine learning approach for automated classification of amplitude and duration of distal leg dystonia and choreoathetosis within short video sequences. Available videos of a heel-toe tapping task were preprocessed to optimize key point extraction using markerless motion analysis. Postprocessed key point data were passed to a time series classification ensemble algorithm to classify dystonia and choreoathetosis duration and amplitude classes (scores 0, 1, 2, 3, and 4), respectively. As ground truth clinical scoring of dystonia and choreoathetosis by the Dyskinesia Impairment Scale was used. Multiclass performance metrics as well as metrics for summarized scores: absence (score 0) and presence (score 1-4) were determined. Thirty-three participants were included: 29 with dyskinetic CP and 4 typically developing, age 14 years:6 months ± 5 years:15 months. The multiclass accuracy results for dystonia were 77% for duration and 68% for amplitude; for choreoathetosis 30% for duration and 38% for amplitude. The metrics for score 0 versus score 1 to 4 revealed an accuracy of 81% for dystonia duration, 77% for dystonia amplitude, 53% for choreoathetosis duration and amplitude. This methodology study yielded encouraging results in distinguishing between presence and absence of dystonia, but not for choreoathetosis. A larger dataset is required for models to accurately represent distinct classes/scores. This study presents a novel methodology of automated assessment of movement disorders solely from video data.

Identifying Key Drivers in the Pathogenesis of Martorell Hypertensive Ischaemic Leg Ulcer: A Comparative Analysis with Chronic Venous Leg Ulcer.

Martorell hypertensive ischaemic leg ulcer (Martorell HYTILU) is a rare but significant cause of distal leg ulcers. Although hypertension and diabetes are known factors in its development, the precise pathogenesis of Martorell HYTILU remains elusive. To reach a better understanding of Martorell HYTILU, transcriptomic analysis was conducted through RNA sequencing and immunohistochemical comparison of Martorell HYTILU (n = 17) with chronic venous ulcers (n = 4) and healthy skin (n = 4). Gene expression analysis showed a marked activation of immune-related pathways in both Martorell HYTILU and chronic venous ulcers compared with healthy skin. Notably, neutrophil activity was substantially higher in Martorell HYTILU. While pathway analysis revealed a mild downregulation of several immune pathways in Martorell HYTILU compared with chronic venous ulcers, keratinization, cornification, and epidermis development were significantly upregulated in Martorell HYTILU. Additionally, STAC2, a gene encoding for a protein promoting the expression of the calcium channel Cav1.1, was significantly upregulated in Martorell HYTILU and was detected perivascularly in situ (Martorell HYTILU n = 24; chronic venous ulcers n = 9, healthy skin n = 11). The high expression of STAC2 in Martorell HYTILU suggests that increased calcium influx plays an important role in the pathogenesis of the disease. Consequently, calcium channel antagonists could be a promising treatment avenue for Martorell HYTILU.

Cutaneous biomarkers of therapeutic efficacy in early treatment of hereditary ATTR amyloid polyneuropathy with tafamidis.

ATTR (ATTRv) amyloidosis neuropathy is characterized by progressive sensorimotor and autonomic nerve degeneration secondary to amyloid deposition caused by a misfolded transthyretin protein (TTR). Small nerve fiber neuropathy is an early clinical manifestation of this disease resulting from the dysfunction of the Aδ and C small nerve fibers. Tafamidis, a selective TTR stabilizer, has proven its efficacy in the earlier stages of hATTR. To evaluate the clinical course and utility of cutaneous pathological biomarkers in patients with ATTR amyloidosis treated with tafamidis compared to control patients. Forty patients diagnosed with early stages of ATTRv amyloidosis (polyneuropathy disability [PND] scores 0-II) underwent small and large nerve fiber neurological evaluations, and annual skin biopsies for intraepidermal nerve fiber density (IENFD) and amyloid deposition index (ADI) estimation. Thirty patients were allocated to receive tafamidis, and 10 patients served as controls. Tafamidis pharmacokinetics analysis was performed in patients who received the treatment. At baseline, 12% of patients in stage PND 0 and 28% in PND I displayed small nerve fiber denervation in the distal thigh, whereas 23% and 38%, respectively, in the distal leg. Similarly, 72% and 84% had amyloid deposition in the distal thigh and 56% and 69% in the distal leg. Following 1 year of treatment, the tafamidis group showed significant clinical improvement compared to the control group, revealed by the following mean differences (1) -9.3 versus -4 points (p = <.00) in the patient's neuropathy total symptom score 6 (NTSS-6) questionnaire, (2) -2.5 versus +2.8 points (p = <.00) in the Utah Early Neuropathy Score (UENS), and (3) +1.2°C versus -0.6 (p = .01) in cold detection thresholds. Among the patients who received tafamidis, 65% had stable or increased IENFD in their distal thigh and 27% in the distal leg. In contrast, all patients in the control group underwent denervation. The ADI either decreased or remained constant in 31% of the biopsies in the distal thigh and in 24% of the biopsies in the distal leg of the tafamidis-treated patients, whereas it rose across all the biopsies in the control group. At the 4-year follow-up, the tafamidis group continued to display less denervation in the distal thigh (mean difference [MD] of -3.0 vs. -9.3 fibers/mm) and the distal leg (mean difference [MD] -4.9 vs. -8.6 fibers/mm). ADI in tafamidis-treated patients was also lower in the distal thigh (10 vs. 30 amyloid/mm2) and the distal leg (23 vs. 40 amyloid/mm2) compared to control patients. Plasma tafamidis concentrations were higher in patients with IENFD improvement and in patients with reduced amyloid deposition. Patients without amyloid deposition in the distal leg at baseline displayed delayed disease progression at 4 years. Cutaneous IENFD and amyloid deposition assessments in the skin of the distal thigh and distal leg are valuable biomarkers for early diagnosis of ATTR amyloidosis and for measuring the progression of small nerve fiber neuropathy. Early treatment with tafamidis slows the clinical progression of the disease, skin denervation, and amyloid deposition in the skin. Higher plasma concentrations of tafamidis are associated with better disease outcomes, suggesting that increasing the drug dose could achieve better plasma concentrations and response rates. This study describes the longest small nerve fiber neuropathy therapeutic trial with tafamidis and is the first to report small fiber symptoms, function, and structural assessments as outcomes.

Free Flaps in Patients with Advanced Arteriosclerosis of the Tibial Vessels: Mini Vein Graft to the Peroneal Artery.

Lower extremity reconstruction with free flaps in patients with only peroneal artery runoff remains a challenge. Here, we present a novel technique for reconstruction of medial defects in the distal leg using a medial approach to the peroneal artery and a short interposition vein graft anastomosed end to side to the peroneal artery. A retrospective, single-center study was performed including all patients who underwent lower extremity reconstruction with free flaps anastomosed to the peroneal artery using a mini vein graft from November 2020 to March 2022. The primary outcome measure was limb salvage. Secondary endpoints were flap survival and postoperative complications. Seven patients received lower extremity free flap reconstruction with a mini vein graft to the peroneal artery. Flap loss rate was 0%. Limb salvage was achieved in five patients (71%). At 6-month follow-up, all patients were ambulatory. One patient died 1 month after surgery due to heart failure. Mini vein graft to the peroneal artery allows reliable and safe free flap reconstruction of distal leg defects in patients with only peroneal artery runoff.

Exploring the success of fasciocutaneous flap techniques in treating distal leg injuries, a Sub-Saharan African experience from Sudan

BackgroundSoft tissue and bone injuries in the lower extremities associated with high-energy trauma remain a formidable challenge to treat. The timing of the operation, the most suitable type of tissue, and the decision between local or free flap coverage remain under discussion. MethodThis prospective, cohort, multi-center study was conducted in Khartoum, Sudan, from April 2021–September 2021. The study included 70 patients. Data was collected using a questionnaire filled with patients after getting informed consent. ResultsMales were 53(75.7 %) and females were 17(24.3 %). Male to female ratio was 3.1: 1. The mean age of the patients was 27.2 ± 3.4 years. The indications for the use of fascia-cutaneous flap in the management of traumatic soft tissue injuries of distal legs were distal substance loss areas of the leg 55(78.6 %), bone exposure 60(85.7 %), open fracture 29(41.4 %), and tendon exposure 31(44.3 %). The type of fasciocutaneous flap used for the patients in this study was perineal artery flap in 20(28.6 %), sural flap in 19(27.1 %), anterior tibial artery perforator flap in 18(25.7 %), and posterior tibial perforator flap in 13(18.6 %) of the patients in 42(60 %) of the patients, no complications were reported. The reported complications were infection 16(5.7 %), distal flap necrosis 8(11.4 %) and total loss 4(5.7 %). ConclusionDespite advances in microsurgery and free flap use, a fascia-cutaneous flap is still a valid option for distal leg soft tissue reconstruction in settings where this service is unavailable. fasciocutaneous flaps are an excellent option for distal leg defects to cover soft-tissue defects, exposed bones, and tendons.

Application of the ankle pump method in a sitting position to evaluate calf perforating veins by color Doppler ultrasound

ObjectiveWe investigated the feasibility and efficacy of assessing calf perforating veins (PVs) using the ankle pump in a sitting position (AP-sit) method by color Doppler ultrasound. MethodsWe performed a multicenter prospective clinical trial between November 2022 and October 2023. Eligible patients with chronic venous disease and healthy controls were enrolled. The calf PVs were assessed using three different methods: manual compression in a standing position, manual compression in a sitting position, and AP-sit method. The reflux durations and detection rate of incompetent PVs (IPVs) were compared among the three methods. The number and diameter of calf PVs and distribution of IPVs were analyzed. ResultsA total of 50 patients with chronic venous disease and 50 healthy controls were included. There were 173 calves analyzed, including 97 healthy calves and 76 calves with chronic venous disease. The number of PVs per calf was higher in the diseased calves (median, 7.0; interquartile range [IQR], 6.0-8.0) than in the healthy calves (median, 5.0; IQR, 3.0-6.0; P < .001). The diameter of IPVs (median, 2.3 mm; IQR, 2.0-3.1 mm) was larger than that of competent PVs (median, 1.4 mm; IQR, 1.2-1.7 mm). Most of the IPVs (78.8%) were located in the medial and posterior middle of the calf. The reflux duration induced by the AP-sit method was greater than that induced by the manual compression methods (P < .001). Although the AP-sit method had a higher detection rate (92.0%) of IPVs than the manual compression methods (71.7% and 74.3% for standing and sitting, respectively; P < .001), especially in the distal lower leg, the manual compression methods found IPVs not found using the AP-sit method. ConclusionsDiseased calves with chronic venous disease have more PVs than do healthy calves. IPVs are commonly larger than competent PVs, with most IPVs located in the medial and posterior middle of the calf. Most importantly, the AP-sit method provides a convenient and effective approach for assessing the calf PVs, especially those located in the distal calf, as an alternative or complementary method to traditional manual compression, which is valuable in the daily practice of sonographers.

Reliable Method for Estimating Nerve Fiber Density in Epidermis Using Routine Histopathologic Tissue Preparation: A Promising Diagnostic Tool for Small Fiber Neuropathy.

Practical yet reliable diagnostic tools for small-fiber neuropathy are needed. We aimed to establish a histopathologic protocol for estimating intraepidermal nerve fiber density (eIENFD) on formalin-fixed, paraffin-embedded tissue (FFPE), evaluate its reliability through intraobserver and interobserver analyses, and provide normative reference values for clinical use. Sixty-eight healthy participants underwent nerve conduction studies and quantitative sensory testing. Skin biopsies from the distal and proximal leg were taken and processed using routine immunohistochemistry (anti-PGP9.5 antibodies) on thin 5 µm sections. eIENFD was assessed with a modified counting protocol. Interobserver and intraobserver reliabilities were excellent (ICC=0.9). eIENFD was higher in females than males (fibers/mm, 14.3±4.4 vs. 11.6±5.8, P <0.05), decreased with age ( r s =-0.47, P <0.001), and was higher proximally than distally (15.0±5.5 vs. 13.0±5.3, P =0.002). Quantile regression equations for the fifth percentile of distal and proximal eIENFD were presented: 13.125-0.161×age (y)-0.932×sex (male=1; female=0) and 17.204-0.192×age (y)-3.313×sex (male=1; female=0), respectively. This study introduces a reliable and reproducible method for estimating epidermal nerve fiber density through immunostaining on 5-µm thin FFPE tissue samples. Normative data on eIENFD is provided. Regression equations help identify abnormal decreases in small nerve fiber density.

The Role of the Fascia-Only Anterolateral Thigh Flap in Extremity Reconstruction: The Fascia-Only Anterolateral Thigh Flap.

Free flap selection in extremity reconstruction can be challenging. The ideal flap has to be thin and pliable to achieve optimal contour and function. We explore the role of the fascia-only anterolateral thigh (fALT) flap in extremity reconstruction. We conducted a retrospective review of our experience using fALT-free flap for extremity reconstruction over a 2-year period. Patient demographics, mechanism of injury, flap characteristics, complications- and follow-up were recorded. Descriptive statistics were calculated. Twelve patients were included. The median (interquartile range [IQR]) age was 34 (28-52) years. One fALT flap was used for upper extremity reconstruction, while 11 flaps were used for lower extremity reconstruction (4 for lower third of the leg, 4 for dorsum of foot, and 3 for heel). The median (IQR) flap surface area was 90 (63-120) cm2 and time from injury to reconstruction was 10 (6-16) days. The postoperative course was uneventful for all flaps except for 1 flap failure and 1 delayed healing. The median (IQR) follow-up was 2 (1-4) months. In all cases, durable soft tissue reconstruction was achieved with no need for revisions. The fALT-free flap can be successfully used in extremity reconstruction. The ALT fascia has robust perfusion that allows for the harvest of a large flap that can be surfaced with a split thickness skin graft. Its thin pliable tissue provides excellent contour for the hand, distal leg, and foot that does not require future thinning, optimizing the cosmetic and functional result.