Lateral Skin Research Articles

Use of lateral calcaneal flap for coverage of posterior heel defects

Lateral calcaneal flap is frequently used for coverage of lateral calcaneum and posterior heel defects. We conducted a prospective study using lateral calcaneal artery flap to cover posterior heel defects from July 2011 to June 2015 in the Department of Burn and Plastic Surgery, Khulna Medical College to observe the clinical outcome of use of lateral calcaneal artery flap. A total number of ten soft tissue defects in posterior heel with and without exposed Achilles tendon or calcaneus due to different causes were reconstructed with lateral calcaneal artery flap. All ten flaps survived completely with no subsequent breakdown of the skin, even after regular wearing of normal shoes. The flap donor sites were grafted with split-thickness skin grafts in all cases. Partial graft loss was noted in two cases which were eventually healed spontaneously with dressing without the need for a secondary graft. Epidermal necrosis developed in one case which was ultimately healed with conservative treatment. There was no loss of sensation in flap area but sensory disturbance at the lateral part of the dorsum of foot was found in all cases. Our results were satisfactory in terms of coverage adequacy, perioperative morbidity, and functional and aesthetical outcomes. The lateral calcaneal artery skin flap can be used safely to provide sensory skin coverage in posterior heel defects.Mediscope Vol. 4, No. 1: Jan 2017, Page 5-10

Enhancement of Cricothyroidotomy Education Using a Novel Technique: Cadaver Autografting

BackgroundCricothyroidotomy is a lifesaving procedure required in up to 2% of emergent airways. Emergency medicine training programs frequently instruct this procedure via cadaver training, but cadaver cost and availability limit the opportunity for all trainees to perform the critical initial skin incision. Cadaver autografting is a novel way to simulate all steps of the procedure. ObjectiveOur aim was to determine whether the technique of autografting cadaver tissue improves the experience of cricothyroidotomy simulation education for emergency medicine trainees. The investigators hypothesized that autografted cadaver tissue would be a useful adjunct. MethodsIn this prospective crossover study, volunteers were randomized to first perform cricothyroidotomy on previously incised native neck tissue or on autografted tissue, and then vice versa. The autograft consisted of cadaver iliotibial band covered with lateral thigh skin and subcutaneous tissue to simulate cricothyroid membrane and native anterior neck anatomy. Volunteer emergency medicine residents and sub-interns were included. Twenty-seven residents and nine students participated. Outcomes were evaluated via Likert scale. ResultsThirty of 36 (83%) participants agreed or strongly agreed that they preferred cadaver autografting to the previously incised native tissue. Thirty-two of 36 (89%) agreed or strongly agreed that cadaver autografting was useful vs. 23 of 36 (64%) who answered similarly regarding previously incised native tissue (p = 0.001). Twenty-six of 36 (72%) were more comfortable with cricothyroidotomy in the emergency department after using cadaver autografting vs. 19 of 36 (53%) after using the native tissue (p = 0.003). ConclusionsAutografted cadaver tissue while simulating cricothyroidotomy was perceived to be a useful adjunct by the majority of participating emergency medicine trainees.

Management and patients perspective regarding a common peroneal nerve schwannoma: a rare cause of lower leg pain in a young individual

The differential diagnosis of exercise-induced lower leg pain in young individuals is extensive and includes entities such as chronic exertional compartment syndrome, popliteal arterial entrapment syndrome, cystic adventitial disease, medial...

Abstract: Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip and Palate Repairs Reduces the Rate of Alveolar Fistula Formation

INTRODUCTION: This study was performed to assess the efficacy of the nasal lining flaps for closing the nasal floor in unilateral and bilateral cleft lip and palates. We believe this technique is superior to traditional techniques, resulting in a low rate of fistula formation at the alveolus. Some surgeons do not close the nasal floor during primary cleft lip repair, leaving a symptomatic alveolar fistula that is present until the alveolar bone grafting. The traditional approach for closure involves the use of anteriorly-based medial (M-flap) and lateral (L-flap) skin flaps. However, these skin flaps are thin and provide notoriously unreliable coverage. The nasal lining flaps were devised to reconstruct the nasal floor with robust, well-vascularized flaps. These flaps create an anatomic reconstruction of the nasal floor while providing support for the alar base(s). The undersurface of the one-layer repair eventually fills in secondarily. METHODS: Cleft repairs performed by two craniofacial surgeons at a university children’s hospital were identified. One surgeon used the nasal lining flaps while the other used primarily M- and L-flaps to close the nasal vestibule. Patients were included in the study if they had a complete cleft lip and palate and at least 6 months of follow-up. RESULTS: There were 64 patients in the study. Thirty-seven (37) underwent closure with nasal lining flaps while 27 underwent closure using traditional techniques. The rates of alveolar fistula formation were 3% (1/37) and 30% (8/27), while the rates of non-alveolar fistula formation were 16% (6/37) and 15% (4/27), respectively. The lower rate of alveolar fistula formation in the group that underwent closure with the nasal lining flaps was statistically significant (p=0.003, Fisher’s exact test). There was no statistically significant difference in rates of non-alveolar fistula formation (p=1, Fisher’s exact test). CONCLUSION: The nasal lining flaps have multiple advantages. This technique closes the nasal floor at the time of primary lip repair, when visualization is easiest. The repair is simple to perform and has a high success rate. Closure of the alveolar region with soft tissue likely improves quality of life by preventing fluid or food regurgitation into the nose. The nasal floor closure does not prevent the need for bone grafting, but can make the surgery easier since the nasal side is already closed.

Pentalogy of Cantrell

Pentalogy of Cantrell is a rare syndrome that consists of defects involving the diaphragm, abdominal wall, pericardium, heart and lower sternum. A 2 –day- old male neonate presented to the pediatric surgical unit in the Maternity and Child Teaching hospital\AL-diwaniya with abdominal wall defect,precious baby deliverd by C\S to the mother with history of primary infertility for more than 13 year, The first clinical evaluation revealed epigastric omphalocele ( liver ,spleen and transverse colon were exposed with rupture sac , sternal defect , and ectopia cordis. U\S ,echocardogram and radiological studies were done to exclude others associated anomalies , Staged closure decided because the primary closure will significantly compromise ventilation or abdominal viscera .The first surgery was closure of both abdominal and thoracic defect ,bilateral flank and lateral chest wall release incisions and skin flap done for this closure. The patient had an uncomplicated postoperative course. A chest CT was performed at 2 weeks of life and demonstrated a very hypoplastic appearing anterior chest wall and a stenosis of the left mainstem bronchus as the cause of the patient's left lung hyperinflation. Monthly evaluation were done till he became at age of two years and every thinks were normal a part from abdominal distention (herniated viscera) which affected and limited the physical activity so the second stage was done, reinforced Dacron mesh placed to the anterior abdominal wall to protects the herniated bowel and redirects the pressure in the abdomen and to promotes enlargement of abdominal cavity.

Antihyperalgesic effect by herpes vector-mediated knockdown of NaV1.7 sodium channels after skin incision.

Postincisional hyperalgesia and allodynia play an important role in perioperative medicine. NaV1.7 sodium channel has proven to be a key player in several pain states, including acute, inflammatory, and neuropathic pain. This study investigated the effects of silencing NaV1.7 through Herpes-based gene therapy with an antisense transcript on pain states after incision of the skin in rodents. Seventy-six Balb/C mice were subdivided into six groups and were treated with no virus, control virus, or NaV1.7 antisense vector before lateral hindpaw skin incision or sham procedure. All mice were tested for mechanical allodynia, cold allodynia, and thermal hyperalgesia. For time series analysis, a two-way analysis of variance with post-hoc Bonferroni testing was used. After incision mice developed significant hypersensitivity to mechanical, cold, and heat stimuli. The NaV1.7 antisense vector blocked the hypersensitivity to mechanical, cold, and heat stimuli that was normally observed 24 and 48 h after incision. We demonstrated that a gene therapy-based NaV1.7 knockdown affects postincisional hyperalgesia and allodynia. The data provide evidence that the incision model leads to periwound hypersensitivity after incision and that application of the NaV1.7 antisense virus prevents this sensitization. This then, in turn, provides presumptive support to the hypothesis that overexpression of the NaV1.7 channel is an important mechanism underlying hyperalgesia and allodynia following skin incision.

Estimation of losses in strip and circular wire conductors of radiofrequency planar surface coil by using the finite element method

AbstractAn accurate coil design is a fundamental task to maximize signal‐to‐noise ratio in magnetic resonance applications. Coil design techniques take advantage of computer simulations especially when coil size is comparable to the radiofrequency (RF) wavelength. In particular, the estimation of the losses within the conductors as well as the radiative losses, both as a function of frequency, is instrumental to a complete coil performance characterization. However, the cross‐sectional shape of the conductors strongly affects the radiofrequency coil's performance, especially at those frequencies where conductor losses represent the dominant power dissipation mechanism. Indeed, at radiofrequencies, the current flowing in the conductor is distributed in the proximity of its surface instead of being uniformly distributed over the cross section; it follows that an accurate conductor losses estimation can be performed only in the case of wire conductors by using analytical formulations. For strip conductors, although different theoretical approaches have been proposed in literature by taking into account the losses, no closed‐form expression for conductors resistance is available which takes into account both classical and lateral skin effects. In this work, finite element method (FEM) simulations have been performed for estimating conductor and radiative losses in planar surface loops made of strips and circular wires; the results have been compared against analytical formulations and literature data. Workbench tests performed on two circular coil prototypes, the first one constituted by a strip and the second one by circular wire conductors, tuned at 63.9 MHz and 127.8 MHz, showed a good agreement with FEM simulations.

The finger lateral local flaps to repair clinical application of finger tip defect

Objective To discuss the clinical influence and advantages of applying the local flap of finger tip lateral skin to repair the fingertip defective injuries. Methods From August, 2013 to December, 2015, used the way of local the flap of finger tip lateral skin to repair the first-fourth fingertip defects for 32 cases and 32 fingers, among which there were 20 males and 12 females; finger categories: 11 thumbs, 9 index fingers, 8 middle fingers and 4 ring fingers. The defective area of fingertips was 0.5 cm×0.8 cm-1.0 cm×1.5 cm, all with bone exposure, 23 cases had defects at the end part of phalanx, 32 cases had different extent of nail bed defects. Reasons for the injuries: 13 cases of grind injuries, 11 cases of punch pressing injuries, 8 cases of sharp tool cutting injuries. The time from injury to the treatment was 0.5-3.0 h, all of them had no associated injuries. Results Thirty-two cases of finger flaps all survived, with the follow-up for 3-24 months and average follow-up of 6 months, the flaps were slightly bloated after 3 months comparing with the normal skin, there was no contracture in the flap area and pedicle scars, two-point discrimination was 4-5mm, the farinterphalangeal joint flexion was normal. Conclusion The local flap of fingertip lateral skin can repair the defects of fingertip with less scar, not bloated flap, satisfying appearance, operation is simple, and good function, so it’s the ideal way to repair the defects of fingertip. Key words: Finger tip defect; Surgical flap; Local transfer flap; Microsurgical technique

MONOCRYL and DERMABOND vs Staples in Total Hip Arthroplasty Performed Through a Lateral Skin Incision: A Randomized Controlled Trial Using a Patient-Centered Assessment Tool

BackgroundThere are various possible methods of skin closure in total hip arthroplasty (THA) through a lateral skin incision. The cost and time required for each can vary between techniques. The objective of this study was to determine whether there is a difference in patient and surgeon rating of scar outcome using a combination of subcuticular suture and skin adhesive (subcuticular MONOCRYL and DERMABOND [SMD]) vs staples for skin closure after THA. MethodsPatients undergoing THA were recruited from a university hospital. Patients were randomized to staples or SMD. Patient and Observer Scar Assessment Scale data were collected postoperatively. In addition, visual analog scale pain scores, wound drainage, length of stay, time to closure, and total cost were collected. ResultsOne hundred twenty-nine patients were available for final analysis. There was no significant difference in Patient and Observer Scar Assessment Scale scores at 6 weeks or 3 months (P = .71). There was no difference in visual analog scale pain scores (P = .64, P = .49). The staple group had a higher rate of discharge on postoperative days 1 and 3 (P < .001, P < .001) but had a 1.6-minute shorter time of closure (P < .001). There was no significant difference in length of stay or total cost (P = .5). ConclusionAlthough there are some small initial advantages to each method of skin closure, there is little difference in scar outcome when comparing SMD and staples.

MicroRNAs, Aging, Cellular Senescence, and Alzheimer's Disease.

Aging is a normal process of living being. It has been reported that multiple cellular changes, including oxidative damage/mitochondrial dysfunction, telomere shortening, inflammation, may accelerate the aging process, leading to cellular senescence. These cellular changes induce age-related human diseases, including Alzheimer's, Parkinson's, multiple sclerosis, amyotrophic lateral sclerosis, cardiovascular, cancer, and skin diseases. Changes in somatic and germ-line DNA and epigenetics are reported to play large roles in accelerating the onset of human diseases. Cellular mechanisms of aging and age-related diseases are not completely understood. However, recent discoveries in molecular biology have revealed that microRNAs (miRNAs) are potential indicators of aging, cellular senescence, and Alzheimer's disease (AD). The purpose of our chapter is to highlight recent advancements in miRNAs and their involvement in cellular changes in aging, cellular senescence, and AD. This chapter also critically evaluates miRNA-based therapeutic drug targets for aging and age-related diseases, particularly Alzheimer's.

양식 뱀장어 (Anguilla japonica)의 황달에 관하여

The disease occurred in cultured eel (Anguilla japonica) in a recirculatory culture system without any separated filtration apparatus. As the pond had a high level of nitrite with <TEX>$60mg/{\ell}$</TEX>, 1% NaCl was added to reduce nitrite toxicity to eel. The first outbreak was observed a week after the NaCl treatment and continued for 10 days. Accumulated mortality was about 0.2-0.5%. Affected fish ranged from 150-350 g were usually anorexic and exhibited yellow colour in the skin of the abdominal region and at the base of pectoral fins, as well as in the eyes. In a few individuals with severe symptoms, the lateral skin was also yellowish. The spleen, kidney, muscle and gall bladder were yellowish and the liver was pale-yellow colour but green on the posterior part. The gall bladder was shrunken without bile. Some abnormal erythrocytes such as "tear drop" cells (dacrocyte) were observed in peripheral blood smears stained with May-Grunwald Giemsa. Hematocrit values and hemoglobin contents in the jaundiced eel were significantly lower compared with apparently heathy eel. Severe haemosiderosis accompanied by erythrophagocytosis was found in the kidney and spleen. Haemosiderin deposits were observed in macrophages of the haematopoietic tissue of the kidney and in the splenocytes. But no significant alterations were found in the hepatic cells. In this study we report the first outbreak of jaundice in cultured eel in Korea. Pathological and hematological investigations suggested that severe hemolysis may resulted in jaundice in eel although the cause of hemolytic jaundice was not identified in this study.

Quantitating the lateral skin stiffness by a new and versatile electro-mechanical instrument. Preliminary studies.

A new electro-mechanical device for measuring the lateral stiffness of the skin is now available. It basically allows to recording the forces that the skin opposes to a lateral displacement (1-2 mm) of a pinching type movement. Preliminary assays of this device to various skin sites and an artificial substrate aimed at defining its major characteristics (sensitivity, reproducibility, variations according to skin site). The calibration of the device (Khelometer® ) and assessment of its reproducibility were carried out through the use of elastometer substrates of various stiffness's. The device was then used, in vivo, at different skin sites (scalp, inner and outer forearms, cheeks) of 213 healthy Japanese women of various ages. The short-time effect of a hydrating regimen (7% glycerol) was recorded on the outer forearm. This new device offers an appreciable reproducibility in vitro and in vivo (coefficient of variation of 2-4% and 5-14%, respectively). Unlike other biophysical methods, the Khelometer® can be easily applied onto the human scalp that shows a higher stiffness than the two other skin sites, increasing with age and presence of alopecia. In all the three studied skin sites, the impact of age leads to significantly higher lateral skin stiffness (LSS, expressed as N/mm) values. The latter were found significantly different between the two sides of the forearms where the outer (sun-exposed) side showed statistically slightly higher LSS, than the unexposed inner side. LSS values found on cheeks (≈0.5 N/mm) were about four times lower than those of the scalp (≈2 N/mm) and about half those of forearms (≈1 N/mm). The effect of a 7% glycerol based formula was recorded 20 min post application onto the forearm, leading to a slight drop in LSS (approx. 15%) as compared to a vehicle-applied skin site. These preliminary studies clearly indicate that this new device, applicable to any skin site, offers appreciable assets such as sensitivity and reproducibility. Accordingly, it appears as a new approach in the non-invasive biophysical measurements of the skin surface, in both advanced and applied research investigations.

LONG-TERM EFFECTIVENESS OF TRANSPIANTATION OF ILIAC BONE FLAP PEDICLED WITH DEEP ILIAC CIRCUMFLEX VESSELS FOR AVASCULAR NECROSIS OF FEMORAL HEAD AT STAGE II AND III

To assess the long-term effectiveness of the transplantation of iliac bone flap pedicled with deep iliac circumflex vessels for treating avascular necrosis of femoral head (ANFH) at Ficat stage II and III. Thirty-two cases (43 hips) of ANFH underwent iliac bone flap transplantation pedicled with deep iliac circumflex vessels between October 2000 and February 2006, and the clinical data were retrospectively reviewed. Of 32 cases, 27 were male (38 hips), and 5 were female (5 hips), aged 21-52 years (mean, 36.6 years); there were 8 cases (11 hips) of hormone ANFH, 18 cases (23 hips) of alcoholic ANFH, and 6 cases (9 hips) of idiopathic ANFH. The disease duration ranged from 2-52 months (mean, 8.2 months). According to Ficat staging criteria, 26 hips were classified as stage II and 17 hips as stage III. The preoperative Harris hip score (HSS) was 68.2±8.4. The HHS scores and X-ray photograph were compared between at pre- and post-operation to assess the outcomes clinically and radiologically. All incisions healed by first intention. Two cases had numbness of the lateral femoral skin. Four patients (6 hips) failed to be followed up, and the other 28 cases were followed up 98-187 months (mean, 129.3 months). Five patients (6 hips) showed aggravation or no relief with progression to stage IV at 8-69 months, who received total hip arthroplasty. The 10-year survival rate was 83.78% (31/37). The HHS score was significantly increased to 86.7±9.0 at last follow-up (t=-48.313, P=0.000). The hip function was excellent in 9 hips, good in 13 hips, and fair in 9 hips, and the success rate was 75.68%. Radiographic examination showed signs of bone remodeling at 6-8 weeks. After bone healing, the femoral head density gradually became uniform. Until last follow-up, ANFH progressed from Ficat stage II to III in 5 hips, from Ficat stage II to IV in 3 hips, and from Ficat stage III to IV in 3 hips; complete hip shape, continuous Shenton line, and normal joint space were observed in the other 26 hips, and the radiographic success rate was 70.27% (26/37). The pedicled iliac bone flap transplantation for ANFH at Ficat stage II and III can provide good osteogenesis and vascular reconstruction of the femoral head. The long-term follow-up effectiveness is satisfactory.

Management of Zygomatic Fractures in Young Patients: Technical Modifications for Aesthetic and Functional Results.

The zygomaticomaxillary complex is very vulnerable to injury because of its intrinsically prominent convexity. There are 2 different surgical approaches for the therapy of these fractures: closed reduction and open reduction. In the open reduction 2 or 3 fixation points with related incisions are usually necessary in dislocated fractures: osteosynthesis must be performed starting from zygomaticofrontal suture when dislocated at this site, followed by zygomatic body fixation on the anterior sinus wall, anterior orbital floor margin fixation, and finally orbital floor reconstruction in case of eye globe dislocation with diplopia. This study evaluated the combination of the transconjunctival (TC) approach without canthotomy in association with the transoral maxillary approach and lateral rim skin incision (SI) without canthotomy for frontozygomatic dislocated fractures to achieve proper reduction and stabilization without any aesthetic decay in young patients. A less invasive and more aesthetic technique is shown for treating dislocated zygomaticomaxillary complex fractures with 2 or 3 fixation points and platelet-rich fibrin (PRF) use to promote tissue healing. Ten patients (mean age: 32) were referred for dislocated zygomaticomaxillary complex fracture. Five patients were treated by TC approach without canthotomy in association with the transoral maxillary approach and, when needed, eyebrow SI without canthotomy for frontozygomatic dislocated fractures (group 1). Five more patients were treated by traditional subciliar incision at lower eyelid and vertical lateral incision at lateral margin of the orbit (group 2). Autologous PRF for orbital floor reconstruction was used. The follow-up period was 6 months long. Follow-up radiographs (TC) and photos were routinely used to evaluate the adequacy of reduction and lower eyelid right position or retraction. All cases were successful; there were no problems at surgery and postoperative time. During the 6-month follow-up, all 5 patients of group 1 showed satisfactory facial symmetry, no noticeable scarring, no ectropion or lower eyelid significant droop, and no functional impairment. Mean difference for lower eyelid droop between the 2 groups of patients was 1.4 mm at T1 and 1.2 mm at T2. Aesthetic result is a priority in the treatment planning of orbitozygomatic fractures because of the fundamental role of the eye and lid area in the aesthetic of the face. In our experience best aesthetic results were achieved through a latero cantal horizontal SI combined to a vertical periosteal incision at the frontozygomatic rim without canthotomy, thus performing a different double-layer incision. In the patients with large orbital floor dislocation, reconstructive titanium mesh was covered by autologous PRF membranes, which can improve the vascularization of the surgical site, by promoting neoangiogenesis. In young patients these techniques are indicated because of the need of better aesthetic results that can be achieved by preventing postoperative functional impairment with lower eyelid droop and unnatural aesthetic asymmetry of the 2 lower lids. This more conservative technique resulted in better aesthetic results, avoiding most common complications.

Repair the lateral skin and soft tissue defect of the middle and rear foot wih the plantar medial flap transferred before the achilles tendon

Objective To investigate the methods of repair the lateral skin and soft tissue defect of the middle and rear foot with the plantar medial flap transferred before the achilles tendon. Methods Fifteen cases with the lateral skin and soft tissue defect of the middle and rear foot were repaired with the plantar medial flap pedicled with posterior tibia artery transferred before the achilles tendon from January, 2012 to October, 2015. All the 15 patients were followed up in the way by telephone or back to hospital postoperatively 3 months to 3 years, including 6 cases by telephone follow-up and 9 cases of back-to-hospital follow-up, to observe the appearance, functions of the skin flap and whether the skin flap survived well. Results The flaps of 15 cases survived well. Postoperative follow-up of 3 months to 3 years, the sensation of the flap was good, without any ulcer or necrosis. The patients walked well and were satisfied with the flap. Conclusion To repair the lateral skin and soft tissue defect with the plantar medial flap transferred before the achilles tendon as a new method is feasible with the good ability of faster sensory recovery, the good appearance and function. Key words: Plantar medial flap; Achilles tendon; Middle and rear foot; Skin and soft tissue defect

Choosing of the posterior lateral leg pedide skin flaps supplyed by different blood repair of foot and ankle soft tissue defect

Objective According to the characteristics of skin defects in ankle and foot select the posterior lateral leg pedide skin flaps supplyed by different blood to repair, providing advice and reference. Methods Between January, 2001 and December, 2015, 163 cases of soft tissue defects at the foot and ankle were treated in our department. ①The sural neurovascular flap was used in 93 cases in ankle and foot defect. ②The sural nerve nutritional vessel flap pediele with the perforating branch of the peroneal artery in 36 cases in ankle and foot defect. ③The sural nerve nutritional vessel flap pediele with the perforating branch of the peroneal artery including sensory reconstruction in 16 cases in heel rejion defect. ④Peroneal artery perforator flap in 10 cases in anterior ankle, lateral malleolus and posterior malleolus defect.⑤The use of the sural fasciocutaneous flap alonged with peroneal artery and perforators in 8 cases in dorsal foot defect. The donor site with skin graft. Results Of the 93 sural neurovascular flaps, 8 had partial loss, which were cured after dressing. All the sural nerve nutritional vessel flaps pediele with the perforating branch of the peroneal artery survived. Sensory grading standard by UK Medical Research Council was used to evaluate the recovery of sensory function on the last follow-up. The sensory function recovery of heel region flaps with reconstruction of the sensory was between S0 and S1. All peroneal artery perforator flaps survived. One of the sural fasciocutaneous flap alonged with peroneal artery and perforators occurred distal epidermis, which were cured after dressing. All patients were followed up 6-50 months (mean 20 months). All patients had recoveryed walking function, and infection wound had no recurrence after surgery. Conclusion According to the location, size, severity and the injury of peripheral vascular, select the most simple, safe, minimal damage flap for the soft tissue defects at the foot and ankle. The right choice and the exact design can improve flap survival rate, and recieve good clinical results. Key words: Foot and ankle; Soft tissue defect; Surgical flap; Repair; Sense reconstruction

A methodology for on‐board CBCT imaging dose using optically stimulated luminescence detectors

Cone‐beam computed tomography CBCT systems are used in radiation therapy for patient alignment and positioning. The CBCT imaging procedure for patient setup adds substantial radiation dose to patient's normal tissue. This study presents a complete procedure for the CBCT dosimetry using the InLight optically‐stimulated‐luminescence (OSL) nanoDots. We report five dose parameters: the mean slice dose (DMSD); the cone beam dose index (CBDIW); the mean volume dose (DMVD); point‐dose profile, D(FOV); and the off‐field Dose. In addition, CBCT skin doses for seven pelvic tumor patients are reported. CBCT‐dose measurement was performed on a custom‐made cylindrical acrylic body phantom (50 cm length, 32 cm diameter). We machined 25 circular disks (2 cm thick) with grooves and holes to hold OSL‐nanoDots. OSLs that showed similar sensitivities were selected and calibrated against a Farmer‐type ionization‐chamber (0.6 CT) before being inserted into the grooves and holes. For the phantom scan, a standard CBCT‐imaging protocol (pelvic sites: 125 kVp, 80 mA and 25 ms) was used. Five dose parameters were quantified: DMSD, CBDIW, DMVD, D(FOV), and the off‐field dose. The DMSD for the central slice was 31.1±0.85 mGy, and CBDIW was 34.5±0.6 mGy at 16 cm FOV. The DMVD was 25.6±1.1 mGy. The off‐field dose was 10.5 mGy. For patients, the anterior and lateral skin doses attributable to CBCT imaging were 39.04±4.4 and 27.1±1.3 mGy, respectively.OSL nanoDots were convenient to use in measuring CBCT dose. The method of selecting the nanoDots greatly reduced uncertainty in the OSL measurements. Our detailed calibration procedure and CBCT dose measurements and calculations could prove useful in developing OSL routines for CBCT quality assessment, which in turn gives them the property of high spatial resolution, meaning that they have the potential for measurement of dose in regions of severe dose‐gradients.PACS number(s): 87.57.‐s, 87.57.Q, 87.57.uq

A comparison of kneeling ability after lateral or midline incisions in total knee arthroplasty

Kneeling is often impaired following total knee replacement. There is no clinical study comparing a lateral to a midline skin incision with regard to kneeling. Patients with a well-functioning total knee replacement enrolled in the trial. The participants with a lateral skin incision were matched with those with a standard midline incision. Twenty-two patients were enrolled in the study: 10 had a lateral skin incision, and 12 had a midline incision. Those with a lateral skin incision had a significantly higher Forgotten Joint Score than with a midline skin incision (Difference of Means Lateral vs Midline=10.9 [p value 0.0098]), and an improved ability to kneel at 110 degrees of flexion (Kneeling Ability Test; Difference of Means Lateral vs Midline=41.7 [p value 0.020]). These results suggest that a lateral skin incision may provide reduced joint awareness and improved kneeling ability. Further investigation with a randomised controlled trial is needed.

Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon and Posterior Heel Wound Complications

Category: Ankle Introduction/Purpose: Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here we describe coverage of a series of posterior heel and achilles wounds via simple, local tissue transfer, a bipedicle fasciocutaneous flap. This surgical technique can be performed by an orthopaedic foot and ankle surgeon without resources of tertiary/specialized care or microvascular support. Methods: Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with wound breakdown following midsubstance Achilles tendon repair. Case 2 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 3 was a heel venous stasis ulcer with calcaneal exposure in a diabetic vasculopath. All three cases were treated with the following technique: an incision was immediately posterior to the lateral malleolus. The length of the incision was approximately 25% greater than the proximal to distal measurement of the wound. The dissection was carried to the flexor retinaculum and carried posteriorly to create a fasciocutaneous flap attached proximally and distally. This flap was then mobilized posteriorly to close the desired defect, leaving an ellipsoid shaped skin defect laterally. A split thickness skin graft was used to cover the defect created by the flap transposition. Results: All three patients demonstrated initial complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site following surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear. Conclusion: The bipedicled fasciocutaneous flap described offers a simple, predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap allows for relatively short operative times and can be customized to facilitate defect coverage. Ultimately, the flap is sufficiently durable to withstand the local tissue stresses required for ambulation at an early stage. This provides a reasonable alternative to complicated and time consuming microvascular reconstruction, but does require careful follow-up to manage the patient’s underlying comorbid conditions that may complicate wound healing.

The Lateral Proximal Phalanx Flap for Contractures and Soft Tissue Defects in the Proximal Interphalangeal Joint: An Anatomical and Clinical Study.

Background: The management of contractures and soft tissue defects in the proximal interphalangeal (PIP) finger joint remains a challenge. We report a transposition flap from the lateral skin of the proximal phalanx that is based on perforating branches of the digital arteries and can be used safely for both palmar and dorsal cover defects. Methods: We first completed an anatomic study, dissecting 20 fingers in fresh cadavers with arterial injections and made the new flap in patients with dorsal or palmar defects in PIP joints. Results: In cadavers, we can reveal 4 constant branches from each digital artery in the proximal phalanx, with the more distal just in the PIP joint constituting the flap pedicle. Between February 2010 and February 2015, we designed 33 flaps in 29 patients, 7 for dorsal and 26 for palmar defects, with no instances of flap necrosis and 4 distal epidermolysis. The patients were between 4 and 69 years with no major complications, and all of the skin defects in the PIP joint were resolved satisfactorily without any relevant sequelae at the donor site. Conclusions: This flap procedure is an easy, reliable, versatile, and safe technique, and could be an important tool for the management of difficult skin defects and contractures at the PIP joint level.