Lateral Wall Defects Research Articles

Reconstruction method for massive lateral chest wall sarcoma using titanium plates and mesh: a case report

BackgroundVery large chest wall resections can lead to acute thoracic insufficiency syndrome due to the interdependence of lung expansion and thoracic volume. Chest wall tumor surgeries often encounter complications, with the size of the chest wall defect being a significant predictor. Several methods for large chest wall reconstruction have been described, aiming to provide stability, prevent flail chest, and ensure airtight closure. However, no single method fulfills all requirements. Composite chest wall reconstruction using titanium plates and Gore-Tex patches has shown the potential to minimize physiologic abnormalities caused by extensive defects.Case presentationA 42-year-old man with myxofibrosarcoma underwent multiple surgeries, chemotherapies, and radiation therapies due to repeated local recurrences. After right arm amputation and resection of the right third to fifth ribs, a local recurrence was detected. A 30 × 40 cm chest wall defect was resected en bloc, and a titanium plate was used for three-dimensional formability, preventing flail chest and volume loss. The Gore-Tex patch was then reconstructed into an arch shape, allowing lateral thoracic mobility. The patient recovered well and did not experience respiratory dysfunction or local recurrence but later succumbed to distant metastasis.ConclusionsIn this case, the combination of a titanium plate and a Gore-Tex patch proved effective for reconstructing massive lateral chest wall defects. The approach provided stability, preserved thoracic volume, and allowed for lateral mobility. While the patient achieved a successful outcome in terms of local recurrence and respiratory function, distant metastasis remained a challenge for myxofibrosarcoma patients, and its impact on long-term prognosis requires further investigation. Nevertheless, the described procedure offers promise for managing extensive chest wall defects.

Unique laparoscopic emergency management of traumatic obstructed abdominal wall hernia: A case report and review of literature

Abstract Traumatic abdominal wall hernia (TAWH) is a rare clinical occurrence, with only limited cases published since 1906. This type of hernia is primarily caused by low- or high-energy blunt force trauma, resulting in damage to abdominal wall musculature while the skin is intact. The diagnosis and management of TAWH poses a lot of challenges and complexities. Herein, we present a case of a 32-year-old male Saudi patient who sustained significant abdominal trauma as a driver involved in a front collision while wearing a seat belt. Upon arrival at the trauma center, the patient was hemodynamically stable and exhibited clinical signs of left flank bulge, seat belt sign, and abdominal bruising. First, a focused assessment with sonography for trauma (FAST) was performed, which revealed minimal free fluid in the abdomen. Subsequent contrast-enhanced IV computed tomography (CT) scan confirmed a 3.6-cm left lateral abdominal wall defect with herniation of short segments of the large and small bowel loops and adjacent subcutaneous fluid. Following initial observation, the patient developed signs of bowel obstruction. A repeat CT scan showed interval progression of the hernia, partial small bowel obstruction, and other concerning findings. An emergency laparoscopic exploration revealed a large defect at the left lumber region containing omentum and long segments of the small bowel with mild distension. The bowel and omentum were reduced. The surgical repair included herniorrhaphy and mesh placement. The patient recovered well and was discharged on the third postoperative day. This case underscores the importance of thorough evaluation and timely intervention in TAWHs. Rapid surgical management, aided by advanced imaging techniques, can lead to favorable outcomes even in complex cases involving bowel herniation and associated complications.

Lumbar hernia: An unusual abdominal hernia: A case report and review of literature (radiological perspective) in a tertiary center in south-south Nigeria

Lumbar hernias are unusual abdominal wall defects involving the posterolateral abdominal wall: the superior lumbar triangle of Grynfelt, which is the most common site, and the inferior lumbar triangle of Petit. They are located between the muscular layers of the abdominal wall and can be easily ignored because of abdominal obesity. In general, it is difficult to diagnose because of their unclear non-specific symptoms. However, radiographic studies have been valuable in confirming the diagnosis. The introduction of ultrasonography and computed tomography (CT) has greatly improved the diagnosis of lumbar hernia. Following the establishment of the diagnosis, operative management is indicated due to chance of incarceration. Our case study is an 80 years old man who presented to the Radiology department for an emergency abdominal ultrasound scan investigation on account of abdominal pain/abdominal swelling on the lateral aspect of the right flank of about 5 days as explained by his relative. The abdominal ultrasound shows a hyperechoic mass in the right flank that extends through a defect in the transversus abdominis muscle. This mass measures 5.3x4.9cm and shows no flow on Doppler interrogation. Note mild fluid collection seen surrounding the mass. Also note marked subcutaneous oedema. Another imaging modality was employed; non contrast computed tomography and shows a lateral abdominal wall defect in the right lower internal oblique with sac containing bowel loop and omental fat. Other visualized bowel loops are normal in caliber and wall thickness.

Is Sliding Compression Necessary for Intramedullary Nailing Fixation of AO/OTA Type A3.3 Intertrochanteric Fracture?

The intramedullary nail is considered the gold standard for treating AO/OTA type A3.3 intertrochanteric fractures. However, it still faces a significant rate of failure, mainly due to the critical factor of comminuted lateral wall defects leading to inadequate proximal sliding compression. The primary objective of this study is to investigate the requirement of sliding compression in the treatment of unstable AO/OTA type A3.3 intertrochanteric fractures. To achieve this, we conduct a comparative analysis between two approaches: InterTAN alone and proximal femoral anti-rotation blade nailing (PFNA) combined with lateral wall reconstruction for treating AO/OTA type A3.3 intertrochanteric fractures with lateral wall damage. A retrospective analysis was conducted on the clinical data of patients who underwent intramedullary nailing fixation for AO/OTA type A3.3 intertrochanteric fractures at our hospital from January 2012 to January 2022. Patient characteristics as well as treatment details, including operative time, intraoperative blood loss, weight-bearing time, fracture healing time, tip apex distance (TAD) loss, Harris hip scores (HHS), Parker-Palmer mobility score (PPMS), and postoperative complications, were collected and analyzed. Continuous variables were analyzed using independent sample t-tests, while categorical variables were examined using the chi-square test. For group comparisons, variance analysis was applied, and pairwise comparisons were conducted using the LSD-t test. These patients were divided into PFNA combined with lateral wall reconstruction group (sliding compression group) and InterTAN fixation group (static fixation group) based on surgical methods. The operation time, intraoperative bleeding loss, HHS at 12 months and PPMS at 12 months in the sliding compression group were significantly higher than those in the static fixation group, and time to weight-bearing and fracture healing time were significantly lower than those in the static fixation group (p < 0.05). There were no significant differences between two groups in terms of the TAD at 2 days, 2, and 12 months postoperatively, the incidence of complications (p > 0.05). At 6 months postoperatively, femoral neck length was shortened compared to 2 days postoperatively in both groups, and the sliding compression group had a significantly greater degree of femoral neck shortening than the static fixation group (p < 0.05). The use of PFNA with lateral wall reconstruction for A3.3 intertrochanteric fractures demonstrated superior mobility, efficiency, and reduced internal fixation failure rates compared to InterTAN. These findings suggest that sliding compression may be required for intramedullary nailing treatment.

A conservative surgical strategy for spontaneous cerebrospinal fluid leakage: a rare case report

A 59-year-old male with no history of trauma or surgery presented with clear rhinorrhea occurring when he bent his head forward. A CT scan revealed localized fluid accumulation and a lateral wall defect involving the left sphenoid sinus. Using the transpterygoid approach, we widened the anterior wall of the sphenoid sinus inferolaterally to expose the lesion as much as possible. Reconstruction involved placing an interposition graft between the dura and the bony defect using the underlay technique, followed by free mucosal grafting. Histopathological examination revealed neuroglial cells, confirming the diagnosis of spontaneous cerebrospinal fluid rhinorrhea due to a meningoencephalocele.

Self-healing, injectable hydrogel based on dual dynamic covalent cross-linking against postoperative abdominal cavity adhesion

Clinically, increasing the peritoneal barrier is an effective adjunct to reducing postoperative peritoneal adhesion. This study presents a facile template for preparing a supramolecular hybrid hydrogel through dynamic covalent cross-linking between carboxymethyl chitosan (CMCS), 2-formylphenylboronic acid (2-FPBA), and quercetin (Que). The as-prepared complex CMCS/2-FPBA/Que (CFQ) hydrogel exhibited favorable antibacterial, anti-inflammatory, and antioxidant effects. A L929 cytotoxicity evaluation confirmed the favorable cytocompatibility of the CFQ hydrogel. The postoperative anti-adhesion ability of the CFQ hydrogel was further evaluated in rats with lateral wall defects and cecal abrasions. Compared with control groups, the tissue adhesion rate was significantly reduced by increasing the Que concentration in all the hydrogel-treated groups. Additionally, the sustained-release time of the C3F0.8Q0.08 hydrogel can exceed 14 days, which is highly desirable for clinical wound treatment. Statement of significancePostoperative adhesions are a very common postoperative complication that seriously affects the quality of life of patients. The currently commonly used methods for preventing adhesion mainly use degradable barrier materials for physical separation. In this study, we prepared a dual dynamic covalently cross-linked CFQ hydrogel, which is not only degradable and injectable, but also has multiple properties such as antibacterial, antioxidant and anti-inflammatory, which can effectively prevent postoperative adhesion and promote wound healing.

Orbital Roof and Lateral Wall Reconstruction Using Split-Thickness Calvarial Bone Graft with Titanium Mesh Complex for a Spheno-Orbital Meningioma

ABSTRACT Objective: To describe our reconstruction of an orbital roof and lateral wall defect using a split- thickness calvarial bone graft with titanium mesh complex after resection of a meningioma of the left greater wing of the sphenoid with extension to the left frontotemporal bone and left orbital roof and lateral wall. Methods: Study Design: Surgical Innovation Setting: Tertiary Private University Hospital Patient: One Results: A 44-year-old woman with a left frontotemporal mass associated with left eye proptosis and epiphora underwent reconstruction of the left orbital roof and lateral wall defect using split-thickness calvarial bone graft with titanium mesh and screws after a left frontotemporal craniectomy, superior and lateral orbital wall resection of a mass of the sphenoid wing with orbital and frontotemporal extension. Final histopathology was consistent with meningioma. Surveillance of the mass and orbital reconstruction showed evidence of bone growth and osteointegration of the titanium mesh into the bone grafts. Conclusion: The initial good outcome of orbital roof and lateral wall reconstruction using split-thickness calvarial bone graft with titanium mesh is evidenced by osteointegration of the titanium mesh and revascularization leading to new bone growth. This autogenous-alloplastic complex may provide a more stable option for orbital reconstruction, but long term follow-up is needed for surveillance of recurrence and monitoring the status of orbital reconstruction.

Lateral abdominal wall reconstruction

Lateral abdominal wall (LAW) defects are defined as hernias, bulges, or surgical wounds that occur within the anatomic region bounded by the linea semilunaris, costal margin, iliac crest, and paraspinous musculature. Reconstruction of the LAW is complicated by the relatively complex anatomy, asymmetric biomechanical forces on the repair, and progressive nature of concomitant denervation injuries. Furthermore, the relative rarity and varied nature of these defects have complicated comparative analysis and the development of consensus regarding optimal surgical management. Although mesh reinforcement of LAW defects is a universal component of available repair techniques, significant variation exists regarding mesh material selection, anatomic plane utilization, and extent of mesh reinforcement. Special consideration must be given to extirpative defects that extend beyond the aforementioned boundaries of the LAW. In this review, we outline the incidence of LAW defects, pertinent risk factors, common history and physical examination findings, supplementary diagnostic modalities, defect classification systems, surgical indications, and available repair techniques. The outcomes data in this review are presented to help guide surgical management and optimize outcomes for affected patients.

Improving of long-term follow-up after cystocele repair

IntroductionThe anterior vaginal wall is the most common site of repair compared with apex and posterior vaginal wall, and is also the site with the highest recurrence rate after surgery. The aim of this study was to evaluate the anatomical location of apex in patients with cystocele staged 2–3 (POP-Q), to correct all anatomical defects and to improve cystocele repair results. Materials and methodsThis was a single-center prospective study of women with cystocele of stage 2–3 with and without apical prolapse who underwent combined surgical treatment. The authors performed combined surgical procedures in women with apical prolapse, including pectopexy. Clinical and anatomical follow-ups were carried out at least in 12 months. ResultsAll patients revealed good to excellent results, with a high rate of satisfaction. There were no significant differences in recurrence among women with and without apical prolapse. Of the 22 women after pectopexy, the only one had apical prolapse of grade 1. The median cystocele recurrence rate was 3.8% in group without apical prolapse (grade 1), and 4.5% (grade 1) in pectopexy group. Sexual matters, incontinence score and QoL were significantly improved in both groups. The main reason for cystocele low recurrence rate is defect-oriented multicompartment strategy in all cases including patients with and without apical defect. ConclusionPectopexy can be a good choice for prolapse surgery, including the positive effect in cases of lateral anterior wall defect. Using this strategy, it becomes possible to perform native tissue vaginal repair with encouraged long-term follow-ups.

Repair of Large Lateral Abdominal Wall Defect Post Resection of Abdominal Wall Sarcoma: A Paradigm

Repair of Large Lateral Abdominal Wall Defect Post Resection of Abdominal Wall Sarcoma: A Paradigm

Selection of internal fixation method for femoral intertrochanteric fractures using a finite element method.

BACKGROUNDFailure to fix unstable intertrochanteric fractures impairs return to daily activities.AIMTo simulate five different internal fixation methods for unstable proximal femoral fractures.METHODSA three-dimensional model of the femur was established from sectional computed tomography images, and an internal fixation model was established. Finite element analysis of the femur model was established, and three intertrochanteric fracture models, medial defect, lateral defect, and medial-lateral defects, were simulated. Displacement and stress distribution after fixation with a proximal femoral anti-rotation intramedullary nail (PFNA), integrated dual-screw fixation (ITN), PFNA + wire, PFNA + plate, and PFNA + wire + plate were compared during daily activities.RESULTSThe maximum displacement and stress of PFNA and ITN were 3.51 mm/473 MPa and 2.80 mm/588 MPa for medial defects; 2.55 mm/288 MPa and 2.10 mm/307 MPa for lateral defects; and 3.84 mm/653 MPa and 3.44 mm/641 MPa for medial-lateral defects, respectively. For medial-lateral defects, reconstructing the medial side alone changed the maximum displacement and stress to 2.79 mm/515 MPa; reconstructing the lateral side changed them to 3.72 mm/608 MPa, when both sides were reconstructed, they changed to 2.42 mm/309 MPa.CONCLUSIONFor medial defects, intramedullary fixation would allow early low-intensity rehabilitation exercise, and ITN rather than PFNA reduces the risk of varus and cut-out; for lateral wall defects or weakness, intramedullary fixation allows higher-intensity rehabilitation exercise, and ITN reduces the risk of varus. For both medial and lateral defects, intramedullary fixation alone will not allow early functional exercise, but locating lateral or medial reconstruction will. For defects in both the inner and outer sides, if reconstruction cannot be completed, ITN is more stable.

Assessing lateral uterine wall defects and residual myometrial thickness after cesarean section

ObjectiveLateral wall ruptures in women with a history of cesarean section are less common but more complicated than anterior wall ruptures. Residual myometrial thickness (RMT) is believed to be valuable for assessing the probability of ruptures. This study aimed to assess the utility of OmniView (a sonographic reslicing technique) in evaluating the lateral uterine wall after cesarean section and evaluate the relationship between lateral and anterior wall RMT using OmniView and sagittal two-dimensional ultrasound. Study designThis cross-sectional study examined changes in both the anterior and lateral uterine wall in women with a history of cesarean section in the past 12–18 months. OmniView with volume contrast imaging with a 2-mm slice thickness was used to generate coronal planes, and the OmniView RMT (OV-RMT) was calculated as a percentage. Blinded to the OV-RMT results, sonographic multiplanar views were used to acquire the optimum sagittal plane for evaluating the RMT, and the sagittal RMT (S-RMT) was calculated as a percentage. The reproducibility of OV-RMT and S-RMT between two observers was tested using interclass correlation (ICC). The relationship between two variables was tested using Spearman’s rank correlation. ResultsIn 208 recruited patients, the prevalence of lateral uterine wall defects was 79 %. The interobserver and intraobserver reproducibility of S-RMT and OV-RMT had ICC coefficients over 0.9 with a p-value <0.001. S-RMT and OV-RMT did not follow a normal distribution, and the medians were significantly different (55.5 and 85.7, respectively). Spearman’s rank correlation between OV-RMT and S-RMT had a rho (ρ) value of 0.24 (p < 0.05). Passing-Bablok regression had an intercept of 47.95 and a slope of 0.65. ConclusionOmniView can be used to assess lateral uterine wall defects, and OV-RMT is a reproducible and reliable method for quantifying this assessment. The RMT on the coronal plane was independently more intact than that on the sagittal plane, which might account for the lower incidence of lateral ruptures. Further studies could reveal a critical OV-RMT value that is safe for a trial of labor.

Precision in Oculofacial Surgery: Made-To-Specification Cast-Molded Implants in Orbital Reconstruction.

To describe the utilization of customized made-to-specification porous polyethylene implants and to evaluate clinical characteristics and outcomes of patients who received these implants for unilateral orbital defects. A retrospective review of 9 patients was performed. Three-dimensional surface models were generated from high-resolution computed tomography scans. Orbital constructs were modeled after the normal, contralateral orbits and mirrored across the vertical midline to generate the target orbital implant. Measured outcomes included globe position, extraocular motility, facial symmetry, and diplopia. Patients ranged 25-56 years old (mean: 37) and included 6 males and 3 females. Cases consisted of 6 orbital floor fractures due to trauma, 1 lateral wall defect after neurofibroma resection, 1 floor/medial wall defect after myxoma resection, and 1 superior orbital rim defect after intraosseous hemangioma resection. Seven patients had ≥1 prior repair. All patients had previous hard and soft tissue defects and varying degrees of restrictive globe motility. Patients exhibited improved ductions after implant placement and improved facial appearance and symmetry. Post-operatively, 1 patient was found to have a small orbital hematoma between the implant and orbital floor, resolving within weeks. Precision, personalized oculofacial surgery is the next wave in tailoring surgical care to the individual patient. Customizable implants are manufactured to specifically mold to an individual patient's unique bony architecture, which can lead to superior outcomes in reconstructing orbital and craniofacial bony defects. This technique is particularly useful in patients with prior unsuccessful repair.

Fetal Autopsy Showing Two Ventral Body Wall Defects: An Unusual Presentation

Thoracoschisis and gastroschisis are types of ventral body wall defects. Usually thoracoabdominoschisis presents as a continuous defect. Here the authors present the case of autopsy of 18 weeks old fetus with two well-separated ventral body wall defects. Thoracoschisis was a right lateral thoracic wall defect while gastroschisis, a midline infraumblical abdominal wall defect. Through the right lateral thoracic wall parts of two organs appeared to be protruding. On dissection, 8th and 9th ribs with the liver and the lower lobe of the right lung were herniating outside the body. The right lung was haemorrhagic. Various embryological theories on ventral body wall defects have been discussed in view of the present case.

Failure analysis of proximal femoral nail antirotation in treatment of geriatric intertrochanteric fractures

To analyze the failure factors of proximal femoral nail antirotation (PFNA) in the treatment of geriatric intertrochanteric fractures. The clinical data of 136 cases of intertrochanteric fracture treated with PFNA internal fixation between May 2015 and June 2017 were retrospectively analyzed. There were 106 males and 30 females, aged from 60 to 80 years, with an average age of 75.5 years. According to Evans-Jensen classification, there were 45 cases of type Ⅰ, 50 cases of type Ⅱ, 23 cases of type Ⅲ, 13 cases of type Ⅳ, and 5 cases of type Ⅴ. The time from injury to operation was 2-4 days, with an average of 3 days. According to the X-ray films before and after operation, the fracture types (stable and unstable), reduction quality (according to Baumgaertner's criteria), integrity of lateral wall and posteromedial cortex of the patients with failure of PFNA internal fixation were summarized, and the causes of failure were analyzed. All the 136 patients were followed up 7-18 months (mean, 13.6 months). There were 17 cases (12.5%) of PFNA internal fixation failure after operation, including 3 cases of stable fracture and 14 cases of unstable fracture; the quality of fracture reduction was excellent in 2 cases, good in 5 cases, and poor in 10 cases; 10 cases with complete lateral wall and 7 cases with defect; 9 cases with complete posteromedial cortex and 8 cases with defect. Reasons for failure of internal fixation: ① There were 8 cases of coxa varus at 12 weeks after operation due to the loss of posteromedial cortex of femoral intertrochanteric, 7 of them continued non-weight-bearing observation and fracture healed at 6 months after operation; 1 case underwent total hip arthroplasty with spiral blade excision after operation. ② There were 7 cases of internal fixation failure caused by lateral wall defect, including 2 cases of screw blade retraction, continued non-weight-bearing observation, and removed the internal fixator after fracture healing; 2 cases of malunion of rotation with the rotation of no more than 15°, fracture healed at 6 months after operation without special treatment; and 3 cases of rupture of lateral intertrochanteric wall during operation, continued non-weight-bearing observation and fracture healed at 6 months after operation. ③ The distal locking of the main screw was deviated in 2 cases during operation. One of them was found and replanted in time during operation, and 1 case was found with fracture of femoral shaft on 3 days after operation, following 1 year of non-weight-bearing observation and fracture ending healing. The types of intertrochanteric fractures (especially unstable fractures), the integrity of the proximal lateral wall of femur, and the defect of the posteromedial cortex are the internal risk factors for the success or failure of PFNA in the treatment of geriatric intertrochanteric fractures. The effective protection of the lateral wall during operation and the good quality of fracture reduction are the external factors that must be paid attention to.

A Combination Flap for Nasal Defect Reconstruction.

Nasal reconstruction is a common plastic surgery procedure following cancer resection. Whereas most small and medium defects are managed using standard local flaps, reconstructive options available for large defects of the nose such as a heminasal defect are very few. Most of the large defects are usually managed using a forehead flap, which involves at least 2 stages or using free tissue transfer. The author describes a combination flap that can be used for reconstruction of heminasal defects as well as lateral wall defects. A cheek advancement flap with the nasolabial flap incorporated in it as a combined flap was used for reconstructing heminasal defects and lateral wall defects in 11 patients. Four of the cases were following Mohs surgery for skin cancer, and others, primary reconstruction following wide excision of skin cancer. Five of the cases required cartilage support with or without lining, and others were skin-only defects. All were done as single-stage procedures. The cases were followed up over a period ranging from 6 to 18 months. There were no immediate complications in any of the cases, and all flaps survived completely. Assessment was done in terms of function, appearance, requirement for further procedures, and patient satisfaction. Outcome was deemed excellent in 8 patients. One patient had deviation of the nasal septum, and 2 patients had cheek scars in an unfavorable direction. The combination flap is a simple, single-stage procedure useful for reconstruction of heminasal and lateral wall defects. This technique is easily reproducible and provides consistently good results.

The medial femoral wall can play a more important role in unstable intertrochanteric fractures compared with lateral femoral wall: a biomechanical study

BackgroundThe major objective of the present study is to investigate the differences in the load and strain changes in the intertrochanteric region of human cadaveric femora between the loss of medial or lateral wall and after treatment with proximal femoral nail antirotation (PFNA).MethodsAfter measuring the geometry of the proximal femur region and modeling the medial or lateral wall defect femoral models, six pairs of freshly frozen human femora were randomly assigned in the medial or lateral wall group. According to a single-leg stance model, an axial loading was applied, and the strain distribution was measured before and after PFNA implantation. The strains of each specimen were recorded at load levels of 350, 700, and 1800 N and the failure load. Paired t test was performed to assess the differences between two groups.ResultsThe failure mode of almost all defect model femora was consistent with that of the simulated type of intertrochanteric fractures. After the PFNA implantation, the failure mode of almost all stabilized femora was caused by new lateral wall fractures. The failure load of the lateral wall group for defect model femora was significantly higher than that of the medial wall group (p < 0.001). However, the difference disappeared after the PFNA was implanted (p = 0.990). The axial stiffness in all defect model femora showed the same results (p < 0.001). After the PFNA implantation, the axial stiffness of the lateral wall group remained higher than that of the medial wall group (p = 0.001). However, the axial stiffness of the lateral wall group showed that the femora removed from the lateral wall were higher than the PFNA-stabilized femora (p = 0.020). For the axial strain in the anterior wall after the PFNA implantation, the strain of the lateral wall group was significantly lower than that of the medial group (p = 0.003). Nevertheless, for the axial strain of the posterior wall after the PFNA implantation, the strain of the medial wall group was significantly lower than that of the lateral group (p < 0.001).ConclusionsIn summary, this study demonstrated that PFNA is an effective intramedullary fixation system for treating unstable intertrochanteric fractures. Compared with the lateral wall, the medial femoral wall is a more important part in the intertrochanteric region. We suggest that in treating intertrochanteric femoral fractures with medial wall fractures, the medial wall fragment should be reset and fixed as much as possible.

Retrospective cohort study of combined approach for trunk reconstruction using arteriovenous loops and free flaps

Defect reconstruction of the trunk can be performed using microsurgical free flap transplantation. In cases of missing or inappropriate recipient vessels, microsurgical defect reconstruction of the trunk can be achieved by combining free flaps with arteriovenous loops. Here we present our 5-year experience of trunk reconstruction using AV loops and free flaps in a retrospective evaluation. We analyzed 32 cases of trunk reconstruction using a combined approach of free flap transplantation and arteriovenous loops between 2011 and 2016 regarding postoperative complications and perioperative course. Twenty-one patients suffered from sternal defects, 4 from presacral defects, 3 patients presented with lateral chest wall defects, 2 patients suffered from lumbosacral defects, 1 patient had a gluteal defect and 1 patient a defect at the clavicle. In all cases, free flap transplantation and arteriovenous loop creation were performed in a two-stage procedure. There were 8 thromboses of the arteriovenous loops with 4 flap failures. Only 1 flap loss was located in the sternal region, whereas one presacral flap and both lumbosacral flaps were lost. Reconstruction of large soft tissue defects of the trunk by a combined approach with an arteriovenous loop creation and consecutive free flap transplantation represents a reliable procedure in ventral and posterior cranial localization, whereas in the caudal posterior region, AV loop thrombosis can occur. Therefore, to minimize flap loss, a two-stage procedure should be performed.

Effect of acetabular tilt angle on acetabular version in adults with developmental dysplasia of the hip

To investigate the difference in acetabular tilt angle (ATA) between adults with deve-lopmental dysplasia of the hip (DDH) and normal adults and the effect of ATA on acetabular version. Between February 2009 and October 2015, 31 adult female patients with DDH (39 hips) (DDH group) and 31 female patients with osteoarthritis of the knee (31 hips) who had no history of hip disease (control group) were included in this study. The average age was 39 years (range, 18-59 years) in the DDH group, and was 69 years (range, 52-79 years) in control group. The morphometric parameters of the acetabulum including ATA, acetabular anteversion angle (AAA), acetabular inclination angle (AIA), acetabular cranial anteversion angle (ACAA), and acetabular sector angle (ASA) were mea- sured by CT reconstruction; The ASA was used as an index for acetabular coverage of the femoral head. The correlation between ATA and other parameters was analyzed using Pearson correlation analysis. The values of ATA, AAA, and AIA of the DDH group were significantly larger than those of the control group ( P<0.05). The ASA in all directions was significantly decreased in the DDH group when compared with the values in the control group ( P<0.05). There was no significant difference in ACAA between two groups ( t=1.918, P=0.523). The ATA was positively correlated with AAA and ACAA in the DDH group ( r=0.439, P=0.001; r=0.436, P=0.002), but there was no correlation between ATA and AIA ( r=0.123, P=0.308). In the control group, the ATA was not correlated with AAA, ACAA, and AIA ( r=-0.004, P=0.724; r=-0.079, P=0.626; r=-0.058, P=0.724). Regarding acetabular coverage of the femoral head, the ATA and AAA were correlated negatively with anterior ASA ( P<0.05) and positively with posterior ASA ( P<0.05), but had no correlation with superior ASA ( P>0.05) in the DDH group; AIA was correlated negatively with anterior ASA and superior ASA ( P<0.05) and had no correlation with posterior ASA ( r=-0.092, P=0.440). In the control group, there was no correlation between ATA and ASA in any direction ( P>0.05). In the DDH group, defects of the acetabular anterior wall, lateral wall, and posterior wall were observed in 18 hips (46.2%), 15 hips (38.5%), and 6 hips (15.3%), respectively. ATA value of the posterior wall defect [(15.70±10.00)°] was significantly smaller than those of the acetabular anterior wall and lateral wall defects [(22.91±5.06)° and (21.59±3.81) °] ( P<0.05), but no signficant difference was found between anterior wall and lateral wall defects ( P>0.05). ATA will influence acetabular version in DDH. The anterior rotation of the acetabular fragment during periacetabular osteotomies is an anatomically reasonable maneuver for hips with anterolateral acetabular defect, while the maneuver should be avoided in hips with posterior acetabular defect.

Indications for open procedures in the endoscopic era.

Endoscopic sinus surgery became the gold standard in inflammatory disorders of the nose and paranasal sinuses, in cerebrospinal fluid leak and epistaxis management, and established its efficacy in the oncology of the region. However, there are certain limitations which make an external approach mandatory. This article reviews the recent literature describing the cases where an open procedure is still indicated. Despite the evolution of endoscopic surgery external approaches are still indicated. Osteoplastic flap remains an option for the refractory inflammation of the frontal sinus. Benign and malignant tumours with lateral or superior extension, neurovascular involvement, and bony/soft tissue erosion usually require an external approach. Superior and lateral posterior wall defects of frontal sinus with cerebrospinal fluid leak may mandate an open procedure. Management of severe epistaxis may still necessitate in selected cases an external approach when endoscopic surgery fails and embolization setting is not available. Although advances in endoscopic instrumentation and techniques steadily decrease the indications for external approaches, they continue to have a role in the management of nasal disorders. This study summarizes the recent literature and provides a comprehensive review of the up-to-date remaining indications for open procedures in the nose and paranasal sinuses.