Prospective study of functional outcomes and return to sports after anterior cruciate ligament reconstruction in the knee.

PURPOSE: Individual factors of low rates of return to sport after anterior cruciate ligament (ACL) reconstruction were unclear. We evaluated the impact of various individual factors after ACL reconstruction for return to sport in athletes. METHODS: A prospective study was performed in 1274 athletes, who had undergone ACL autograft reconstruction. Individual factors survey about return to sport was performed during the second year after surgery. Athlete responses were analyzed with a multivariate logistic model adjusted for baseline patient characteristics and an adjusted Cox model. RESULTS: Younger age and involvement in higher-level sporting activities were associated with a significantly higher frequency and a significantly shorter time to return to sport (running, training, competition; p = 0.001 to 0.028). Men returned to sport more rapidly than women, for both training (p = 0.007) and competition (p = 0.042). Although there was no difference to return to sport between hamstring (HT) and patellar tendon (PT) autograft. We note that MacFL surgery (Mac Intosh modified with intra- and extra-articular autografts used the tensor fasciae latae muscle) was associated with a higher frequency (p = 0.03) and rapidity (p = 0.025) of return to training than HT. Sports people practicing no weight-bearing sports returned to training (p < 0.001) and competition (p < 0.001) more rapidly than other sports people. By contrast, the practicing pivoting sports with contact started running again sooner (p < 0.001). CONCLUSION: Younger age, male sex, higher level of sports, sportspeople practicing no weight-bearing sports, and MacFL surgery reduce time to return to sport after ACL reconstruction.

Lesion-directed screening to optimize skin cancer detection in dermatology practice: an observational study.

BACKGROUND: Early detection of skin cancer is still a major challenge in dermatology practice today. While surveillance programs are offered to high-risk patients, systematic total-body examination (TBE) in the general population is not cost-effective. In the past, we demonstrated that a lesion-directed screening (LDS) in the general population delivered similar detection rates to TBE and was less time-consuming. OBJECTIVES: To study whether a lesion-directed early-access consultation can optimize skin cancer detection in dermatology practice. METHODS: In this observational study, we offered an early-access consultation in patients contacting the dermatology department concerning 1 or 2 lesions of concern meeting predefined criteria. RESULTS: 342 persons were seen at the dermatology department after triage by phone. Skin cancer detection rate was 13.2% (4.1% for melanoma). If advised/referred by a doctor skin cancer detection rate was 23.6% (9% for melanoma). With a history of skin cancer, detection rate was 24.3% (4.3% for melanoma). In patients with no referral and a negative history of skin cancer, detection rate was 7.7% (1.7% for melanoma), which is at least triple the rates reported by population-based screening programs. In patients in whom the index lesion was benign, worry of having skin cancer had decreased significantly by the end of the consultation. Additional total-body examination in these patients had low additional detection rate (0.5%) and a high number of unnecessary excisions (number needed to excise 13). CONCLUSIONS: An early-access dermatology consultation for LDS after triage by phone resulted in high overall skin cancer and melanoma detection rates. Our data indicate that performing TBE is especially useful if the index lesion is suspicious. In addition to surveillance programs in high-risk patients, LDS may be a way to optimize skin cancer detection in the general population and use available time more efficiently in daily dermatology practice.

Evaluation kinaesthetic proprioceptive deficit after knee anterior cruciate ligament (ACL) reconstruction in athletes.

PURPOSE: The objective of this study was to evaluate kinaesthetic proprioceptive deficit after knee anterior cruciate ligament (ACL) reconstruction in two populations of athletes, those in the post-surgery period and those in re-training during the intensive program-training phase. METHODS: We performed a prospective study in ACL-operated athletes without previous knee injuries, with 32 athletes in each group. Time since surgery in the operated athletes in the post-surgery group was 21 to 35 days, and between three and 9 months in the re-training group. We also analysed a control group of 32 uninjured non-operated subjects with a similar sporting level. Proprioception was evaluated using the threshold to detection of passive motion (TDPM) test with Biodex-type isokinetic equipment comparing operated knees, non-operated knees and control uninjured non-operated group. The control group was tested twice, 1 day apart to control reproducibility, using the intraclass correlation coefficient (ICC). The p-value threshold for statistical significance between different groups in hypothesis testing was <.05. RESULTS: TDPM reproducibility was excellent (right knee: ICC = 0.80, left knee: ICC =0.72). We found a bilateral kinaesthetic deficit in post-surgery patients compared to the control group (p < 0.001 and p = 0.011), which was significantly higher on the operated side (p = 0.001). Re-training patients had no significant difference between operated and uninjured knees, but had a kinaesthetic deficit on operated limbs (p = 0.036) compared to the control group. CONCLUSION: There was a bilateral deficit in post-surgery athletes with a significant difference between injured and healthy knees, which could be explained by a change in the central nervous system. Compared to the control group, a proprioceptive deficit was only seen for re-training patients on the operated side and not in the healthy limb. Kinaesthetic recovery may be faster for the uninjured side as initial deficit is lower. Level of evidence II.

Graft failure is more frequent after hamstring than patellar tendon autograft.

PURPOSE: The risk of graft failure after anterior cruciate ligament (ACL) reconstructions with hamstring or patellar tendon was evaluated in a French population of athletes. METHODS: Athletes who had undergone ACL autograft reconstruction and who received rehabilitation care at the European Center for Sports Rehabilitation (CERS; Capbreton, France) were screened for this prospective cohort study. Eligibility criteria included a simple hamstring autograft or patellar tendon autograft surgical technique. Patients were contacted by phone to participate in follow-up during the second year after surgery. The primary endpoint was the graft failure frequency, evaluated with a multivariate logistic model with adjustment for baseline patient characteristics. The secondary endpoint was time to graft failure, analyzed by an adjusted Cox model. RESULTS: A total of 2424 athletes were included after having a hamstring autograft (semitendinosus and gracilis) or a patellar tendon autograft between 2011 and 2014. Of the 988 athletes who responded to a follow-up phone call (40.7% response rate), 33 were excluded for new contralateral ACL rupture (3.3%), with 955 included for analysis (713 hamstring autografts; 242 patellar-tendon autografts). There were no significant differences between the baseline characteristics of the patients analyzed and the population which did not respond to the questionnaire. A significant difference in the frequency of graft failure was seen, 6.5% for hamstring autografts vs 2.1% for patellar-tendon autografts [adjusted odds ratio (OR) = 3.64, 95% CI (1.55; 10.67); p = 0.007]. Mean time to graft failure was 10.7 vs 17.4 months for hamstring and patellar-tendon autografts respectively [adjusted hazard ratio (HR) = 3.50, 95% CI (1.53; 10.11); p = 0.008]. Age less than 25 years significantly increased the frequency of graft failure [adjusted OR = 3.85 (1.89; 8.72); p < 0.001]. The rate of patients returning to competitive sport after the first graft was not significantly different for the two techniques: 70.8% for hamstring and 77.8% for patellar tendon [adjusted OR = 0.718; 95% CI (0.50; 1.02)]. CONCLUSIONS: Graft failure is significantly more frequent after hamstring than patellar tendon autografts in a French population, despite similar rates of return to competition. Athletes aged less than 25 years have a higher risk of failure than those aged ≥ 25 years. Our results are in accordance with recent Scandinavian studies. LEVEL OF EVIDENCE: II.

Laser-assisted photodynamic therapy for superficial basal cell carcinoma and Bowen's disease: a randomized intrapatient comparison between a continuous and a fractional ablative CO2 laser mode.

BACKGROUND: Laser-assisted photodynamic therapy is being explored as a method to enhance efficacy of photodynamic therapy (PDT). OBJECTIVE: To compare a continuous (CL) and a fractional (FL) ablative CO2 laser-assisted methyl aminolevulinate (MAL) PDT in the management of superficial basal cell carcinoma (sBCC) and Bowen's disease (BD). METHODS: Thirty treatment areas in fifteen patients with inoperable, histologically verified sBCC or BD received CL or FL after intrapatient randomization. Laser treatment was followed by MAL application and illumination occurred 3 h later. This treatment was repeated after 2 weeks. An equivalence analysis was performed on the primary endpoint efficacy, while secondary endpoints pain, side-effects and aesthetics were evaluated using paired samples tests. Patients were also asked for their preferred treatment. RESULTS: An excellent efficacy of 92.9% (sBCC, 100%; BD, 80%) was found in both CL + PDT and FL + PDT after 12 months. Equivalence could not be established. Little pain was perceived in most patients during PDT illumination. PDT treatment in FL + PDT was less painful, significantly during the second treatment (P = 0.026). Side-effects were mild to moderate with erythema being the most frequent immediate side-effect, followed by oedema, crusting and burning sensation. Pigmentary changes occurred in 21% (CL + PDT) to 29% (FL + PDT), and aesthetics were good to excellent in all patients. CL + PDT and FL + PDT did not significantly differ in side-effects (P = 0.219-1.000) or aesthetics (P = 0.157-1.000). CONCLUSIONS: Results in this pilot study support the promising role of laser-assisted PDT. Both treatment arms demonstrated the same efficacy as well as comparable side-effects and aesthetics. PDT illumination was significantly less painful in the FL + PDT group, suggesting a preference for FL + PDT. The authors recommend further investigation with a larger sample size, a subgroup analysis between sBCC and BD and comparison of different treatment protocols before one technique could be preferred to another.

Critical appraisal of the oxidative stress pathway in vitiligo: a systematic review and meta-analysis.

BACKGROUND: The pathogenesis of vitiligo remains a topic of extensive debate. This is partly due to the moderate efficacy of current treatments. The role of the oxidative stress pathway in vitiligo is a popular although controversial research topic. OBJECTIVE: To clarify the role of the oxidative stress pathway in vitiligo compared to other inflammatory skin disorders and to assess the therapeutic role of antioxidants. METHODS: We conducted a systematic search of the existing literature on the aberrancies of the oxidative stress pathway in vitiligo. Subsequently, the efficacy of both topical and oral antioxidants in clinical trials was investigated. RESULTS: A deregulated oxidative pathway is clearly evident with elevated superoxide dismutase, decreased catalase and increased lipid peroxidation. However, similar results have been obtained in other inflammatory skin diseases such as psoriasis, atopic dermatitis, lichen planus and urticaria. This questions the unique role of oxidative stress in the development of vitiligo. Some isolated successes have been reported with oral ginkgo biloba, polypodium leucotomos and vitamin C and E preparations, while other clinical trials have failed to show reproducible results. The use of topical antioxidants delivers in general no beneficial results. CONCLUSION: The oxidative pathway is affected in vitiligo, but its unique initiating or contributory role in the pathogenesis is less evident. Interesting data support the added value of oral antioxidants in vitiligo although confirmatory studies are missing.

Nonablative fractional laser resurfacing for the treatment of scars and grafts after Mohs micrographic surgery: a randomized controlled trial.

BACKGROUND: Mohs micrographic surgery is a tissue sparing surgical technique for removal of skin cancer. To optimize the cosmetic result of scars and skin grafts after surgery non invasive procedures as non-ablative fractional laser (NAFL) resurfacing are attractive. OBJECTIVE: To evaluate efficacy and safety of 1540 nm NAFL in the treatment of scars and skin grafts after Mohs micrographic surgery. METHODS: An intra-individual randomized controlled trial (RCT) with split lesion design and single blinded outcome evaluations. Patients receive four treatments at monthly interval with NAFL [StarLux-300 with Lux 1540 nm fractional handpiece (Palomar technologies)]. Primary endpoint to evaluate efficacy is a blinded on site visual and palpable Physician Global Assessment (PhGA). Adverse event and pain registration are used to evaluate safety. Patient's global assessment (PGA) and skin reflectance measurements are secondary endpoints. RESULTS: The PhGA score comparing the treated to the untreated control side of 24 patients is significant different 1 (P = 0.009) and 3 (P = 0.001) months after treatment (Wilcoxon signed rank test). Patients experienced mild to moderate pain. Four days after the treatments patients reported erythema (67%), oedema (31%), crusts (22%), burning sensation (14%), purpura (9%) and vesicles (4%). No long term adverse events are reported. PGA is significant different 1 (P < 0. 001) and 3 months (P < 0. 001) after the last treatment. Skin reflectance do not show significant difference. CONCLUSION: This study shows that nonablative 1540 nm fractional laser is a safe and effective treatment for the improvement of scars and grafts after Mohs surgery.

New insights in segmental vitiligo: case report and review of theories.

Segmental vitiligo and generalized vitiligo are in general considered to be separate entities. The aetiopathogenesis of segmental vitiligo remains unclear, although several hypotheses have been put forward including mainly neuronal mechanisms. The typical association with other autoimmune diseases, as seen in generalized vitiligo, seems to be significantly less in segmental vitiligo, although recent insights point towards a possible immune-mediated overlap between the two subtypes. In this article, we describe a case with simultaneous presence of segmental vitiligo, alopecia areata, psoriasis and a halo naevus. To our knowledge, this is the first case with this exceptional combination. This concomitant presence could support the involvement of a shared autoimmune-mediated process, and may provide new insights into the pathogenesis of segmental vitiligo and direct future research. In the light of this remarkable case, different possible aetiopathogenetic mechanisms leading to the clinical presentation of segmental vitiligo are discussed and a new three-step theory is proposed.

Intrapatient comparison of 308-nm monochromatic excimer light and localized narrow-band UVB phototherapy in the treatment of vitiligo: a randomized controlled trial.

BACKGROUND: Limited data are available about the use of 308-nm monochromatic excimer light (MEL) and localized 311-nm narrow-band ultraviolet B (NB-UVB) in the treatment of vitiligo. The aim of this study was to evaluate the efficacy of 308-nm MEL versus localized 311-nm NB-UVB in vitiligo patients. METHODS: Eleven patients participated in this prospective intrapatient placebo-controlled randomized trial. In each patient, 3 lesions were selected and treated with NB-UVB, MEL and placebo during 24 sessions, respectively. Repigmentation was evaluated clinically and by objective surface measurement. RESULTS: Twenty percent of the lesions treated with NB-UVB achieved repigmentation scores above 50%. None of the lesions treated with MEL achieved a repigmentation higher than 50% after 24 sessions. CONCLUSION: Localized 311-nm NB-UVB is effective in the treatment of vitiligo. It should be considered for localized vitiligo as it is easily accessible. In this study the efficacy of localized 311-nm NB-UVB was superior to 308-nm MEL.

Multicentre intraindividual randomized trial of topical methyl aminolaevulinate-photodynamic therapy vs. cryotherapy for multiple actinic keratoses on the extremities.

BACKGROUND: Methyl aminolaevulinate-photodynamic therapy (MAL-PDT) is an effective treatment in facial/scalp actinic keratosis (AK). OBJECTIVES: The aims of this study were to compare efficacy, safety, cosmetic outcome and patient preference of MAL-PDT vs. cryotherapy in patients with AK at other locations. METHODS: A multicentre, controlled, randomized, open, intraindividual, right-left comparison was performed. Patients with nonhyperkeratotic AK were treated once with MAL-PDT and cryotherapy on either side of the body. At week 12, lesions showing noncomplete response were retreated. The primary efficacy variable was the lesion response at week 24. Investigator's assessment of cosmetic outcome, patient's preference in terms of cosmetic outcome and a patient preference questionnaire were also analysed at week 24. RESULTS: In total, of 121 patients with 1343 lesions (98% located on the extremities and the remainder on the trunk and neck) were included. Both treatments provided a high mean percentage reduction in lesion count at week 24 with significantly higher efficacy for cryotherapy: 78% for MAL-PDT and 88% for cryotherapy (P=0.002, per protocol population). Investigator's assessment of cosmetic outcome was significantly better for MAL-PDT than cryotherapy (P<0.001), 79% of lesions having an excellent cosmetic outcome with MAL-PDT vs. 56% with cryotherapy at week 24. The cosmetic outcome achieved by MAL-PDT compared with cryotherapy was also preferred by patients (50% vs. 22%, respectively, P<0.001), and 59% of patients would prefer to have any new lesions treated with MAL-PDT compared with 25% with cryotherapy (P<0.001). Both treatment regimens were safe and well tolerated. CONCLUSIONS: MAL-PDT showed inferior efficacy for treatment of non-face/scalp AK compared with cryotherapy. However, both treatments showed high efficacy, and MAL-PDT conveyed the advantages of better cosmesis and higher patient preference.

Early treatment of hemangiomas with lasers. A review.

Hemangiomas can present a difficult problem in management. Much controversy exists over whether it is better to watch and wait for natural involution or to be more aggressive and attempt to prevent some of the potential negative sequelae. Different modalities have been employed in the treatment of hemangiomas, including systemic therapy - antiangiogenic drugs, i.e. systemic corticosteroids and alpha-interferon - and local therapy - surgical procedures, arterial embolization and cryotherapy. Overall, a very conservative approach to therapy has been recommended because of treatment risks, treatment inadequacy and lack of evidence showing superiority over natural involution. Recently laser treatment has been used in the therapeutic approach of hemangiomas. This review discusses the pros and contras of early laser treatment of hemangiomas. For superficial hemangiomas, the flashlamp pumped pulsed dye laser in particular has proven itself in numerous studies. In the treatment of hemangiomas with subcutaneous components, the Nd:YAG laser is the treatment of choice.

Diagnostic ability of general practitioners and dermatologists in discriminating pigmented skin lesions.

BACKGROUND: Early recognition of melanoma is the key in preventing metastatic disease. OBJECTIVE: The aim of this study was to evaluate diagnostic ability of general practitioners (GPs) and dermatologists concerning pigmented skin lesions in general and melanoma in particular. We also investigated whether the diagnostic ability of GPs changed after a lecture on melanoma. METHODS: A test set of 13 pigmented skin lesions on 35-mm color slides was presented to 160 GPs and 60 dermatologists during educational courses. RESULTS: GPs correctly evaluated biologic behavior of the pigmented skin lesions in 72% of the evaluations. In 71% of these evaluations they correctly identified the lesions. The proportion of lesions correctly identified was positively correlated with the frequency of pigmented skin lesions in everyday practice. Dermatologists made a correct identification of the lesions in 88% of all evaluations, and they correctly evaluated biologic behavior in 94% of these. Recognition of melanoma was proportional to melanoma exposure in everyday practice. Thick melanomas were better recognized than thin melanomas in both physician groups. After a lecture on melanoma, sensitivity of GPs to recognize malignant disease increased from 72% to 84%, without a significant decrease in specificity. The proportion of lesions correctly identified also rose significantly (66% vs 52%).

Time delays and related factors in the diagnosis of cutaneous melanoma.

Delay in melanoma diagnosis was investigated in a population-based sample of 130 patients. The median time elapsing from the first notice of the lesion to excision was 110.5 days. There was no linear correlation between total delay time and Breslow-thickness of the diagnosed melanomas (P=0.19). Patient delay, defined as the time from first notice of a (change in a) lesion to the first observation by a physician, exceeded 2 months in half of all patients. Only 41% of the patients consulted a doctor because they were worried about the lesion. Colour change and itch were associated with a longer patient delay. There was no correlation with age, gender, socio-economic factors, localisation of the lesion and the person who first noticed the lesion. In one quarter of all patients, the time from first observation by a physician to excision of the lesion exceeded 2.5 months. This physician delay seemed to be attributed to misdiagnosis and to a delay occurring during referral.

Current guidelines in melanoma treatment. Melanoma Working Group of Gent and Bordet.

This article focuses on the actual management of cutaneous melanoma, dealing both with established, internationally well-accepted standard procedures and interventions which are still being investigated. It wants to offer a global picture to the dermatologist of what is currently available in the therapeutic arsenal against melanoma.

Pyoderma gangrenosum as an early revelator of acute leukemia.

Bullous pyoderma gangrenosum is an atypical, more superficial variety of the classical pyoderma and is often associated with myeloproliferative disorders. We present the case of a patient who presented initially with subcutaneous nodules and who developed bullous lesions afterwards. Histological evaluation showed the presence of neutrophilic infiltrates in both lesions. A few months after the diagnosis of bullous pyoderma gangrenosum, an underlying leukemia was revealed. Our case illustrates the importance of regular blood and bone marrow examinations in patients with atypical bullous pyoderma gangrenosum, resulting in a rapid diagnosis of the underlying disease.

Under-registration of melanoma in Belgium: an analysis.

The overall underestimation of incident cancer cases in the Belgian National Cancer Registry is estimated at about 20-25%, with a probable larger under-registration among males. Melanoma incidence is suspected to be underestimated even further because of the hospital-based reporting system of the National Cancer Registry. To investigate the suspected underestimation of melanoma in Belgium, the official data were compared with international data on melanoma incidence and the results of a melanoma registration programme launched in the province of East Flanders. The Eindhoven Cancer Registry, which covers a registration area near the Belgian border, was used as a reference to calculate the expected number of melanomas in East Flanders for 1995. The results indicate an ongoing under-registration of melanoma cases by the National Cancer Registry. Based on the Eindhoven Cancer Registry data, the under-registration in East Flanders is estimated at 43% for males and 36% for females. The East Flanders registration programme apparently obtains a better registration in females. This is mainly due to a higher registration in the younger age groups. In these groups a higher proportion of in situ melanomas and a thinner median Breslow thickness of the invasive melanomas is observed.