Lower-Limb Salvage Procedure using Anterolateral Thigh Free Flap and Multiple Tendon Grafts in a Road Injury Patient: A Case Report.

Introduction: The free anterolateral thigh (ALT) flap is commonly used to repair a large loss of soft tissue following a lower-limb injury. An issue to be managed is the choice of adequate recipient vessels when the tibial arteries result damaged. In this scenario, vein grafts can be interposed to connect a healthy recipient vessel to the ALT flap pedicle. Case Report: We present a report of a 19-year-old male who suffered a Gustilo fracture type IIIc after a road injury involving the right lower limb. After a failed first attempt of limb salvage with reconstruction of extensor tendons and a free ALT flap, a second procedure was performed using another ALT flap with interposed vein grafts to reach very proximal recipient vessels. Results: The patient demonstrated excellent recovery and restored ambulation. The effectiveness of the most complex reconstructive options for a high-demanding patient with no comorbidities is demonstrated in this case. Conclusion: The key to success in even the most complex injury cases is early intervention, meticulous surgical planning, and a multidisciplinary approach.

Evaluating Arterialized Vein in Thumb Replantation using Indocyanine Green Angiography: A Case Report.

BACKGROUND The absence of valid vessels for the anastomosis constitutes a contraindication to replantation, but the need for arterial vessels in good condition has recently been questioned and some authors have proposed the arterialization of the veins with promising results. However, this method is not routine in replantation and it is unclear what conditions can establish venous congestion and loss of the replanted segment. CASE REPORT We detail a case where indocyanine green aids in evaluating arterialization of a vein during thumb replantation in a 40-year-old smoker following a crush injury. Multiple attempts to anastomose the princeps pollicis and its collateral vessel failed due to a thrombus formation, leaving the finger non-perfused despite urokinase treatment. To confirm the absence of reperfusion, we administered 0.3 mg/kg of indocyanine green through an upper limb peripheral vein. Observing no reperfusion, we located a suitable radial dorsal vein and performed an arteriovenous anastomosis at the proximal phalanx level. Indocyanine Green Angiography (IGA) revealed a slightly delayed reperfusion but a effective venous outflow. We did not consider it necessary to perform additional venous anastomoses other than the single dorsal radial venous anastomosis. CONCLUSIONS This single case report shows the potential of indocyanine green as a valid aid to evaluate the perfusion of the replantation and also any early venous congestion, being able to modify the operative plan accordingly.

Novel Mini-Invasive Surgical Technique for Treating Fifth Metacarpal Neck Fractures: A Case Report.

BACKGROUND Fracture of the fifth metacarpal of the hand is due to trauma to the clenched fist. The non-displaced fracture can be treated by splinting and immobilization, but fracture dislocation requires individualized management to ensure the return of function. The Jahss maneuver for reduction of volar displaced metacarpal neck fractures involves flexion of the metacarpophalangeal and proximal interphalangeal joint at 90°, with the proximal phalanx used to reduce the metacarpal head. This report is of a 25-year-old male Italian pianist with a displaced fifth metacarpal neck fracture successfully treated by reduction using the Jahss maneuver and K-wire attachment of subchondral bone to the metacarpal. CASE REPORT A pianist presented with a trauma to his right hand due to punching a wall. Radiograph images demonstrated an angulated, displaced right fifth neck fracture. A specific approach was decided, considering the complexity of the musical movements and the patient's performance needs. After fracture's reduction by the Jahss maneuver, 2 retrograde cross-pinning K-wires were inserted at the subchondral bone of the metacarpal head. Healing under splinting was uneventful, and the K-wires were removed after 45 days. At 4 months after surgery, the patient had complete recovery of both range of motion and strength. CONCLUSIONS Our technique avoided piercing the metacarpophalangeal joint capsule, preventing extensor tendon damage, dislocation, instability, and pain and retraction of the extensor cuff. This novel mini-invasive technique successfully achieved early metacarpophalangeal joint motion, joint stability, and complete recovery of movements in all planes.

The Empire Strikes Back: A Chemical Warfare Burn 100 Years after the First World War Ending.

During the First World War, the territories that constituted the front line in North East Italy were the theaters of intense shelling. The military tactics of the time involved the use not only of conventional ammunition but also of special ammunition containing asphyxiating and blistering compounds. However, the technology of the time did not guarantee a high explosion rate, leaving a considerable quantity of unexploded material on the ground. Although more than 100 years have passed since the end of the Great War, it is still common to find unexploded ordnance in the areas that were the site of combat. The demining campaign is still underway by the bomb squad of the Italian army with the medical support of the Military Corps of the Italian Red Cross. This case report reports the case of a young patient who came into contact with a vesicant chemical bomb along the Piave River and was subsequently admitted to the Major Burns Center of the Padua Hospital, where he was treated until full recovery. Although it is a rather rare eventuality, experiences like this provide the opportunity for the admitting surgeon to promptly and competently manage patients exposed to chemical warfare.

Traumatic peripheral nerve injuries: a classification proposal.

BACKGROUND: Peripheral nerve injuries (PNIs) include several conditions in which one or more peripheral nerves are damaged. Trauma is one of the most common causes of PNIs and young people are particularly affected. They have a significant impact on patients' quality of life and on the healthcare system, while timing and type of surgical treatment are of the utmost importance to guarantee the most favorable functional recovery. To date, several different classifications of PNIs have been proposed, most of them focusing on just one or few aspects of these complex conditions, such as type of injury, anatomic situation, or prognostic factors. Current classifications do not enable us to have a complete view of this pathology, which includes diagnosis, treatment choice, and possible outcomes. This fragmentation sometimes leads to an ambiguous definition of PNIs and the impossibility of exchanging crucial information between different physicians and healthcare structures, which can create confusion in the choice of therapeutic strategies and timing of surgery. MATERIALS: The authors retrospectively analyzed a group of 24 patients treated in their center and applied a new classification for PNI injuries. They chose (a) five injury-related factors, namely nerve involved, lesion site, nerve type (whether motor, sensory or mixed), surrounding tissues (whether soft tissues were involved or not), and lesion type-whether partial/in continuity or complete. An alphanumeric code was applied to each of these classes, and (b) four prognostic codes, related to age, timing, techniques, and comorbidities. RESULTS: An alphanumeric code was produced, similar to that used in the AO classification of fractures. CONCLUSIONS: The authors propose this novel classification for PNIs, with the main advantage to allow physicians to easily understand the characteristics of nerve lesions, severity, possibility of spontaneous recovery, onset of early complications, need for surgical treatment, and the best surgical approach. LEVEL OF EVIDENCE: according to the Oxford 2011 level of evidence, level 2.

Retrospective Analysis of Predictive Factors for Complications in Abdominoplasty in Massive Weight Loss Patients.

INTRODUCTION: Ex-obese patients present with redundancy of abdominal skin and soft tissue due to massive weight loss (MWL). The plastic surgeon can restore the body shape through body contouring procedures. Hence the need to adequately direct patients to body contouring by identifying suitable candidates exists. Our work aims to retrospectively analyze the abdominoplasty complications in our case series to identify associated risk factors and evaluate the effect of combined procedures on abdominoplasty outcomes. MATERIALS AND METHODS: We retrospectively investigated predictive factors of abdominoplasty procedure complications on 213 MWL patients who received abdominoplasty with and without rectus sheath plication, abdominal liposuction, and other body contouring procedures. We identified risk and protective factors with univariate and multivariate regression analysis. Furthermore, we assessed the impact of additional procedures on the complication rates. RESULTS: The overall complication rate was 49.8% (26.8% minor complications; 23% major complications). The delayed wound healing rate was 27.7%, and the revision surgery rate was 25.8% (14.7% early revision; 14.2% late revision). These results were compared with literature reports. Several negative predictors emerged as non-modifiable (advanced age, diabetes mellitus, surgical mode of weight loss) or modifiable (preoperative obesity and body mass index (BMI); active smoking; preoperative anemia; use of fibrin glue or quilting sutures). Performing rectus sheath plication improved most of the outcomes. Liposuction of hypochondriac regions and flanks led to increased safety and reduced the risk of surgical dehiscence and delayed wound healing, in contrast to epimesogastric liposuction. The other combined body contouring procedures did not worsen the outcomes, except for poor scarring. CONCLUSION: Our findings encourage us to continue associating rectus sheath plication, liposuction, and other body contouring surgeries with abdominoplasty. We emphasize the importance of proper patient selection, particularly with regard to anemia, before body contouring surgery in the interests of offering safe surgery and satisfactory results. Further studies are needed to investigate how the optimal BMI cut-off and abstinence from smoking (in terms of time) before surgery reduce postoperative complications. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/journal/00266 .

Topography of the deep branch of the ulnar nerve between genders: a cadaveric study with potential clinical implications.

The lack of meticulous knowledge concerning the topographical anatomy of the deep branch of the ulnar nerve (DUN) may pose difficulties, leading to a delay or a misdiagnosis of a DUN injury. Identification of the DUN is quite difficult without precise anatomical landmarks as reference points. The current study investigates the topography of the DUN between genders, taking as a reference point a well-known landmark, the Kaplan line, used in hand surgery for carpal tunnel release. Twenty-two (15 males and 7 female) fresh frozen adult cadaveric hands were dissected by using magnifying loupes (3.5 and 5.0 x). We marked values proximal to the Kaplan line as positive (+), while we marked distal ones as negative (-). The mean distance DUN-Kaplan line was 1.69 ± 4.45 mm. In male hands, the mean distance was 4.17 ± 1.88 mm, distal to the Kaplan line, while in females, the mean distance was -4.92 ± 0.69 mm proximal to the Kaplan line. Gender dimorphism was detected, with higher statistically significant values in male hands (p = 0.001). Cadaveric studies of the DUN topography, course, and distribution pattern are uncommon. The current study provides an accurate description of the DUN topography, taking the Kaplan line as a reference point, emphasizing gender differences. The DUN is located distally in males and proximally in females. Knowledge of these predictable anatomical relations may help hand surgeons intraoperatively when dealing with a DUN lesion, because of hand trauma or during the decompression of the DUN.

Reverse posterior interosseous flap: different approaches over the years - A systematic review.

The posterior interosseous flap (PIOF), as fasciocutaneous flap, represents an interesting option in reconstructive surgery of the upper limb. The PIOF allows coverage of losses of substance of the dorsal side of the hand and, with technical modifications, up to the proximal interphalangeal (PIP) joint without any need of microsurgical technique or the sacrifice of the main vascular axes for the hand. Its dimensions can reach up to 22 cm x12 cm and have excellent versatility since it can incorporate vascularized bone grafts and tendon grafts for complex substance losses. Despite the above-mentioned advantages, among the factors that limit its diffusion, indeed, there is the complex dissection technique originally described. Several authors also report a variable incidence of venous congestion, attributing it to the reverse flow vascularity of the flap. However, in the hands of experienced surgeons, this flap has a negligible incidence of complications. For these reasons, the authors performed a systematic review of the literature to organize the various technical updates over the years to extend the indications of the PIOF and reduce the incidence of complications, thus providing a valuable tool for reconstructive surgeons.

Xeroderma Pigmentosum: A Genetic Condition Skin Cancer Correlated-A Systematic Review.

Background: Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder of UV radiation-induced damage repair that is characterized by photosensitivity and a propensity for developing, among many others, skin cancers at an early age. This systematic review focused on the correlation between the clinical, pathological, and genetic aspects of XP and skin cancer. Methods: A systematic review was conducted through a literature search of online databases PubMed, Cochrane Library, SciELO, and Google Scholar. Search terms were "Xeroderma pigmentosum", "XP", "XPC", "Nucleotide excision repair", "NER", "POLH", "Dry pigmented skin", and "UV sensitive syndrome" meshed with the terms "Skin cancer", "Melanoma", and "NMSC". Results: After 504 abstracts screening, 13 full-text articles were assessed for eligibility, and 3 of them were excluded. Ten articles were selected for qualitative assessment. Conclusions: Patients with XP usually suffer shorter lives due to skin cancer and neurodegenerative disease. Deletion/alteration of a distinct gene allele can produce different types of cancer. The XPC and XP-E variants are more likely to have skin cancer than patients in other complement groups, and the most common cause of death for these patients is skin cancer (metastatic melanoma or invasive SCC). Still, aggressive preventative measures to minimize UV radiation exposure can retard the course of the disease and improve the quality of life.

Acute Calcium Pyrophosphate Crystal Arthritis of the Wrist Elicited by Anti-COVID-19 Vaccination After Carpal Tunnel Release.

BACKGROUND Calcium pyrophosphate dihydrate deposition disease includes a variety of clinical syndromes, including acute calcium pyrophosphate (CPP) crystal arthritis. Most patients with CPP crystal arthritis have a primary/idiopathic form presenting with severe pain, swelling, and stiffness. COVID-19 infection, which originated in China in December 2019, required extraordinary efforts to develop and test new vaccines to halt the pandemic. The Vaxzervria vaccine has shown excellent safety and efficacy in phase 3 trials with a mechanism based on the expression of the SARS-CoV-2 spike protein gene coding for the S-antigen, which stimulates the immune response. CASE REPORT We describe an acute event of crystal arthritis after a carpal tunnel syndrome release followed by administration of the second dose of anti-COVID-19 Vaccine Oxford-AstraZeneca (ChAdOx1 nCoV-19). Medical treatment resulted in full resolution of the symptoms in 2 weeks. CONCLUSIONS Although most episodes of acute arthritis happen spontaneously, certain factors may trigger the acute CPP crystal arthritis such as intercurrent illnesses or surgeries. Although the association between carpal tunnel syndrome and CPP arthritis has been known for over 40 years, surgical release of the carpal ligament has always been associated with full resolution of symptoms. This is the first case report describing an exacerbation after carpal canal release, concomitant with the administration of the vaccine. According to our opinion, the vaccination associated with a prior surgery in the same anatomical site could have synergically triggered the arthritis flare-up, in a predisposed patient, with a mechanism still unknown.

Physical fitness changes induced by thermal aquatic standardized exercise in chronic venous disease patients.

BACKGROUND: Lack of physical activity represents a risk factor for both cardiovascular and chronic venous diseases (CVD), nevertheless a specific exercise protocol for CVD patient is still missing. This investigation was aimed to assess the impact of a standardized exercise protocol in a thermal water environment on physical fitness and quality-of-life (QoL) in CVD patients. METHODS: Sixteen (16) CVD patients performed 5 standardized exercise sessions in a thermal water pool. Before starting the exercise protocol, the cohort filled International Physical Activity Questionnaire (IPAQ) to determine their physical activity level. At baseline and at the end of the exercise program, leg volume, QoL, musculoskeletal and cardiovascular physical fitness were assessed by means of water plethysmography, validated questionnaire and functional test, blood pressure and heart rate at rest were also reported. RESULTS: All the patients were categorized as physically inactive: average activity time 235.6 (155.2) MET-minutes per week. At the end of the study, a significant leg volume reduction was found (-16%; p < .002). Significant improvement in lower limb strength (p < .0001), endurance (p < .006), rapidity and balance (p < .05) together with decrease in resting heart rate (-1.8%, p < .0001) and systolic blood pressure (-1.1%, p < .04) were reported, significant improvement in bodily pain (p < .0005) and social function (p < .002) QoL items were observed. CONCLUSIONS: The proposed exercise protocol in thermal aquatic environment demonstrated to be an effective treatment modality improving both cardiovascular and musculoskeletal outcomes and QoL in sedentary CVD patients. Aquatic environment investigations require proper analysis of the various factors involved, in a standardized and reproducible way. The herein report can be a reference for further studies on different health related conditions.

Lumbrical Muscles Neural Branching Patterns: A Cadaveric Study With Potential Clinical Implications.

BACKGROUND: Lumbrical muscles originate in the palm from the 4 tendons of the flexor digitorum profundus and course distally along the radial side of the corresponding metacarpophalangeal joints, in front of the deep transverse metacarpal ligament. The first and second lumbrical muscles are typically innervated by the median nerve, and third and fourth by the ulnar nerve. A plethora of lumbrical muscle variants has been described, ranging from muscles' absence to reduction in their number or presence of accessory slips. The current cadaveric study highlights typical and variable neural supply of lumbrical muscles. MATERIALS: Eight (3 right and 5 left) fresh frozen cadaveric hands of 3 males and 5 females of unknown age were dissected. From the palmar wrist crease, the median and ulnar nerve followed distally to their terminal branches. The ulnar nerve deep branch was dissected and lumbrical muscle innervation patterns were noted. RESULTS: The frequency of typical innervations of lumbrical muscles is confirmed. The second lumbrical nerve had a double composition from both the median and ulnar nerves, in 12.5% of the hands. The thickest branch (1.38 mm) originated from the ulnar nerve and supplied the third lumbrical muscle, and the thinnest one (0.67 mm) from the ulnar nerve and supplied the fourth lumbrical muscle. In 54.5%, lumbrical nerve bifurcation was identified. CONCLUSION: The complex innervation pattern and the peculiar anatomy of branching to different thirds of the muscle bellies are pointed out. These findings are important in dealing with complex and deep injuries in the palmar region, including transmetacarpal amputations.

Studying nerve transfers: Searching for a consensus in nerve axons count.

Axonal count is the base for efficient nerve transfer; despite its capital importance, few studies have been published on human material, most research approaches being performed on experimental animal models of nerve injury. Thus, standard analysis methods are still lacking. Quantitative data obtained have to be reproducible and comparable with published data by other research groups. To share results with the scientific community, the standardization of quantitative analysis is a fundamental step. For this purpose, the experiences of the Italian, Austrian, German, Greek, and Iberian-Latin American groups have been compared with each other and with the existing literature to reach a consensus in the fiber count and draw up a protocol that can make future studies from different centers comparable. The search for a standardization of the methodology was aimed to reduce all the factors that are associated with an increase in the variability of the results. All the preferential methods to be used have been suggested. On the other hand, alternative methods and different methods have been identified to achieve the same goal, which in our experience are completely comparable; therefore, they can be used indifferently by the different centers according to their experience and availability.

Nodular fasciitis of the anterior chest wall mimicking myxofibrosarcoma: A case report and literature review.

Nodular fasciitis is a benign tumor of soft tissues originating from the proliferation of fibroblasts and myofibroblasts, generally developing between the subcutaneous tissue and the underlying muscular layer. Nodular fasciitis predominantly localizes in the upper extremities, trunk, head and neck. Biomolecular and immunohistochemical analyses result essential to demonstrate the benign origin of the process, also confirmed by very low recurrence rate after complete excision, which represents the gold standard for treatment. We report the case of a 36 years-old man who developed a nodular protuberance clinically evident in the upper-left side of the thorax. We further, highlight the main characteristics of this rare neoplasm trough a thorough review of the literature.

The Use of a Hypoallergenic Dermal Matrix for Wrapping in Peripheral Nerve Lesions Regeneration: Functional and Quantitative Morphological Analysis in an Experimental Animal Model.

INTRODUCTION: The aim of this research was to test, in an animal model, the nerve regeneration technique with a hypoallergenic acellular dermal matrix used to wrap the microsurgical neural suture. MATERIALS AND METHODS: Two groups of rats received the cut of limb right median nerves. The regeneration technique considers for both groups an end-to-end nerve suture. In the experimental group (A) was used also a wrapping protocol by a conduit of collagen matrix currently used in oral surgery. The animals underwent functional grasping tests (at 1, 3, 5, and 7 months) and a histological and quantitative analysis of distal nerve was performed at the end of experimental time. RESULT: After seven months, the grasping test reveals functional recovery in each tested animal; this improvement is more evident in Group A. The fibers appear well organized with restored myelin sheaths in both groups. Group A showed a great quantity of connective tissue surrounding the nerve. The quantitative morphology analysis in both groups shows a similar fibers density, fiber diameter, and myelin thickness. The differences between the groups in axon mean diameter are significant. In Group A M/d, D/d, and g-ratio is significantly higher compared to control group. CONCLUSIONS: Histological and functional assessments show a functional recovery of the injured nerve in the test groups, stressed by the results of the grasping tests and the meaningful increasing in fiber diameter and higher g-ratio. Moreover, a connective tissue cuff distinguishes the distal portion of the injured nerve. Considering the easy availability and handling of the material used in this study we can conclude that this experimental technique can be considered as a valid alternative to protect nerves in nerve wrap surgery.

Anterolateral Thigh Flap in a Chicken Model: A Novel Perforator Training Model.

BACKGROUND: Preclinical training in perforator flap harvesting is typically conducted on living animal models; however, repeated training is not possible with these models because of ethical and/or economical constraints. We describe an anterolateral thigh flap (ALT flap) training model using chicken thigh that seems to be an appropriate training model prior, for example, to raise a perforator flap in a living rat or swine model. METHODS: A total of 10 chicken legs were used in this study. Six chicken legs were anatomically dissected to confirm the presence of the perforator and to identify the main vascular tree. In four chicken legs, a skin flap was planned based on the perforator and intramuscular dissection was performed under magnification. RESULTS: The perforator was identified in all dissections and was consistently found 3 cm above the line extending from the patella to the head of the femur in its third proximal. Proximally, the mean diameter of the artery and vein was 0.56 (σ = 0.04) and 0.84 (σ = 0.06) mm, respectively. The mean dissection time to raise the flap was 88 (σ = 7) min. CONCLUSION: This is the first description of a nonliving biological simulation model for training in perforator flap dissection that mimics an ALT flap. As an ex vivo chicken model, it is a cost effective and readily accessible model suitable for repeated practice.