Interlocking horizontal mattress suture versus Kakiuchi technique in repair of Achilles tendon rupture: a biomechanical study.

BACKGROUND: In recent years, the type of surgical treatment for Achilles tendon rupture has been the subject of controversial debate. This biomechanical study evaluates for the first time in literature the ultimate failure load (UFL) of interlocking horizontal mattress (IHM) suture as compared with Kakiuchi suture in Achilles tendon rupture. The hypothesis is that IHM suture can be performed also for Achilles tendon rupture and ensures higher resistance compared with the traditional Kakiuchi suture. MATERIALS AND METHODS: Twenty fresh bovine Achilles tendons were obtained. Ten preparations were randomly assigned to each of two different groups: group A (10 specimens) sutured by IHM technique, and group B (10 specimens) sutured by Kakiuchi technique. Each construct was mounted and fixed on a tensile testing machine. Static preconditioning of 50 N was applied for 5 min as initial tensioning to stabilize the mechanical properties of the graft, then a load to failure test was performed at crosshead speed of 500 mm/min. RESULTS: Ten specimens were tested for each group. The mean UFL was 228.6 ± 98.6 N in the IHM suture group and 96.57 ± 80.1 N in the Kakiuchi suture group. Statistical analysis showed a significant difference (p < 0.05) with better UFL in the IHM group. In both groups, the failure mode registered in each specimen was suture breakage (rupture of suture thread). CONCLUSIONS: IHM suture achieved better UFL compared with Kakiuchi suture in an animal model of Achilles tendon repair. These results seem to support IHM as a valid option in Achilles tendon rupture.

Treatment of a Femur Nonunion with Microsurgical Corticoperiosteal Pedicled Flap from the Medial Femoral Condyle.

Introduction. The vascularized corticoperiosteal flap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. This flap is usually harvested as a free flap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. The first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. We considered union to have occurred 3.5 months after surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfied with the procedure. Discussion. The corticoperiosteal flap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled flap graft is a reliable and effective treatment for distal femur nonunion.

The mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction.

BACKGROUND: Reconstruction of a functional tongue with proper motility and sensation after subtotal resection is a demanding procedure. The authors describe the reinnervated mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction. METHODS: Thirteen patients (mean age, 54.8 years; range, 49 to 71 years) diagnosed with T3 and T4 squamous cell carcinomas were allocated prospectively to anterior total mobile (n = 7) or subtotal tongue resection (n = 6). All patients received the mushroom-shaped anterolateral thigh perforator flap. A Likert scale ranging from 1 to 4 was used to assess speech intelligibility, swallowing function, and cosmetic results. Epicritic and proprioceptive sensitivity testing was performed with the Pressure-Specified Sensory Device on the tip of the tongue preoperatively, on the neotongue at the donor site preoperatively, and at the recipient site 12 months postoperatively; protopathic thermoreceptor and nociceptors were clinically investigated. Outcomes were analyzed, and values of p < 0.05 were considered significant. RESULTS: All flaps healed uneventfully (mean follow-up, 18 months). Six patients (46.2 percent) recovered a nearly natural deglutition, whereas seven (53.8 percent) had mild impairment (p = 0.274). Normal intelligible speech was achieved in seven cases (53.8 percent), and acceptable intelligible speech was achieved in six (46.2 percent) (p = 0.286). Aesthetic results were excellent in eight patients (61.5 percent) and good in five (38.5 percent) (p = 0.592). All patients recovered epicritic, proprioceptive, and protopathic sensitivity; cortical upgrading phenomena of the recipient nerve were observed. CONCLUSION: The reinnervated mushroom-shaped anterolateral thigh perforator flap was found to be an innovative and effective option for subtotal tongue reconstruction.

Bilobed skin paddle fibula flap for large oromandibular defects.

Although the fibula free flap (FFF) is a useful choice for mandible reconstruction, its application for large oromandibular defects is still debated upon. We report the use of FFF with a bilobed perforator-based skin paddle for combined hemiglossectomy, floor-of-the-mouth, tonsillar pillar, and mandibular body defect. A case of an 84-year-old woman with a 2.5 × 3.5-cm exophytic ulcerated mass on the right side of the tongue, extended to omolateral gengival fornix, tonsillar pillar, and mandibular body, is reported. An osteocutaneus FFF with a 7-cm bone strut and a 17 × 10-cm bilobed shaped skin paddle was performed. The longer lobe was used to restore tongue shape, whereas the smaller lobe was used to line the pelvic floor, gingival, and tonsillar pillar. The postoperative period was uneventful. The patient was capable to protrude her neotongue beyond the virtual incisors line and to touch the hard palate at different degrees of mouth opening. The bilobed perforator-based skin paddle FFF is felt to be a sound option for large compound oromandibular defects offering the possibility to safely base the skin component on a single peroneal perforator while achieving effective tongue mobility preservation.

The BREAST-V: a unifying predictive formula for volume assessment in small, medium, and large breasts.

BACKGROUND: Breast volume assessment enhances preoperative planning of both aesthetic and reconstructive procedures, helping the surgeon in the decision-making process of shaping the breast. Numerous methods of breast size determination are currently reported but are limited by methodologic flaws and variable estimations. The authors aimed to develop a unifying predictive formula for volume assessment in small to large breasts based on anthropomorphic values. METHODS: Ten anthropomorphic breast measurements and direct volumes of 108 mastectomy specimens from 88 women were collected prospectively. The authors performed a multivariate regression to build the optimal model for development of the predictive formula. The final model was then internally validated. A previously published formula was used as a reference. RESULTS: Mean (±SD) breast weight was 527.9 ± 227.6 g (range, 150 to 1250 g). After model selection, sternal notch-to-nipple, inframammary fold-to-nipple, and inframammary fold-to-fold projection distances emerged as the most important predictors. The resulting formula (the BREAST-V) showed an adjusted R of 0.73. The estimated expected absolute error on new breasts is 89.7 g (95 percent CI, 62.4 to 119.1 g) and the expected relative error is 18.4 percent (95 percent CI, 12.9 to 24.3 percent). Application of reference formula on the sample yielded worse predictions than those derived by the formula, showing an R of 0.55. CONCLUSIONS: The BREAST-V is a reliable tool for predicting small to large breast volumes accurately for use as a complementary device in surgeon evaluation. An app entitled BREAST-V for both iOS and Android devices is currently available for free download in the Apple App Store and Google Play Store. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Sagittal split osteotomy of the fibula for modeling the new mandibular angle.

Fibula modeling techniques for mandible reconstruction carry a high risk of bone perfusion impairment and low predictability of osteotomy angles. To restore the parabolic shape of the mandible, the number of osteotomies should be as small as possible to preserve both periosteal and endosteal perfusion. We report our approach with sagittal split osteotomy (SSO) technique for mandibular angle reconstruction.Obwegeser-Dal Pont SSO of fibula flaps was performed on 10 patients who underwent mandibular angle reconstruction. Bone segments were tilted according to stereolithographic template and fixed with 3 bicortical screws in triangular fashion. Fibula-gonial angle at 15 days and 6 months from surgery was compared with the contralateral-mandibular-gonial angle using Kruskal-Wallis test with a P < 0.05 considered significant.Mean bone length and skin paddle size were 15.6 cm (range, 13-18 cm) and 22.5 cm (range, 3 × 4 cm to 11 × 5 cm). Bone unions occurred at 12 months (mean follow-up, 39 months). No differences (P > 0.05) between fibula-gonial angle at 15 days (mean, 122.88 ± 0.55 degrees; range, 122.49-123.27 degrees) and 6 months (mean, 123.36 ± 0.88 degrees; range, 122.73-123.99 degrees) and contralateral-mandibular-gonial angle (mean, 123.20 ± 0.80 degrees; range, 122.62-123.77 degrees) were observed.Fibula SSO allows for new-mandible angle shaping, reducing risk of pedicle and endosteal vascular impairment. Triangular bone fixation thereby emerges as a reliable technique, enhancing functional and aesthetic long-term outcomes.