Experimental demonstration of real-time cardiac physiology-based radiotherapy gating for improved cardiac radioablation on an MR-linac

BACKGROUND

Cardiac radioablation is a noninvasive stereotactic body radiation therapy (SBRT) technique to treat patients with refractory ventricular tachycardia (VT) by delivering a single high-dose fraction to the VT isthmus. Cardiorespiratory motion induces position uncertainties resulting in decreased dose conformality. Electocardiograms (ECG) are typically used during cardiac MRI (CMR) to acquire images in a predefined cardiac phase, thus mitigating cardiac motion during image acquisition.

PURPOSE

We demonstrate real-time cardiac physiology-based radiotherapy beam gating within a preset cardiac phase on an MR-linac.

METHODS

MR images were acquired in healthy volunteers (n = 5, mean age = 29.6 years, mean heart-rate (HR) = 56.2 bpm) on the 1.5 T Unity MR-linac (Elekta AB, Stockholm, Sweden) after obtaining written informed consent. The images were acquired using a single-slice balance steady-state free precession (bSSFP) sequence in the coronal or sagittal plane (TR/TE = 3/1.48 ms, flip angle = 48∘ $^{\circ }$ , SENSE = 1.5,field-of-view = 400 × 207 $\text{field-of-view} = {400}\times {207}$ mm 2 ${\text{mm}}^{2}$ , voxel size =3 × 3 × 15 $3\times 3\times 15$ mm 3 ${\rm mm}^{3}$ , partial Fourier factor = 0.65, frame rate = 13.3 Hz). In parallel, a 4-lead ECG-signal was acquired using MR-compatible equipment. The feasibility of ECG-based beam gating was demonstrated with a prototype gating workflow using a Quasar MRI4D motion phantom (IBA Quasar, London, ON, Canada), which was deployed in the bore of the MR-linac. Two volunteer-derived combined ECG-motion traces (n = 2, mean age = 26 years, mean HR = 57.4 bpm, peak-to-peak amplitude = 14.7 mm) were programmed into the phantom to mimic dose delivery on a cardiac target in breath-hold. Clinical ECG-equipment was connected to the phantom for ECG-voltage-streaming in real-time using research software. Treatment beam gating was performed in the quiescent phase (end-diastole). System latencies were compensated by delay time correction. A previously developed MRI-based gating workflow was used as a benchmark in this study. A 15-beam intensity-modulated radiotherapy (IMRT) plan (1 × 6.25 ${1}\times {6.25}$ Gy) was delivered for different motion scenarios onto radiochromic films. Next, cardiac motion was then estimated at the basal anterolateral myocardial wall via normalized cross-correlation-based template matching. The estimated motion signal was temporally aligned with the ECG-signal, which were then used for position- and ECG-based gating simulations in the cranial-caudal (CC), anterior-posterior (AP), and right-left (RL) directions. The effect of gating was investigated by analyzing the differences in residual motion at 30, 50, and 70% treatment beam duty cycles.

RESULTS

ECG-based (MRI-based) beam gating was performed with effective duty cycles of 60.5% (68.8%) and 47.7% (50.4%) with residual motion reductions of 62.5% (44.7%) and 43.9% (59.3%). Local gamma analyses (1%/1 mm) returned pass rates of 97.6% (94.1%) and 90.5% (98.3%) for gated scenarios, which exceed the pass rates of 70.3% and 82.0% for nongated scenarios, respectively. In average, the gating simulations returned maximum residual motion reductions of 88%, 74%, and 81% at 30%, 50%, and 70% duty cycles, respectively, in favor of MRI-based gating.

CONCLUSIONS

Real-time ECG-based beam gating is a feasible alternative to MRI-based gating, resulting in improved dose delivery in terms of highγ -pass $\gamma {\text{-pass}}$ rates, decreased dose deposition outside the PTV and residual motion reduction, while by-passing cardiac MRI challenges.

Real-time myocardial landmark tracking for MRI-guided cardiac radio-ablation using Gaussian Processes

The high speed of cardiorespiratory motion introduces a unique challenge for cardiac stereotactic radio-ablation (STAR) treatments with the MR-linac. Such treatments require tracking myocardial landmarks with a maximum latency of 100 ms, which includes the acquisition of the required data. The aim of this study is to present a new method that enables tracking myocardial landmarks from few readouts of MRI data, thereby achieving a latency sufficient for STAR treatments. We present a tracking framework that requires few readouts of k-space data as input, which can be acquired at least an order of magnitude faster than MR-images. Combined with the real-time tracking speed of a probabilistic machine learning framework called Gaussian Processes, this allows to track myocardial landmarks with a sufficiently low latency for cardiac STAR guidance. This includes both the acquisition of required data, and the tracking inference. The framework is demonstrated in 2D on a motion phantom, and in vivo on volunteers and a ventricular tachycardia (arrhythmia) patient. Moreover, the feasibility of an extension to 3D was demonstrated by in silico 3D experiments with a digital motion phantom. The framework was compared with template matching - a reference, image-based, method - and linear regression methods. Results indicate an order of magnitude lower total latency (<10 ms) for the proposed framework in comparison with alternative methods. The root-mean-square-distances and mean end-point-distance with the reference tracking method was less than 0.8 mm for all experiments, showing excellent (sub-voxel) agreement. The high accuracy in combination with a total latency of less than 10 ms - including data acquisition and processing - make the proposed method a suitable candidate for tracking during STAR treatments. Additionally, the probabilistic nature of the Gaussian Processes also gives access to real-time prediction uncertainties, which could prove useful for real-time quality assurance during treatments.

The Effects of Adipose-Derived Mesenchymal Stem Cells and Adipose-Derived Mesenchymal Stem Cell-Originating Exosomes on Nerve Allograft Regeneration: An Experimental Study in Rats

INTRODUCTION

Nerve regeneration has been the subject of many studies because of its complex mechanism and functional outcome. Mesenchymal stem cells and exosomes are promising factors in regeneration in many areas. Reconstruction of nerve defects is a controversial issue, and nerve allografts are promising alternatives with many advantages. In this study, it is aimed to evaluate the nerve regeneration in cellularized and decellularized nerve allografts and whether it is possible to accelerate this process with adipose-derived mesenchymal stem cells (ad MSC) or ad MSC-originating exosomes.

METHOD

This study was performed with 36 Lewis and 18 Brown Norway isogenic male rats aged 10 to 12 weeks and weighing 300 to 350 g. The Lewis rats were divided into 6 groups. Nerve allografts at a length of 12 mm that were obtained from the Brown Norway rats' proximal portion of both sciatic nerve branching points were coapted as cellularized in group A and decellularized in group B to the sciatic nerve defects of the Lewis rats. Group A received oral tacrolimus (0.2 mg/kg) for 30 days. Perineural saline (A1-B1), ad MSC (A2-B2), or ad MSC-originating exosomes (A3-B3) were applied to these groups. Walking track analysis, pinch-prick test and electromyelography were applied at the 8th and 16th weeks following surgery. Nerves were examined histopathologically at the 16th week.

RESULTS

Between cellularized groups, better results were shown in A3 about axon-myelin regeneration/organization (P = 0.001), endoneural connective tissue (P = 0.005), and inflammation (P = 0.004). Better results were shown in the B2 and B3 groups electromyelographicaly about latency period (P = 0.033) and action potential (P = 0.008) at late period, and histomorphologicaly at vascularization (P = 0.012).

DISCUSSION

It is argued that regeneration is accelerated with decellularization of nerve allografts by removing the chondroidin sulfate proteoglycans. The positive effects of stem cells are derived by exosomes without the cell-related disadvantages. In this study, better results were obtained by decellularization and perineural application of ad MSC and/or ad MSC exosome.

First experimental exploration of real-time cardiorespiratory motion management for future stereotactic arrhythmia radioablation treatments on the MR-linac

Objective.Stereotactic arrhythmia radioablation (STAR) is a novel, non-invasive treatment for refractory ventricular tachycardia (VT). The VT isthmus is subject to both respiratory and cardiac motion. Rapid cardiac motion presents a unique challenge. In this study, we provide first experimental evidence for real-time cardiorespiratory motion-mitigated MRI-guided STAR on the 1.5 T Unity MR-linac (Elekta AB, Stockholm, Sweden) aimed at simultaneously compensating cardiac and respiratory motions.Approach.A real-time cardiorespiratory motion-mitigated radiotherapy workflow was developed on the Unity MR-linac in research mode. A 15-beam intensity-modulated radiation therapy treatment plan (1 × 25 Gy) was created in Monaco v.5.40.01 (Elekta AB) for the Quasar MRI^4Dphantom (ModusQA, London, ON). A film dosimetry insert was moved by combining either artificial (cos⁴, 70 bpm, 10 mm peak-to-peak) or subject-derived (59 average bpm, 15.3 mm peak-to-peak) cardiac motion with respiratory (sin, 12 bpm, 20 mm peak-to-peak) motion. A balanced 2D cine MRI sequence (13 Hz, field-of-view = 400 × 207 mm², resolution = 3 × 3 × 15 mm³) was developed to estimate cardiorespiratory motion. Cardiorespiratory motion was estimated by rigid registration and then deconvoluted into cardiac and respiratory components. For beam gating, the cardiac component was used, whereas the respiratory component was used for MLC-tracking. In-silico dose accumulation experiments were performed on three patient data sets to simulate the dosimetric effect of cardiac motion on VT targets.Main results.Experimentally, a duty cycle of 57% was achieved when simultaneously applying respiratory MLC-tracking and cardiac gating. Using film, excellent agreement was observed compared to a static reference delivery, resulting in a 1%/1 mm gamma pass rate of 99%. The end-to-end gating latency was 126 ms on the Unity MR-linac. Simulations showed that cardiac motion decreased the target's D98% dose between 0.1 and 1.3 Gy, with gating providing effective mitigation.Significance.Real-time MRI-guided cardiorespiratory motion management greatly reduces motion-induced dosimetric uncertainty and warrants further research and development for potential future use in STAR.

Feasibility of cardiac-synchronized quantitative T1 and T2 mapping on a hybrid 1.5 Tesla magnetic resonance imaging and linear accelerator system

Background and Purpose

Materials and methods

Results

Conclusions

Reconstruction of Extensive Auricular Defects Using a Retroauricular Artery Perforator-Based Propeller Flap

BACKGROUND

Various local techniques have been successfully used for the reconstruction of auricular defects. However, most local techniques are not suitable for extensive auricular defects. The aim of this study is to investigate the utility of a retroauricular artery perforator-based propeller flap for the reconstruction of extensive auricular defects by evaluating aesthetic outcomes using objective and quantitative parameters.

METHODS

Twenty-one patients with extensive full-thickness and partial-thickness defects were treated with retroauricular artery perforator-based propeller flaps harvested from the mastoid and neck regions. The surgical procedures were performed using single-stage reconstruction in postauricular partial-thickness defects and 2-stage reconstruction in full-thickness auricular defects. Levels of final satisfaction and tissue matching as well as donor scar perception were evaluated by the patients and objective observers.

RESULTS

The original sizes and projections of the auricles were achieved. The color, texture, and thickness of the flaps matched well with the adjacent auricles. The vast majority of the patients and observers were very satisfied with the surgical outcome.

CONCLUSIONS

Retroauricular artery perforator-based propeller flaps may preserve the size and projection in both partial- and full-thickness extensive defects of the auricle. With this procedure, there was also excellent matching of the color, texture, and thickness of the flap with the adjacent tissue, as well as acceptable levels of donor scarring, thereby achieving satisfactory aesthetic outcomes.

Application of Sandwich Shape Double Bilobed Flap in Auricular Defects

BACKGROUND

Reconstruction of auricular defects is a challenging surgical procedure because of its complex 3-dimensional structure. Various surgical techniques have been used for the reconstruction of the auricle. However, most of these techniques are not applicable to the reconstruction of marginal and central defects, and the texture and color harmony of the reconstructed parts were not evaluated in detail. Thus, the aim of this study is to present a novel technique, sandwich shape double bilobed flap, which can be used for correcting, both, central and marginal defects of the auricle and to evaluate esthetic outcomes with objective and quantitative parameters.

METHODS

In this study, 24 patients with partial thickness auricular defects were treated with a bilobed flap, and excess tissue in the postauricular sulcus region was transferred to the defective region on the anterior surface. Color compatibility between the flap and surrounding tissues, patient's satisfaction on the final shape and auricular symmetry, as well as anterior scar formation on the auricle were evaluated.

RESULTS

The color, texture, and thickness of the flap matched well with the adjacent auricular tissue and there was no perceptible color difference. The original size, projection, and subunits of auricles were maintained. All patients were mostly very satisfied with surgical outcomes (mean satisfaction score, 4.75 ± 0.4). There was only inconspicuous scar on the visible anterior surface of the auricle (mean patients' scores, 2.22 ± 0.3; mean observers' scores, 2.6 ± 0.4).

CONCLUSIONS

The sandwich shape double bilobed flap technique preserved size and subunits of the auricle. Additionally, this procedure also resulted in inconspicuous scarring as well as similar color, texture, and thickness of the flap with the surrounding tissue, thereby achieving satisfying esthetic outcomes.

Median Nerve's Microcirculation in Carpal Tunnel Syndrome: Superb Microvascular Imaging

BACKGROUND

The objectivity of physical and electrodiagnostic tests is limited in detecting carpal tunnel syndrome and its recurrence. Predicting the median nerve blood supply using superb microvascular imaging will allow exact diagnosis and a good follow-up system. The aims of this study include using superb microvascular imaging to correlate with electromyographic diagnosis, and to determine the impact of surgery on improvement in superb microvascular imaging.

METHODS

Between July of 2019 and January of 2020, 32 wrists of 21 patients were evaluated prospectively. After preoperative electrodiagnostic studies and vascular index measurement with superb microvascular imaging, open carpal tunnel release was performed by a single surgeon, and 3 months later standardized superb microvascular imaging was performed. Preoperative vascular indexes were compared with the mild, moderate, and severe electrodiagnostic study results. Preoperative and postoperative vascular index results were compared.

RESULTS

The average of the preoperative and postoperative imaging groups was 2.77 and 1.48, respectively, and there was a statistically significant difference between the two groups (p < 0.05). Although no significant difference was found between preoperative and postoperative vascular index values in patients presenting with mild carpal tunnel syndrome (p > 0.05), there was a significant decrease in vascular index values in patients presenting with moderate and severe carpal tunnel syndrome after surgical decompression.

CONCLUSIONS

Superb microvascular imaging is emerging as a groundbreaking, new, and reliable technique. Evaluation of the median nerve blood supply is a reliable method that would be helpful for early diagnosis, planning treatment, determining the severity of carpal tunnel syndrome, and postoperative follow-up.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Long-Term Outcomes of Digital Nerve Repair Accompanied by Digital Artery Injury in Flexor Zone 2

Objectives  Better healing results of any tissue or area is closely linked with a well-blood supply in reconstructive surgery. Peripheric nerve healing is closely related to blood supply as well. We aimed to assess whether there was any difference between digital nerve healing with and without extrinsic blood supply.

Methods  We assessed 48 patients with unilateral digital nerve injury at zone 2. Twenty-four of them had unrepairable arterial injury and other 24 had no arterial injury. The 24 patients in the “unrepaired artery group” (UA) and 24 patients in the “intact artery group” (IA) were compared.

Results  Mean follow-up time was 17.7 months. The mean two-point discrimination (2PD) was 5.29 mm in IA group and 5.37 mm in UA group. One neuroma in IA group and two neuromas in UA group were determined. We found no statistically significant difference between these groups in terms of neuroma, 2PD, and cold intolerance. The results of British Medical Research Council sensory recovery clinical scale were comparable for these two groups.

Conclusion  Digital nerve healing is related to numerous factors. We hypothesized that blood flow may be one of these factors; however, at this zone digital artery repair is not the foremost determinant for digital nerve healing. Further researches should be done for upper injury levels. Despite this result, we argue not to leave the digital artery without repairment and we propose to repair both artery and nerve to achieve the normal anatomical integrity and to warrant finger blood flow in possible future injuries.

Foreign Body Inside the Tunnel: A Rare Cause of Acute Cubital Tunnel Syndrome

Foreign bodies are common entities found in hand surgery practice. However, they are a very rare cause of the acute cubital tunnel syndrome. A 48-year-old male patient was consulted for cubital tunnel symptoms after 2-day unconscious state in the intensive care unit. The ulnar nerve was explored, a piece of glass was removed inside the cubital tunnel, and the nerve was repaired. However, compression neuropathy symptoms due to the acute trauma are interesting. Nerve laceration with a foreign body should be considered in acute-onset cubital tunnel syndrome, in which the foreign body history of a trauma patient cannot be determined explicitly.

Endoscopic-Assisted Zygomatic Arch Fracture Repair With a Preauricular Approach

Introduction

Because of numerous negative sequelae with open techniques, endoscopic techniques are beginning to be widely used for maxillofacial fractures. Many endoscopic approaches for this area have been described according to several dissection plans and incisions. The aim of the present study was to report a new surgical incision and dissection method for zygomatic arch fracture that aims at reducing the complication rate of previously defined techniques.

Material and Methods

The authors operated on 8 patients with a new endoscopic-assisted surgical technique. This study focused on evaluating the complication rate and surgical comfort of these patients.

Results

Of the 8 patients, the plate was palpable in the zygomatic arch in one. No complications occurred due to this technique during the 1-year follow-up. Symmetrical facial contour and inconspicuous scars were obtained in all patients. Average operative time was 3 hours; hospitalization time was 1.6 days.

Conclusion

This study demonstrates that an endoscopic-assisted surgical approach with a preauricular mini-incision can be safely performed in isolated multifragment zygomatic arch fractures. Using individually designed plates improved our results. This technique is easy to apply, its cosmetic results are good, and its complication rate is low.

Management of exposed ventriculoperitoneal shunt on the scalp in pediatric patients

PURPOSE

The exposure of a ventriculoperitoneal shunt on the scalp is a serious complication. There are limited studies evaluating this complication's management in the literature. The aim of this study is to define the management of shunt salvage and the reconstruction of the scalp.

METHODS

This retrospective study included seven pediatric patients with ventriculoperitoneal shunts that were exposed on the scalp for various reasons. The demographic characteristics of the patients and the medical and surgical treatments used were recorded. The patient follow-up durations and complications associated with these methods were determined.

RESULTS

Four female and three male patients with an average age of 5.7 were followed for an average of 9.4 months. All but one of these patients were treated without removing the shunt. While one skin flap was used in one patient, successful repairs were made with double skin flaps in five patients. There were no complications during follow-up for the patients treated with these methods.

CONCLUSION

In this study, the appropriate management of shunt exposure, which is common in pediatric cases, has been revealed. Given appropriate infection prevention, the reconstruction of the scalp is possible without the removal of the shunt.

Malign Differentiation of a Large Buschke Loewenstein Tumor in Penis

Buschke-Loewenstein tumor (BLT) is a giant condyloma acuminatum which is very rare and commonly affects the anogenital region. The malignant transformation and localization in penis is very rare. This article aims to present a case with BLT with malignant transformation in penis. A 59-year-old male patient was referred, who has have been suffering from a cauliflower-like lesion in the penis for 8 years. Biopsies revealed a BLT with malignant transformation. The lesion was excised largely and reconstructed with local flaps and skin grafts. Defined by Buschke and Loewenstein in 1925, giant condyloma acuminatum is a rare and important disorder because of the sexually transmitting capability.

Foot and ankle reconstruction with vertically designed deep inferior epigastric perforator flap

INTRODUCTION

The deep inferior epigastric perforator (DIEP) flap is one of the most commonly utilized flaps of reconstructive surgery. Although the horizontal flap design is the most commonly used, this flap can be vertically designed to avoid drawbacks such as excessive tissue dissection, relatively reduced flap perfusion, and scarification of the contralateral flap opportunity. The aim of this report is to present our case series for foot and ankle reconstruction with vertical designed DIEP flap.

PATIENTS AND METHODS

The free vertically designed DIEP flaps (VDIEP) were used in eight patients (7 male, 1 female) whose age is in a range of 20-66 years for soft tissue reconstructions in the ankle and foot region over a five-year period. The range of defects' size was from 8 × 5 cm to 15 × 7 cm and the causes were electrical burn, trauma and diabetic foot infections.

RESULTS

Flap dimensions varied from 10 × 6 cm to 17 × 9 cm. All the flaps had two or more perforators, and all flaps survived completely. There were no early or late complications. We followed up the patients for 10 months in average. We observed no functional problems, especially in main motions of foot and ankle like eversion, inversion, flexion or extension except one patient. Donor site scars were acceptable in all patients.

CONCLUSIONS

The VDIEP flap may be an option for selected lower extremity soft tissue reconstructions, and it may be an alternative to classically designed abdominal flaps.

The Vascular Anatomy of the Capitate: New Discoveries Using Micro-Computed Tomography Imaging

PURPOSE

To study the intraosseous 3-dimensional microvasculature of the capitate bone using a novel high-resolution micro-computed tomography (μCT) imaging technology, and to examine the blood supply as it relates to the most common fracture types.

METHODS

Ten cadaveric wrists were injected with a lead-based contrast agent. The capitates were harvested and imaged using a μCT scanner. The intraosseous vascularity was incorporated into a 3-dimensional image. We measured the vascular pattern as well as the vessels' cross-sectional area, number, and distribution. An average capitate fracture line was calculated using clinical data from 22 patients with capitate fractures. The fracture line was projected on the representative capitate to assess its relation with the nutrient vessels' entry points.

RESULTS

The capitate is a well-vascularized carpal supplied by dorsal and volar vascular systems that anastomose in 30% of cases. There was no predominance of one vascular system over the other. Most vessels enter the capitate at the distal half and supply the proximal pole in a retrograde fashion. In addition, most specimens (70%) also had at least one vessel entering the proximal pole through the volar capitate ligaments and supplying the proximal pole directly. The average fracture line had an oblique orientation, and 90% of the specimens had a blood vessel entering proximal to that line.

CONCLUSIONS

This μCT vascular study further verifies that the capitate receives most of its vasculature in a retrograde fashion, but the study also shows that most capitates have vessels supplying the proximal pole directly. These findings might explain why most capitate waist fractures do not progress to proximal pole avascular necrosis.

CLINICAL RELEVANCE

This study characterizes the microvasculature of the capitate and might shed light on processes involved in bone healing and the etiology of capitate avascular necrosis.

Reverse Adipofascial Radial Forearm Flap Surgery for Soft-Tissue Reconstruction of Hand Defects

Objective: The reverse radial forearm flap has been used for soft-tissue hand defect surgical procedures worldwide. One of the major drawbacks of this flap, however, is donor site morbidity, as the donor site is closed with a skin graft. Problems with skin graft donor areas include adhesion, contracture, and wound-healing complications. In this study, only the adipofascial component of a reverse radial forearm flap was used to prevent these problems; in addition, a skin graft was applied over the flap instead of over the donor site. Methods: Between January 2011 and December 2013, a total of 13 hand defects were reconstructed with a reverse adipofascial radial forearm flap. Patients were evaluated for functional results using total active motion criteria and disability of the arm, shoulder, and hand scores, operation time, hospitalization time, and patient satisfaction. Results: All flaps and grafts placed on flaps survived completely and donor sites healed without complications. The total active motion criteria and the disability of the arm, shoulder, and hand score demonstrated that the functional outcomes were successful. Patient satisfaction scores using the visual analog scale had a mean of 88.3 (SD = 2.95) mm. Operation time for the flap surgery was 126.1 (SD = 21.80) minutes, and patients were discharged at an average of 6.3 (SD = 1.44) days. Conclusion: Use of an adipofascial component in reverse radial forearm flap surgery is appropriate for reducing problems with donor site skin grafts. Patients' functional outcomes denoted that the reverse adipofascial radial forearm flap is a reliable and effective method to cover soft-tissue defects of the hand. Level of Evidence: IV.

Capitate Fractures: A Review of 53 Patients

PURPOSE

To describe the demographics, diagnosis, management, and outcomes of capitate fractures in the adult and pediatric population treated in our institution.

METHODS

We performed a retrospective chart and radiographic review of 53 patients with capitate fractures treated in our institution between 2002 and 2015. Patients' demographic characteristics, mechanism of injury, management including surgery-related data, and outcomes, including complications, were recorded. A radiographic evaluation of the location and pattern of the fracture was performed.

RESULTS

Capitate fractures were prevalent in young males and older females. Fracture location was variable with 9 different locations; in addition 80% of patients had an associated fracture in the wrist or hand. The most common fracture pattern was the transscaphoid, transcapitate perilunate dislocation. Most diagnoses were made with the aid of advanced imaging. Within this series, there was only 1 case (4%) of fracture nonunion and there were no cases of avascular necrosis of the proximal pole in limited follow-up. Isolated capitate fractures were significantly more common in children. In addition, children had better functional outcomes than adults.

CONCLUSIONS

This series provides updated information on this rare injury. Nonunion of the capitate, which was previously described as the most common complication, was rare in this cohort.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Dupuytren-Like Contracture of the Foot: Ledderhose Disease

Introduction  Plantar fibromatosis is a rare hyperproliferative disease of plantar aponeurosis and is also called Ledderhose disease. Case properties and treatment are discussed in this report.

Case Report  A 30-year-old man presented with painful bilateral plantar nodules. He had multiple and bilateral fixed and solid nodules on the plantar and medial side of his feet measuring 1 cm each. Ultrasound was performed and hypoechoic homogeneous nodules were detected. The patient underwent surgery, and the nodes were removed via a plantar incision with 2-cm safety distance.

Discussion  Ledderhose disease is a rare, hyperproliferative disorder of the plantar aponeurosis. The nodules are slow growing and found in the medial part of the plantar fascia. The precise etiology remains unknown. The treatment options are conservative management, steroid injections, radiotherapy, and surgery.

Conclusion  The main cause of this disease remains uncertain. Related conditions should be evaluated, and a patient who presents with Dupuytren or Peyronie disease should also be investigated for Ledderhose disease.

V-Y and rectangular flap combination for syndactyly repair

OBJECTIVE

For syndactyly repair, several delicate, well-planned flap combination techniques have been reported. This study presents technique details with functional and aesthetic results of a dorsal rectangular and volar V-Y advancement flap combination for web reconstruction and S incisions for finger separation in patients with syndactyly.

METHOD

Ten patients with 16 syndactyly webs were treated. Patients were examined in terms of function and aesthetic. Evaluation criteria included the Vancouver Scar Scale, range of motion, degree of web creeping, parent's satisfaction rates, and finger abduction. During the initial period, vascular compromise of fingers, haematoma, infection, seroma, flap necrosis, or graft failures were not noted in any patients. No patients required revision surgery. During the later period, parent satisfaction scores were excellent or good, finger function was complete, and the Vancouver Scar Scale showed that two webs had hyperpigmented areas and two had supple pliability.

CONCLUSION

This simple syndactyly release technique can provide a low rate of web creep, good scar quality, and optimal functional results.