Real-world data on malignant and borderline phyllodes tumors of the breast: A population-based study of all 921 cases in the Netherlands (1989 -2020)

AIM

The aim of our study is to analyze patterns in treatment and outcome in a population-based series of patients with borderline and malignant phyllodes tumors (PT).

MATERIAL AND METHODS

Data on all patients with a borderline or malignant PT (1989-2020) were extracted from the Netherlands Cancer Registry and the Dutch nationwide pathology databank (Palga) and retrospectively analyzed.

RESULTS

We included 921 patients (borderline PT n = 452 and malignant PT n = 469). Borderline PT patients more often had breast-conserving surgery (BCS) as final surgery (81 vs. 46%). BCS rates for borderline PT increased over time (OR 1.08 per year, 95%CI 1.04 - 1.13, P < 0.001). In malignant PT adjuvant radiotherapy was given in 14.7%; this rate increased over time (OR 1.07 per year, 95%CI 1.02 - 1.13, P = 0.012). Local recurrence rate (5-year estimate of cumulative incidence) was 8.7% (95%CI 6.0-11.4) for borderline PT and 11.7% (95%CI 8.6-14.8) for malignant PT (P = 0.187) and was related to tumor size ≥ 20 mm (HR 10.6 (95%CI 1.5-76.8) and positive margin (HR 3.0 (95%CI 1.6-5.6), p < 0.001), but not to negative margin width (HR 1.3 ( 95%CI 0.7-2.3), p = 0.350)). Distant metastasis occurred only in malignant PT with a 5-year cumulative incidence of 4.7% (95%CI 3.3 - 6.1).

CONCLUSION

This population-based series showed an increase in BCS in borderline PT and an increase in adjuvant radiotherapy in malignant PT over time. We identified malignant PT, BCS, larger tumor size and positive final margins as possible risk factors for local recurrence. Small but negative margins can be accepted.

Segmental femoral fracture malunion: evidence and prognostic analysis of medical intervention in the third century BC

We examined the remains of an individual who was unearthed from the Tuchengzi site and was believed to be from the Warring States period in China. The remains exhibited segmental femoral fracture. We aimed to deduce the cause of fracture, medical interventions, healing process, and motion behavior after fracture healing using several techniques, including macroscopic observation, computed tomography (CT), and finite element analysis. Based on the morphology of the long bones, it appeared that the individual was male. The fractures resulted in an adduction angle of 5.47° and an anterior flexion angle of 21.34° in the proximal femur, while the femoral neck anteversion angle had been replaced by a retroversion angle of 10.74°. Additionally, the distal femur formed an abnormal anterior convex angle of 144.60°. CT revealed mature callus formation and visible trabecular bundles. The finite element analysis indicated that the maximum von Mises stress in the femur was 17.44 MPa during standing and 96.46 MPa during walking. We suggest that medical practitioners in the Warring States period possessed a good knowledge of thigh anatomy, enabling them to perform fracture reduction and fixation. Reasonable medical intervention facilitated fracture healing and load recovery. Satisfactory fracture healing ensured that the individual could engage in normal standing and walking activities after rehabilitation.

Update on Chemical Peels

Chemical peeling is a procedure used for cosmetic improvement of the skin or treatment of some medical skin disorders, by the application of chemical exfoliant. In spite of a long history of clinical use of chemical peels, understanding of the science behind the procedure is still evolving. In this article, we review new concepts, understandings, and publications in the field of chemical peels.

Large Brown Tumour of Mandible with Bleeding as Initial Presentation: A Case Report

Brown Tumour or Osteitis fibrous cystic or Von-Recklinghausen disease of bone is a non-malignant condition due to abnormal metabolism of bones in hyperparathyroidism. Although pathognomonic of hyperparathyroidism, brown tumours are rare and only case reports are found in literature. We report a case of brown tumour of mandible with recurrent episodes of bleeding. A 46 year old male patient presented in emergency with bleeding from ulceroproliferative mass from left floor of mouth. After control of bleeding, radiological, laboratory and histopathological investigations were done that led to the diagnosis of brown tumour of mandible in the presence of parathyroid adenoma of left lower parathyroid gland. Left upper and lower parthyroidectomy was done with segmental resection of mandible with mass and titanium plating. Brown tumour of facial bones is a rare entity. Very rarely it can reach enormous sizes to cause bleeding. Although parathyroidectomy and correction of parathormone levels cause regression of small tumours, large brown tumours with complications should be managed with surgical resection and reconstruction.

Surgical outcomes of segmental diaphyseal forearm fractures in adults: a small case series on plate osteosynthesis, intramedullary nailing, and other surgical methods

BACKGROUND

Segmental fractures often result from high-energy or indirect trauma that causes bending or torsional forces with axial loading. We evaluated surgical outcomes of patients with forearm segmental diaphyseal fractures.

METHODS

We retrospectively analyzed data from patients with forearm segmental fractures for which they underwent surgery at the Pusan National University Trauma Center from March 2013 to March 2022. We also analyzed accompanying injuries, injury severity score (ISS), injury mechanism, occurrence of open fracture, surgical technique, and treatment results.

RESULTS

Fifteen patients were identified, one with bilateral segmental diaphyseal forearm bone fracture, for a total of 16 cases. Nine of the patients were male. The overall mean age was 50 years, and the mean follow-up period was 16.2 months. Six cases who underwent surgery using plate osteosynthesis achieved bone union without length deformity at final follow-up. Three of seven patients who underwent intramedullary nailing alone underwent reoperation due to nonunion. Six cases achieved bone union at final follow-up, three of which showed length deformity. Three patients underwent surgery using a hybrid method of IM nailing, plates, and mini cables. One patient who underwent surgery with a plate and one patient who underwent surgery with IM nailing alone showed nonunion and were lost to follow-up.

CONCLUSION

Plate osteosynthesis is considered the gold standard for treatment of adult forearm diaphyseal segmental fractures. In this study, IM nailing was associated with high rates of non-union and length deformity. However, the combination of IM nailing and a plate-cable system may be an acceptable alternative in segmental diaphyseal forearm fracture, achieving a union rate similar to that provided by plate fixation.

Pancreatectomy with venous vascular resection for pancreatic cancer: Impact of types of vein resection on timing and pattern of recurrence

INTRODUCTION

Few studies analysed the impact of different venous resection techniques on recurrence in patients with pancreatic ductal adenocarcinoma (PDAC). Primary aim was to compare local recurrence rate and disease-free survival (DFS) between patients who underwent pancreatectomy with tangential versus segmental resection of portal vein/superior mesenteric vein.

MATERIALS AND METHODS

All consecutive patients who underwent pancreatectomy with venous resection for PDAC between 2009 and 2019 were included. A propensity score matching (PSM) was used to reduce the effect of treatment selection bias.

RESULTS

Overall, 120 patients (68%) underwent pancreatectomy with tangential venous resection and 57 patients (32%) were submitted to pancreatectomy with segmental venous resection. After a median follow-up of 24 months, local recurrence was comparable between the two groups (tangential: n = 32/120, 26.7% versus segmental: n = 10/57, 17.5%; p = 0.58). The median DFS was 17 months (IQR 9-31) in patients who underwent tangential resection, as compared to 12 months (IQR 5-21) in those who underwent segmental resection (p = 0.049). After PSM (n = 106), the median DFS was 18 months (IQR 9-26) in the tangential resection group, and 12 months (IQR 5-21) in the segmental resection group (p = 0.17). In the PSM population, lymph node ratio (HR 4.83; p = 0.028) and tumor size >25 mm (HR 3.26; p = 0.007) were identified as determinants of local recurrence.

CONCLUSION

Tangential venous resections are not associated with a higher rate of local recurrence. Long-term outcomes are more related to tumors characteristics than to venous resection techniques. A step-up approach to vein resection, with tangential resection being performed whenever technically feasible, should be strongly encouraged.

Utilisation of bioactive glass S53P4 inside an induced membrane for severe bone defect with high risk of infection: a multi-center preliminary experience

BACKGROUND

The induced membrane technique has been developed to address bone defect of critical size from various origins. Despite its exceptional efficacy, several cases underwent a failure, which is regularly associated with a septic problem. The best way to conduct in this situation remains debated.

PURPOSE

To estimate use of bioactive glass S53P4 (BAG-53P4) in induced membrane technique failures or with an anticipated high risk of failure.

MATERIAL AND METHOD

We conducted a retrospective analysis of patients from several medical centers in Europe where BAG-S53P4 has been used inside an induced membrane. The etiology of the defect, the bone fixation used, the delay the bioactive glass was placed, the reason why the bioactive glass was used and the results were reported.

RESULTS

Eight cases were included (3 women and 5 men). Mean age was 43 years (16-82; Standard deviation 23). Mean height was 171 cm (162-184; SD 7), mean weight was 69 kg (60-85; SD 8) and Body Mass Index was 23,39 M/Kg2 (21,9-25,1; SD 1,22). Mean length of defect was 68 mm (40-100mm, SD 23). All patients received BAG-S53P4 granules (BonAlive Biomaterials Ltd, Turku, Finland) to fill the resultant cavity (3 as a stand-alone in the induced membrane and 5 mixed with autograft). Three patients were implanted with BAG-S53P4 during the second stage of a first induced membrane technique because of a high risk of infection (three open fractures); two patients were implanted with BAG-S53P4 during the second stage of a first induced membrane technique because of the great size of the defect (two infectious non-union); two patients were implanted with BAG-S53P4 as a third stage of induced membrane technique, i.e. inside a previously grafted membrane, because of a recurrence of the infection; and one patient was implanted with BAG-S53P4 during the second stage of a second induced membrane technique to avoid a new failure. At a follow-up of 16 months, all healed without any recurrence of the infection.

DISCUSSION

Critical size bone defects caused by an open fracture or an active infection can usually be addressed by the induced membrane technique. However, some cases are at high risk of failure because of the occurrence or recurrence of an infection. In these cases, bioactive glass may help the surgeon to improve the rate of bone union.

CONCLUSION

BAG-S53P4 may be considered as bone graft in an induced membrane technique, especially when there is a high probability of occurrence or recurrence of a bone infection.

The effects of dry needling to the thoracolumbar junction multifidi on measures of regional and remote flexibility and pain sensitivity: A randomized controlled trial

BACKGROUND

Dry needling (DN) has been consistently shown to decrease pain sensitivity and increase flexibility local to the site of treatment, however it is unclear whether these effects are limited to the region of treatment or can be observed remote to the area of treatment.

OBJECTIVE

To determine the immediate, short-term effects of DN to the thoracolumbar junction on regional and remote flexibility, and to observe if changes in pain sensitivity can occur remote to site of treatment.

DESIGN

Double-blind randomized clinical trial.

METHODS

Fifty-four subjects with low back pain and decreased length in at least one hamstring were randomized to receive either DN or sham DN to the T12 and L1 multifidi. Participants underwent regional (fingertip-to-floor) and remote flexibility (passive knee extension, passive straight leg raise) and pressure pain threshold (PPT) testing of the upper and lower extremity before, immediately after and 1 day after treatment. ANCOVAs were used to analyze flexibility data, with the covariate of pre-treatment values. Paired t-tests were used for difference in remote pain sensitivity.

RESULTS

Statistically larger improvements in regional flexibility, but not remote flexibility, were observed immediately post-treatment in those who received DN than in those receiving sham DN (p = .0495; adjusted difference 1.2, 95% CI 0.002-2.3). Differences between upper and lower extremity PPT were not significant.

CONCLUSION

DN can potentially have immediate changes in regional flexibility, but effects are not sustained at 24-h follow-up. DN may not affect remote flexibility or segmental pain sensitivity.

A retrospective study on mandibular reconstruction using iliac crest free flap

PURPOSE

To assess the availability, success rate and complications of microvascular iliac crest free flap for reconstruction of mandibular segmental defects.

METHODS

In this retrospective-descriptive study, we report patients who had undergone segmental mandibular resection for pathologic lesions and received reconstruction with iliac crest microvascular free flap between 2016 and 2019. Clinical and demographic data of all the cases were collected. Success was regarded as complete consolidation of the bone graft in panoramic radiograph. Postoperative complications were defined as major or minor based on the need for intervention. T-test, Kolomogorov_Smirnov, and multivariate analysis were used and the p-value<0.05 was considered to be statistically significant.

RESULTS

Of all 30 patients, 16 were women and 14 were men with an average age of 27.2 years (range 14-40). Patients were followed for 12-60 month (mean: 38.4). One flap was lost due to unsalvageable venous thrombosis. Six other cases had post-op complications while smoking and diabetes were associated with more complications (P = 0.036). Twenty-three patients received primary reconstruction which was more successful than secondary ones (P = 0.003). Osteogenic sarcoma was associated with greater risk of complications (P < 0.01).

CONCLUSIONS

The results of this study suggest that iliac crest microvascular free flap serves as a promising option for the reconstruction of mandibular defects, providing excellent contour and acceptable success rate with low donor site morbidity. Future studies will focus on the role of systemic diseases in post-op complications and flap failures.

Spread of segmental/multifocal idiopathic adult-onset dystonia to a third body site

BACKGROUND

Adult-onset focal dystonia can spread to involve one, or less frequently, two additional body regions. Spread of focal dystonia to a third body site is not fully characterized.

MATERIALS AND METHODS

We retrospectively analyzed data from the Italian Dystonia Registry, enrolling patients with segmental/multifocal dystonia involving at least two parts of the body or more. Survival analysis estimated the relationship between dystonia features and spread to a third body part.

RESULTS

We identified 340 patients with segmental/multifocal dystonia involving at least two body parts. Spread of dystonia to a third body site occurred in 42/241 patients (17.4%) with focal onset and 10/99 patients (10.1%) with segmental/multifocal dystonia at onset. The former had a greater tendency to spread than patients with segmental/multifocal dystonia at onset. Gender, years of schooling, comorbidity, family history of dystonia/tremor, age at dystonia onset, and disease duration could not predict spread to a third body site. Among patients with focal onset in different body parts (cranial, cervical, and upper limb regions), there was no association between site of focal dystonia onset and risk of spread to a third body site.

DISCUSSION AND CONCLUSION

Spread to a third body site occurs in a relative low percentage of patients with idiopathic adult-onset dystonia affecting two body parts. Regardless of the site of dystonia onset and of other demographic/clinical variables, focal onset seems to confer a greater risk of spread to a third body site in comparison to patients with segmental/multifocal dystonia at onset.

An ulcerated giant segmental hemangioma resulting in contracture of the left elbow

The majority of infantile hemangiomas are benign and will resolve on their own. We report a 4-month-old infant with an ulcerated giant segmental infantile hemangioma involving the left upper limb who developed a contracture of the left elbow despite treatment with oral propranolol, proper wound care, and regular intense physiotherapy. To our knowledge, contracture resulting from an infantile hemangioma has not been reported previously.

Surgical Management of Multifocal Trigeminal Schwannomas

BACKGROUND

Isolated trigeminal schwannomas occur in 0.07% to 0.3% of intracranial tumors and account for 0.8% to 8% of intracranial schwannomas and 1/3 of Meckel cave tumors. The presence of multisegmental schwannoma is rare, resulting in a limited understanding of its optimal management.

OBJECTIVE

To describe potential surgical options to manage this rare entity.

METHODS

A 2-institution retrospective review of all patients with pathologically confirmed trigeminal schwannoma managed with resection from January 2009 through January 2019 was conducted. A manual chart review was performed to verify patients' inclusion and collect data about age, sex, tumor size, tumor site, treatment modality, surgical approach, complications, and follow-up duration and status.

RESULTS

A total of 4 patients (age range 12-50 yr) who underwent a variety of cranial and orbitocranial approaches for tumor resection were identified. Patients achieved good outcomes with improvement of visual outcomes. One case of infection and 1 case of partial tumor recurrence requiring reresection were identified.

CONCLUSION

Multisegmental trigeminal schwannoma is a rare and unique entity, often associated with trigeminal schwannomatosis. Interdisciplinary management has been shown to be the most effective method for improving patient outcomes with these complex and poorly understood diseases.

Single versus dual orthogonal plating for comminuted midshaft clavicle fractures: a biomechanics study

BACKGROUND

Dual orthogonal plating of clavicle fractures may provide greater stiffness and strength than unilateral plate constructs and allow the use of lower-profile plates. We aim to biomechanically compare three clavicle plating constructs in a comminuted clavicle fracture model.

METHOD

Fifteen clavicle sawbones were osteotomised, simulating a comminuted midshaft fracture and allocated to either: group 1, single superior plate (3.5 mm superior plate); group 2, combination plating (3.5 mm superior plate, 2.8 mm anterior plate) and group 3, dual mini-plates (two 2.8-mm orthogonal mini-plates). Specimens were biomechanically tested under torsion and cantilever bending. Construct stiffness (Nm/degree) and load to failure (Nm) were measured.

RESULTS

Group 2 had higher torsional (0.70 vs. 0.60 Nm/deg, p = 0.017) and cantilever bending stiffness (0.61 vs. 0.51 Nm/deg, p = 0.025) than group 1. Group 3 had lower cantilever bending stiffness (0.39 vs. 0.51 Nm/deg, p < 0.004) and load to failure (40.87 vs. 54.84 Nm, p < 0.01) than group 1. All dual plate constructs that catastrophically failed did so from fracture at the lateral ends of the plates. Single plate constructs failed due to plate bending.

CONCLUSION

Dual orthogonal fixation with mini-plates demonstrated lower stiffness and strength than traditional superior plating. The addition of an anterior mini-plate to a traditional superior plating improved construct stiffness and may have a role in patients seeking early return to activity.

LEVEL OF EVIDENCE

Basic science biomechanical study.

Foot impairments contribute to functional limitation in individuals with ankle sprain and chronic ankle instability

PURPOSE

To investigate the clinical measures of foot posture and morphology, multisegmented joint motion and play, strength, and dynamic balance in recreationally active young adults with and without a history of a lateral ankle sprain (LAS), copers, and chronic ankle instability (CAI).

METHODS

Eighty recreationally active individuals (healthy: n = 22, coper: n = 21, LAS: n = 17, CAI: n = 20) were included. Foot posture index (FPI), morphologic measures, joint motion (weight-bearing dorsiflexion (WBDF), rearfoot dorsiflexion, plantar flexion, inversion, eversion; forefoot inversion, eversion; hallux flexion, extension), joint play (proximal and distal tibiofibular; talocrural and subtalar, forefoot; 1st tarsometatarsal and metatarsophalangeal), strength (dorsiflexion, plantar flexion, inversion, eversion, hallux flexion, lesser toe flexion), and Star Excursion Balance Test (SEBT) (anterior, posteromedial, posterolateral) were assessed.

RESULTS

There were no group differences in FPI or morphological measures. LAS and CAI groups had decreased ankle dorsiflexion (p = 0.001) and greater frontal plane motion (p < 0.001), first MT plantar flexion, and sagittal excursion (p < 0.001); increased talocrural glide (p = 0.02) and internal rotation (p < 0.001) and decreased forefoot inversion joint play (p < 0.001); and decreased strength in all measures (p < 0.001) except dorsiflexion compared to healthy controls. The LAS group also demonstrated decreased distal tibiofibular (p = 0.04) and forefoot general laxity (p = 0.05) and SEBT performance (anterior: p = 0.02; posteromedial: p < 0.001; posterolateral: p < 0.001).

CONCLUSION

Individuals with LAS or CAI have increased pain, impaired physiologic and accessory joint motion, ligamentous tenderness, and strength in the foot and ankle. Clinicians should assess the multiple segments of the ankle-foot complex when caring for individuals with an LAS or CAI.

LEVEL OF EVIDENCE

II.

[Detection of axillary nerve multisegment motor nerve conduction using magnetic stimulation]

Objective: To establish a method for detecting multi-segmental motor nerve conduction of axillary nerve using magnetic stimulation technique, and to preliminarily discuss its clinical application value. Methods: From April 2017 to February 2018, 80 healthy volunteers, 40 male and 40 female, were included and divided into five groups according to age and gender (groupⅠwere <35 years old; groupⅡwere 35-44 years old; group Ⅲ were 45-54 years old; groups Ⅳ were 55-64 years old; groups Ⅴ aged 65-74). Axillary nerve recording electrodes were placed in the deltoid muscle belly, reference electrode was placed in the deltoid muscle check point. Using the magnetic stimulation coil, stimulation was released at spots which were, respectively, 2 fingers from the lateral side of subscapular fossa, 2 fingers from the lateral side of infraclavicular fossae, and Erb's point. The latency, amplitude, detection distance (stimulation to recording electrode) were recorded at each spot, and the height and arm length were also measured. Results: The detection rate of axillary nerve waveform in healthy volunteers was 97.2%. There were no statistically significant differences in latency and amplitude in the different sides, gender (P>0.05).The latency corresponding to different detection distances was compared, and the difference was statistically significant (P<0.05).Height and arm length in different age groups were significantly increased in groupsⅠ, Ⅱ and Ⅲ compared with groups Ⅳ and Ⅴ, with statistical significance (P<0.05). When compared among different age groups, the latency and amplitude of group Ⅳand Ⅴ (more than 55 years old and over) were significantly prolonged and decreased, with statistically significant differences (P<0.05). Conclusions: The method of detecting multi-segmental magnetic stimulation of axillary nerve is stable and the result is reliable, which makes the evaluation of the proximal nerve of upper limbs be possible. However, the biological effects of age on nerve conduction should be carefully considered.

How Does Cage Lordosis Influence Postoperative Segmental Lordosis in Lumbar Interbody Fusion

BACKGROUND

Consideration of sagittal alignment is an integral part of spinal fusion surgery correlating with superior outcomes. Segmental lordosis is an important contributor to sagittal alignment. This study assessed surgical factors influencing segmental lordosis in a 360° fusion model, including cage dimensions, anterior longitudinal ligament resection, facetectomy, and posterior compression.

METHODS

Six L3-4 synthetic spinal motion segments were used in a repeated measures design. Each sample was sequentially instrumented with lateral cages of increasing height and angle. Lordosis was assessed from lateral radiographs of intact and each instrumented condition. The effect of anterior longitudinal ligament resection, posterior compression with pedicle screws, and bilateral facetectomy was additionally examined.

RESULTS

A linear relationship between segmental lordosis and cage height was found. This effect was greater with the anterior longitudinal ligament divided. In cages of the same anterior height, increased intrinsic cage lordosis did not result in increased segmental lordosis; cages with no intrinsic lordosis resulted in the highest segmental lordosis. In examining this finding, it was shown that posterior cage height had a larger influence on segmental lordosis. Posterior compression with pedicle screws and bilateral facetectomy increased the segmental lordosis by a further 3.4° and 2.6°, respectively.

CONCLUSIONS

Cage height was a key factor, with posterior compression further increasing lordosis. The finding that 0° cages results in the most segmental lordosis was an unexpected finding and highlights the importance of appropriate sizing on resulting lordosis. These findings are relevant to cage selection but require further study prior to applying to clinical practice and may influence future cage design.

Inter-spinous process distance: a novel parameter predicting segmental lordosis during posterior cervical spine deformity surgery

PURPOSE

To investigate the normative value of distance between the spinous processes (inter-spinous process distance, ISPD), correlations between patients' demographics and ISPD, and determine cutoff ISPD values that result in segmental lordosis in posterior cervical-thoracic arthrodesis with instrumentation.

METHODS

We reviewed patients with visible lower cervical and cervicothoracic spinous processes (C5-T2) on dynamic X-rays. Radiographic measurements included segmental Cobb angles (S-Cobb) and ISPD, defined as the distance between midpoints of the spinous processes. Correlations between patient demographics and ISPD were evaluated. In addition, the cutoff ISPD values that predict segmental lordosis (S-Cobb < 0°) were determined using the receiver operating characteristics (ROC) curve and linear regression model.

RESULTS

We evaluated a total of 153 films on 51 patients. The mean ISPDs in neutral position were 16.0, 20.7, 23.2, and 26.0 mm at C5/6, C6/7, C7/T1, and T1/T2, respectively There were no or only weak correlations between ISPD and age, race, height, body weight, and BMI. We observed significant difference between male and female ISPDs at C7/T1 and T1/T2 (P < 0.05). The ISPDs had moderate/strong correlations with S-Cobb at each segment (- 0.450 ≤ r ≤ - 0.705). Based on the ROC curves, the following cutoff values of ISPD provided 100% positive predictive value for segmental lordosis: < 10 mm at C5-6; < 15 mm at each level from C6 to T2.

CONCLUSION

ISPD is a simple and useful parameter that correlates with the segmental Cobb angle. During posterior cervical deformity surgery, surgeons can intraoperatively predict adequate segmental lordosis by utilizing the vertebral level specific cutoff values of ISPD. These slides can be retrieved under Electronic Supplementary Material.

Segmental testicular infarction following nephrectomy

Segmental testicular infarction is a rare diagnosis and there are few documented cases in the literature. Those cases that have been reported are usually in the setting of epididymitis, hypercoaguable states, vasculitis, sickle cell disease, post orchidopexy or vasectomy, and idiopathic. We report a case of a patient who developed segmental testicular infarction that was managed conservatively, following nephrectomy for a ruptured kidney and the associated ultrasonographic appearances.

Management of Segmental Bile Duct Injuries After Cholecystectomy: a Systematic Review

BACKGROUND

Injuries to segmental or aberrant bile ducts are encountered less commonly than their major bile duct counterparts and present a unique diagnostic and therapeutic challenge, since the nature of this injury involves a transected bile duct that loses its communication with the main ductal system. In this systematic review, we aim to pool available data on this particular type of biliary injury in an effort to outline available diagnostic and therapeutic modalities and evaluate their efficacy.

MATERIALS AND METHODS

An extensive literature search was performed on MEDLINE, Scopus, and Web of Science to identify isolated segmental or aberrant bile duct injuries.

RESULTS

A total of 21 studies were included in this systematic report. Ten studies reported non-operative management of patients, while 12 reported operative management of included patients. Outcomes of interest were the choice of treatment interventions and their success. Overall, 23 patients were managed non-operatively with a 91% success rate and 30 patients were managed operatively with a 90% success rate.

CONCLUSION

Non-operative management might be a viable alternative to surgery. Hepatobiliary surgeons should be encouraged to publish their results in treating these rare injuries to further elucidate the role and efficacy of such an approach.

Have You Seen SAM?

Introduction

Segmental arterial mediolysis (SAM) is a rare, non-atherosclerotic, non-inflammatory vascular disease mostly affecting medium to large sized abdominal arteries which may cause aneurysms, stenosis, and haemorrhage.

Report

A case is reported of a patient with SAM affecting the renal arteries bilaterally, where the diagnosis was made by excluding other inflammatory, immunological, and infectious mimickers.

Discussion

As SAM carries a significant mortality and morbidity from end organ ischaemia, infarction, or haemorrhage, it should be considered in any patient presenting with abdominal pain.

•

Segmental arterial mediolysis (SAM) should be considered in a patient presenting with acute severe abdominal pain because of the high mortality risk secondary to haemorrhage.

•

The mechanism of aneurysms, stenoses, and haemorrhage is thought to involve disruption of the arterial media.

•

SAM can be differentiated from its other mimickers by its clinical, laboratory, and radiological findings.

Surgical Outcome and Cosmetic Results of Autologous Fat Grafting After Breast Conserving Surgery and Radiotherapy for Breast Cancer: A Retrospective Cohort Study of 222 Fat Grafting Sessions in 109 Patients

BACKGROUND

Breast conserving surgery (BCS) and radiotherapy (RT) often lead to breast deformity. Reconstruction of these defects is a surgical challenge. Lately, the popularity of autologous fat grafting in these patients is growing. The purpose of this study was to assess clinical outcomes and aesthetic results of autologous fat grafting after BCS and RT.

MATERIALS AND METHODS

A database of all patients who underwent fat grafting after BCS and RT was prospectively maintained. Patient demographics, clinical and surgical characteristics and intra- and postoperative complications were analysed. Preoperative and 6-month postoperative photographs were evaluated by a four-member expert-panel assessing the aesthetic outcome (Harvard scale, five-point aesthetic scale and an overall score).

RESULTS

Between June 2008 and January 2016, 109 consecutive patients (114 breasts) underwent 222 fat grafting procedures. The mean clinical postoperative follow-up was 26 ± 19 months (range 10-97). The median number of fat grafting sessions sufficient for a satisfactory surgical result was two (range 1-6). Localized infections occurred in four patients, all treated effectively with oral antibiotics. Fat necrosis that required excision under local anaesthesia occurred once. The overall cosmetic appearance was rated 5.1/10 before and 7.2/10 after reconstruction (p < 0.01). A significant improvement was noted in breast symmetry, volume, shape and scarring.

CONCLUSION

Fat grafting after BCS and RT provides significant aesthetic improvement of the breast. It has a positive effect on the postsurgical scar and irradiated tissue and helps to restore the volume deficit, which makes it suitable as a reconstructive approach in this patient group.

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 www.springer.com/00266 .

Segmental Spinal Muscular Atrophy Localised to the Lower Limbs: First case from Oman

Spinal muscular atrophy (SMA) is a genetic lower motor neuron disease. It usually involves all of the skeletal muscles innervated by the anterior horn cells of the spinal cord. In rare cases, there is also localised involvement of the spinal cord. We report a 10-year-old boy who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in 2015 with muscle weakness restricted to the lower limbs. The presence of a homozygous deletion within the survival of motor neuron 1 gene confirmed the diagnosis of SMA. To the best of the authors' knowledge, this is the first report of an Omani patient with segmental SMA involving only the lower limbs. Treatment for this rare and relatively benign form of SMA is symptomatic and includes physiotherapy.

Segmental Vitiligo

Segmental vitiligo is characterized by its early onset, rapid stabilization, and unilateral distribution. Recent evidence suggests that segmental and nonsegmental vitiligo could represent variants of the same disease spectrum. Observational studies with respect to its distribution pattern point to a possible role of cutaneous mosaicism, whereas the original stated dermatomal distribution seems to be a misnomer. Although the exact pathogenic mechanism behind the melanocyte destruction is still unknown, increasing evidence has been published on the autoimmune/inflammatory theory of segmental vitiligo.

The treatment of segmental tibial fractures: does patient preference differ from surgeon choice?

INTRODUCTION

Segmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator.

MATERIALS AND METHODS

A convenience questionnaire survey of attending surgeons was conducted during the United Kingdom's Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5).

RESULTS

Based on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important.

CONCLUSION

We concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains uncertainty on the optimal surgical management for segmental tibial fractures. Furthermore, psychosocial factors and early post-operative outcomes should be reported as core outcome measures as part of such a trial.

Contrast induced spinal myoclonus after percutaneous coronary intervention

We present a case of a 77-year-old man diagnosed with contrast-induced spinal myoclonus following primary percutaneous coronary intervention. After being admitted with a diagnosis of anteroseptal myocardial infarction, he underwent primary percutaneous coronary intervention to the left anterior descending artery and was prescribed aspirin, clopidogrel, and intravenous heparin. The following day he developed non-intentional irregular jerky movements confined to the truncal area. In view of rhythmic jerking confined to muscles innervated by a restricted segment of the spinal cord, resistance to supra-spinal influences and voluntary action, and no preceding electroencephalography activity in the contralateral sensorimotor cortex, a diagnosis of spinal myoclonus was made. Spinal myoclonus is a rare entity in which myoclonic movements occur in muscles originating from few (segmental), or many adjacent spinal motor roots (propriospinal). Structural lesions are found in the majority of cases but the actual pathophysiology is still unknown. Contrast-induced spinal myoclonus is an even rarer phenomenon with few published reports. We describe postulated mechanisms and the management of this phenomenon. <Learning objective: Myoclonus is a jerky movement due to abrupt involuntary contractions involving agonist and antagonist muscles. Spinal myoclonus is a rare disorder where myoclonic movements occur in muscles originating from spinal motor roots. The cause is usually a structural lesion, but in rare cases it can be induced by contrast. A video of this rare phenomenon is available with this article and the proposed pathophysiological mechanisms and treatment are discussed.>.

Segmental left colectomy: a modified caudal-to-cranial approach. Surg Endosc. 2017;31:1487. [PMID: 27444827 DOI: 10.1007/s00464-016-5100-x]

BACKGROUND

We have designed a modified caudal-to-cranial approach to perform laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.

METHODS

IRB approval and informed consent have been obtained. A dissection is conducted to separate the descending mesocolon of the Gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. These maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. The specimen is extracted by a pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to Knight-Griffin technique.

RESULTS

We performed a laparoscopic segmental colectomy using this approach for 21 patients with benign sigmoid lesions: 13 diverticulitis, 3 flat polypoid lesions (no lift-up sign), and 5 bowel endometriosis. The mean operative time and blood loss were 161.4 ± 15.7 min and 50 ± 40 ml, respectively. There were not a single conversion to open surgery and no any leakage or stricture. Only 2 cases of intraluminal bleeding and 1 case of wound infection (treated conservatively) were observed.

CONCLUSION

We consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall.

The management of segmental tibial shaft fractures: A systematic review

INTRODUCTION

Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures.

METHOD

A PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data.

RESULTS

Thirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from 'excellent' to 'fair'.

DISCUSSION

The available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available.

CONCLUSION

IMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem.

Current status of ultrasound-guided surgery in the treatment of breast cancer

The primary goal of breast-conserving surgery (BCS) is to obtain tumour-free resection margins. Margins positive or focally positive for tumour cells are associated with a high risk of local recurrence, and in the case of tumour-positive margins, re-excision or even mastectomy are sometimes needed to achieve definite clear margins. Unfortunately, tumour-involved margins and re-excisions after lumpectomy are still reported in up to 40% of patients and additionally, unnecessary large excision volumes are described. A secondary goal of BCS is the cosmetic outcome and one of the main determinants of worse cosmetic outcome is a large excision volume. Up to 30% of unsatisfied cosmetic outcome is reported. Therefore, the search for better surgical techniques to improve margin status, excision volume and consequently, cosmetic outcome has continued. Nowadays, the most commonly used localization methods for BCS of non-palpable breast cancers are wire-guided localization (WGL) and radio-guided localization (RGL). WGL and RGL are invasive procedures that need to be performed pre-operatively with technical and scheduling difficulties. For palpable breast cancer, tumour excision is usually guided by tactile skills of the surgeon performing “blind” surgery. One of the surgical techniques pursuing the aims of radicality and small excision volumes includes intra-operative ultrasound (IOUS). The best evidence available demonstrates benefits of IOUS with a significantly high proportion of negative margins compared with other localization techniques in palpable and non-palpable breast cancer. Additionally, IOUS is non-invasive, easy to learn and can centralize the tumour in the excised specimen with low amount of healthy breast tissue being excised. This could lead to better cosmetic results of BCS. Despite the advantages of IOUS, only a small amount of surgeons are performing this technique. This review aims to highlight the position of ultrasound-guided surgery for malignant breast tumours in the search for better oncological and cosmetic outcomes.

The role of cerebellum in patients with late onset cervical/segmental dystonia?--evidence from the clinic

BACKGROUND

There is evidence from animal studies, post-mortem pathology, functional imaging and neurophysiological studies to suggest that the cerebellum may be involved in the pathophysiology of dystonia. We sought to explore further the association of clinical and radiological abnormalities of the cerebellum in patients with dystonia.

METHODS

We retrospectively reviewed patients from our movement disorders research database, with predominant cervical dystonia who have been seen within last 6 months and had available routine magnetic resonance imaging (MRI). The clinical details including presence of cerebellar signs, imaging findings and results of investigations were recorded on a proforma. The results were analysed using percentages and means with standard deviation.

RESULTS

Out of 188 patients included 26 had evidence of cerebellar abnormality on neuroimaging. 17 patients showed cerebellar atrophy and 10 of these had cerebellar signs on examination. These patients were tested negative for common inherited ataxias. 9 patients had cerebellar lesions on MRI, reported as low grade tumour (n = 2), cerebellar infarct (n = 3), cyst (n = 2), white matter hyperintensity (n = 1) and ectopia (n = 1) out of these 4 had cerebellar signs.

CONCLUSION

The findings from our study suggest that there may be overt clinical or radiological cerebellar involvement in 14% of cases with cervical/segmental dystonia. However, larger prospective studies are needed in this context.

Does it really spin? Intra-medullary nailing of segmental tibial fractures--a cadaveric study

This study aims to quantify the effect of intra-medullary reaming on rotational displacement of both long diaphyseal segmental tibial fractures (Melis Type III) and short (Melis Type IV) in a cadaveric model with differing degrees of soft tissue stripping. Eighteen fresh-frozen cadaveric specimens (9 matched pairs), median age at death was 85 years (68-92) were used to perform a standardized reaming procedure for an intra-medullary tibial nail and the rotational displacement of the segmental fracture fragment (long and short diaphyseal fractures) was recorded. Rotational displacement was recorded using a goniometer and K-wires positioned in the proximal, segmental and distal fracture fragments. Type III fractures rotate more than Type IV fractures (p<0.0001). In Type III fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 11.7 SD 12), 13 (SD 16.5) and 307.3 (SD 118.1) degrees respectively. In Type IV fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 8.5 (SD 5.5), 12.7 (SD 9.9) and 135.3 (SD 147.1) degrees respectively. The use of a pointed reduction clamp or unicortical plate eliminated rotational displacement. Reaming is a major risk factor for rotational displacement of segmental tibial fractures irrespective of the degree of soft tissue stripping. Long diaphyseal segmental fractures rotate more than shorter segmental fractures. We recommend always clamping the fracture during reaming to avoid rotational displacement.

Clinical course of segmental vitiligo: a retrospective study of eighty-seven patients

Background

Vitiligo is an acquired disorder characterized by a progressive loss of melanocytes, which is difficult to manage and has an unknown prognosis. The subtype of segmental vitiligo (SV) has been established but it has not been adequately characterized.

Objective

To collect long-term follow-up data for evaluating the clinical course of SV.

Methods

This study included 87 patients who were diagnosed with SV and were monitored at a clinic. Patients were classified into the following three groups according to disease activity.

Results

Among the patients with SV, 63.2% had stable disease, 14.9% had disease recurrence between two and four years after disease onset, and 21.8% had disease recurrence at four or more than four years after disease onset. Among the 44 patients (50.2%) who were monitored continuously over a four-year period, 19 (43.2%) experienced a recurrence at four or more than four years after disease onset.

Conclusion

Our results suggest that, contrary to previous reports, some patients with SV may not experience disease stability over an extended period of time. Disease recurrence can occur after years of stability, and we propose that long-term follow-up data can be used to characterize SV. This information about the clinical course of SV has implications for treatment and prognosis.

Treatment of segmental loss of the tibia by tibialisation of the fibula: a review of the literature

Segmental defects of the tibia are challenging therapeutic problems for both the physician and the patient. These defects may be caused by severe trauma, infection, tumors and congenital processes. Several different techniques have been described for treatment of these defects including the Papineau technique, allograft reconstruction, bone transport using the Ilizarov frame, free vascularized fibular graft, tibiofibular synostosis and medial transport of the fibula with Tuli’s technique, use of the Ilizarov frame and Huntington’s procedure. All of these techniques have their specific advantages as well as disadvantages. Some of these techniques are used rarely i.e. the Papineau technique. The procedure of choice for most large tibial defects is bone transport with Ilizarov’s technique; but in some cases the tibial remnant is inadequate for lengthening and we must use alternative treatments. In the three aforementioned techniques, the fibula is transferred with peroneal and anterior tibial muscles on a pedicle of peroneal vessels. This transfer retains a biological component of vital bone that allows for a shorter time for consolidation, increased remodeling potential and resistance to infection. It also has better long-term mechanical properties. Hypertrophy of the centralized fibula is described as attaining twice its original diameter or twice the size of the contralateral tibia. Hypertrophy has been seen in nearly all cases of the fibular centralization. Maximum hypertrophy is seen in children and besides patient age, is related to bony union and weight bearing. The reported time for hypertrophy of fibula varies from one to four years. No significant change in the diameter of the fibula was observed after five years. Fracture of tibialized fibula was not reported in many studies of fibular centralization with different techniques. In the reviewed articles, there were no cases of valgus deformity of the ankle. Either the patients were satisfied with the final results despite appearance of the lower extremity and the presence of some angular deformities, although in most cases, the deformities were mild. In this review we conclude that tibialisation of the fibula in selected cases is a reasonable alternative for the treatment of massive tibial defects.