Treatment of Thyroid Eye Disease-Associated Ophthalmopathy and Myopathy With Intraorbital Injection of 5-Fluorouracil and Triamcinolone Acetonide

PURPOSE

The authors report a technique of local application of anti-metabolite and corticosteroid mixture in the orbit for treatment of thyroid orbitopathy with moderate-severe inflammation and muscle involvement.

METHODS

Patients of one orbital surgeon seen between March 2019 and May 2020 with active thyroid eye disease and restrictive strabismus were considered for local treatment of the myopathic component of the disease. A mixture of 1 ml 5-FU 50 mg/ml, 0.25 ml triamcinolone 40 mg/ml, and 1 ml lidocaine 2% is injected through the skin using a 25-gauge, 1.5-inch needle into the orbit adjacent to the affected extraocular muscle. Six patients were treated in the outpatient setting and 3 patients have been treated with this intervention intraoperatively at the time of orbital decompression. One was treated with the mixture reconstituted with hyaluronic acid (Healon GV) to address postoperative medial rectus fibrosis to the medial wall, this mixture was applied topically in the operative field and not injected.

RESULTS

All patients had subjective improvement in the eye movement limitation and 2 patients had a change in motility on exam that was temporally correlated to injections. One patient did not disclose high-dose aspirin intake before injection and experienced a retrobulbar hemorrhage immediately following injection which was successfully treated. No complications were noted as a result of the medication itself.

DISCUSSION

The combination of 5-fluorouracil and triamcinolone acetonide for orbital treatment may be a useful adjunct in treating patients with ongoing inflammatory activity, both in the office and in the operating room. The novel combination may optimize ophthalmic outcomes, modifying disease course in some patients.

Decrement Evoked Potential (DEEP) Mapping of the Atria: Unmasking Atrial Fibrillation Substrate

BACKGROUND

Atrial myopathy may underlie the progression of atrial fibrillation (AF) from a treatable disease to an irreversible condition with poor ablation outcomes. Electrophysiological methods to unmask areas prone to re-entry initiation could be key to defining latent atrial myopathy.

METHODS

Consecutive patients referred for AF ablation were prospectively included at four institutions. Decrement evoked potential mapping (DEEP) was performed in eight left atrial sites and five right atrial sites, from two different pacing locations (endocardially from the left atrial appendage, epicardially from the proximal coronary sinus). The electrograms (EGMs) during S1 600 ms drive and after an extra stimulus (S2 at +30 ms above atrial refractoriness) were studied at each location and assessed for decremental properties. Follow-up was 12 months.

RESULTS

Seventy-four patients were included and 85% had persistent AF. A total of 17,614 EGMs were individually analysed and measured. Nine percent of the EGMs showed DEEP properties (local delay of >10 ms after S2) with a mean decrement of 33±26 ms. DEEPs were more frequent in the left atrium than the right atrium (9.4% vs 8.0%; p<0.001) and more prevalent in persistent AF patients than paroxysmal AF patients (9.8% vs 4.6% p=0.001). Atrial DEEPs were more frequently unmasked in normal bipolar voltage areas and by epicardial pacing than endocardial pacing (9.6% vs 8.4%, respectively; p=0.004). Within the left atrium, the roof had the highest prevalence of DEEP EGMs.

CONCLUSIONS

DEEP mapping of both atria is useful for highlighting areas with a tendency for unidirectional block and re-entry initiation. Those areas are more easily unmasked by epicardial pacing from the coronary sinus and more prevalent in persistent AF patients than in paroxysmal AF patients.

Extrapelvic endometriosis located individually in the rectus abdominis muscle: a rare cause of chronic pelvic pain (a case report)

Endometriosis of the rectus abdominis muscle is an extremely rare form of extrapelvic localization of the disease. It is usually iatrogenic and develops after caesarean section or gynecological surgery. Preoperative diagnosis is very difficult and a challenge for gynecologists and surgeons; thus, the diagnosis is histological. The treatment of choice consists of wide local excision of the lesion on healthy margins. We cite a case of isolated endometriosis in the rectus abdominis muscles in a 46-year-old patient with a previous caesarean section, the diagnosis of which was made randomly when performing abdominal total hysterectomy for the treatment of chronic pelvic pain. Histological examination of the surgical specimen confirmed the diagnosis. Simultaneously, the surgical specimen of the uterus and ovaries was free of endometriosis. Postoperatively, the patient mentioned discharge of her symptoms. No further therapeutic intervention was deemed necessary, as it was considered that a complete resection of the endometrial tissue implantation from the muscles of abdominal wall was performed. The present case report lay emphasis on the significant difficulties involved in the preoperative diagnosis of endometriosis of the rectus abdominis muscle. Concurrently, it is pointed out that, despite its rarity, individual extrapelvic endometriosis located in the rectus abdominis muscle should be included among other pathological entities in the differential diagnosis of chronic pelvic pain in women of reproductive age, who gave birth by caesarean section or underwent gynecological surgery with abdominal or laparoscopic access.

Persisting Muscle Dysfunction in Cushing's Syndrome Despite Biochemical Remission

CONTEXT

Glucocorticoid-induced myopathy is a characteristic symptom of endogenous Cushing's syndrome (CS). Its long-term outcome is largely unknown.

OBJECTIVE

To evaluate long-term muscle function following the remission of endogenous CS.

STUDY DESIGN

Observational longitudinal cohort study.

SETTING

Tertiary care hospitals and a specialized outpatient clinic.

PATIENTS

As part of the prospective multicenter German Cushing's Registry, we assessed muscle strength in patients with overt endogenous CS. We studied the patients at the time of diagnosis (n = 88), after 6 months (n = 69), and thereafter annually, following surgical remission over a period of up to 4 years (1 year: n = 55; 2 years: n = 34; 3 years: n = 29; 4 years: n = 22). Muscle function was evaluated by hand grip strength and by chair rising test.

RESULTS

Grip strength was decreased to 83% of normal controls (100%) at the time of diagnosis. It further decreased to 71% after 6 months in remission (P ≤ 0.001) and showed no improvement during further follow-up compared with baseline. Chair rising test performance improved initially (8 seconds at baseline vs 7 seconds after 6 months, P = 0.004) but remained at this reduced level thereafter (7 seconds after 3 years vs 5 seconds in controls, P = 0.038). In multivariate analysis, we identified, as predictors for long-term muscle dysfunction, age, waist-to-hip ratio, and hemoglobin A1c at baseline. Furthermore, muscle strength during follow-up was strongly correlated with quality of life.

CONCLUSION

This study shows that CS-associated myopathy does not spontaneously resolve during remission. This calls for action to identify effective interventions to improve muscle dysfunction in this setting.

A tissue engineering approach for repairing craniofacial volumetric muscle loss in a sheep following a 2, 4, and 6-month recovery

Volumetric muscle loss (VML) is the loss of skeletal muscle that results in significant and persistent impairment of function. The unique characteristics of craniofacial muscle compared trunk and limb skeletal muscle, including differences in gene expression, satellite cell phenotype, and regenerative capacity, suggest that VML injuries may affect craniofacial muscle more severely. However, despite these notable differences, there are currently no animal models of craniofacial VML. In a previous sheep hindlimb VML study, we showed that our lab’s tissue engineered skeletal muscle units (SMUs) were able to restore muscle force production to a level that was statistically indistinguishable from the uninjured contralateral muscle. Thus, the goals of this study were to: 1) develop a model of craniofacial VML in a large animal model and 2) to evaluate the efficacy of our SMUs in repairing a 30% VML in the ovine zygomaticus major muscle. Overall, there was no significant difference in functional recovery between the SMU-treated group and the unrepaired control. Despite the use of the same injury and repair model used in our previous study, results showed differences in pathophysiology between craniofacial and hindlimb VML. Specifically, the craniofacial model was affected by concomitant denervation and ischemia injuries that were not exhibited in the hindlimb model. While clinically realistic, the additional ischemia and denervation likely created an injury that was too severe for our SMUs to repair. This study highlights the importance of balancing the use of a clinically realistic model while also maintaining control over variables related to the severity of the injury. These variables include the volume of muscle removed, the location of the VML injury, and the geometry of the injury, as these affect both the muscle’s ability to self-regenerate as well as the probability of success of the treatment.

Primary hydatid disease of the transverse abdominal muscle A case report

INTRODUCTION

Echinococcus is a parasitic disease that affects all organs and tissues. The most commonly affected are liver (70-80%) and lungs (10-25%), while very rarely, in about 5% of cases, it can be found in the spleen, kidneys, brain, heart, pancreas, muscles and skeleton.

CASE REPORT

Although localization of hydatid cyst in muscle is rare, it is important to consideredPORT it in the differential diagnosis of a cystic mass in the muscle. Clinical diagnosis of cystic echinococcosis is based on general ultrasound imaging, CT, MRI, differentiation of Echinococcus-Ag, ELISA testing, immunoelectrophoresis (IEP), counterimmunoelectrophoresis (CIE).

DISCUSSION

Surgery is the primary treatment for muscle hydatidosis. We present our experience in treating the case of an infected hydatid cyst on transverse abdominal muscle, with infection extending to the right diaphragm and subcutaneous tissue of abdomen and thorax between the transverse abdominal and internal sternal abdominal muscles.

CONCLUSION

The goal of the surgical treatment is total evacuation of the parasite, "sterilization" of the residual cavity and handling of intraoperartive complications. The post-operative course was normal and the patient was discharged to home care ten days after surgery in good general and local condition.

KEY WORDS

Abscess, Echinococcus, Infection, Muscle.

[Clinical Assessment of Fourteen Cases of Thoracic Endometriosis]

We retrospectively assessed the clinical and pathological features of 14 patients with thoracic endometriosis who were treated at our hospital from 2007 to 2017. Thirteen patients presented pneumothorax and 1 patient presented bloody sputum. All were treated surgically. Pneumothorax occurs on the right side in all 13 cases and bloody sputum was from left side lesion. Ten patients presented symptoms closely related with their menstrual cycle (days -2 to 5). At surgery, dark red or dark brown spots, small hiatus and scar-like findings on the surface of the visceral pleura or diaphragm were identified in all cases. Pathological or immunohistochemical examinations of diaphragm or lung tissue specimens revealed endometrial tissue in 6 cases of pneumothorax and a case of bloody sputum. Nine patients received hormonal therapy(8:pneumothorax, 1:bloody sputum). Pleurodesis was performed for 1 pneumothorax patient with recurrent pneumothorax after hormonal therapy. In case of young female with repeated pneumothorax, catamenial pneumothorax must be kept in mind as a differential diagnosis and appropriate timing for surgical treatment should be considered to establish pathologically correct diagnosis.

Management of calcific myonecrosis with a sinus tract: A case report

RATIONALE

Calcific myonecrosis is a very rare late sequela that occurs in patients who have had trauma accompanied by vascular compromise, in which a single muscle or entire muscles in a compartment undergoes necrosis and form a calcified mass. It is mostly a benign entity, but some cases cause bone destruction and form non-healing chronic sinuses. In such cases, wound management becomes difficult and there is a potential risk of secondary infection.

PATIENT CONCERNS

A 60-year-old male was referred for evaluation of a pain, erythematous changes, and draining sinus of the anterolateral aspect of his left leg. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery owing to a distal femur fracture and femoral artery rupture.

DIAGNOSES

A thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The radiographs of the left leg showed a large, fusiform-shaped, radiopaque soft tissue mass in the space between the tibia and fibula. We performed an incisional biopsy to differentiated soft tissue sarcoma and malignant cells were found. Pathologic evaluation revealed acute and chronic inflammation with dystrophic calcification. These findings led to the diagnosis of calcific myonecrosis.

INTERVENTIONS

We performed an extensive debridement of the anterior and deep posterior compartments to ensure definitive treatment. Upon performing extensive debridement, we inserted a drain tube and performed primary closure.

OUTCOMES

The fluid continued to be discharged through the drain even after the surgery; delayed wound healing occurred 4 weeks following the surgery, and there was no recurrence at follow-up conducted 2 years later.

LESSONS

Calcific myonecrosis is mostly a benign entity, but some cases of calcific myonecrosis cause bone destruction and form non-healing chronic sinuses. In such cases, surgical treatment is required, during which the necrotic tissue and calcific material must be extensively debrided and drained.

Treatment of Inferior Oblique Muscle Overaction with Myectomy Or with Anterior Transposition

This paper presents a comparative study of the effectiveness of myectomy and anterior transposition in the treatment of inferior oblique muscle overaction. We operated 160 patients with overaction of the inferior oblique muscle. Eighty patients (148 eyes) were operated by myectomy at the insertion and 80 patients (151 eyes) by anterior transposition of the insertion of the inferior oblique near the temporal side of the insertion of the inferior rectus muscle. Comparison of the two methods, using the chi-squared test, showed that:

1) both surgical procedures were equally effective (χ2=0.26) for correcting overaction of the inferior oblique muscle and V-phenomenon;

2) weakening of the inferior oblique muscle of both eyes was almost always required (in 115 out of 116 cases) in cases with V-phenomenon and often (24 out of 44 cases) in cases of congenital paresis of the superior oblique muscle. We conclude that both procedures are equally effective and equally easy to perform.

Abdominal and Extra-Abdominal Desmoid Tumors. Report of 21 Cases

Desmoid tumors are easily diagnosed when located within the muscles of the abdominal wall. On the contrary, extra-abdominal desmoids, because of their various sites and lack of pathognomonic signs, can be very difficult to diagnose. A review of 21 cases of the Istituto Nazionale Tumori of Milan confirms that these tumors primarily affect young, multiparous women and that even extra-abdominal desmoids are prevalent in women. All patients were treated by radical surgery consisting of wide excision in 18 cases, hemimandibulectomy in 1 case, and amputation of the lower limb in 2 cases. Radical surgery resulted in no recurrences in all cases but one. Our results are in contrast with the relatively high recurrence rates reported in the literature.

Limitation of Knee Flexion by a Fibrotic Band of a Fifth Component of the Quadriceps Muscle in a Child: A Case Report

CASE

We describe the case of a 3-year-old boy who presented with limited flexion in the left knee. High-resolution magnetic resonance imaging allowed visualization of a fibrotic muscle band in the anatomic position of the fifth component of the quadriceps muscle, which was confirmed by surgical findings. After surgical resection, the patient achieved full recovery of range of motion of the knee.

CONCLUSION

To our knowledge, this is the first reported case of a fibrotic muscle band in the anatomic position of a previously described fifth accessory component of the quadriceps muscle that caused limited knee flexion in a child.

A rare case report: enlarged iliopsoas cystic solid mass associated with femoral head necrosis induced by heavy alcohol consumption

RATIONALE

This article presents an unusual case of a large iliopsoas cystic solid mass associated with femoral head necrosis in a patient with heavy alcohol consumption for years.

PATIENT CONCERNS

The patient reported pain and limitation of movement at the right hip for 4 months. A soft tissue mass can be palpated deep in the groin several days after the onset of pain.

DIAGNOSES

The laboratory assessments indicated an inflammatory response of the patient. Imaging was performed on the femoral head and iliopsoas cyst. The pathological feature of the mass was evaluated through biopsy examination. It was found that iliopsoas cystic solid mass is secondary to the femoral head necrosis induced by heavy alcohol consumption.

INTERVENTIONS

The patient underwent elective total hip arthroplasty. The bursa was excised and the anterior hip capsule closure was performed.

OUTCOMES

After the surgery, imaging results showed a well-positioned prosthesis. At 1-year follow-up, the prosthesis was still well-positioned and no signs of recurrence of iliopsoas bursa were found.

LESSONS

We suggested the performance of elective total hip arthroplasty, bursa excision, and closure of the anterior hip capsule in patients with femoral necrosis and iliopsoas bursitis presented simultaneously.

Diaphragmatic hydatid disease: a diagnostic challenge for the radiologist

Primitive hydatid disease of diaphragm is very rare. The preoperative diagnosis of this hydatid location represents a challenge for the radiologist. We reported a case of primitive hydatid cyst of the diaphragm not associated with other hydatid localizations which was diagnosed preoperatively. A 70 year-old woman with no previous medical history, complained of abdominal pain in the right upper quadrant for 7 months. The physical exam and the laboratory tests were unremarkable. Abdominal ultrasound showed multiloculated cystic lesion which appeared to be located in the hepatic dome suggestive of hydatid cyst of the liver.  However, computed tomography showed findings but in favour of the diaphragmatic origin of the cyst which was confirmed peroperatively. Since the exploration of cysts lying between the thorax and the abdomen is difficult by ultrasound, computed tomography with multiplanar reconstruction appears to be indispensable in the preoperative assessment of hydatid cysts in contact with the diaphragm.

Spontaneous bilateral quadriceps rupture in a patient with ankylosing spondylitis: A case report

Ankylosing spondylitis is a prototype rheumatoid factor-negative spondyloarthropathy that causes the vertebrae to fuse making the spine less flexible, resulting in a hunched-forward posture. A 47-year-old male who was a known case of ankylosing spondylitis presented with left quadriceps rupture after raising his right foot to lightly hit a football. He was fitted with a knee immobilizer as an emergency measure. The extent of the rupture was not yet established when patient requested leave to go home. The right quadriceps was ruptured as well when he took his immobilizer off to go the bathroom. We report herein an extremely rare case of ankylosing spondylitis with atrophy in the quadriceps to the extent of causing pathological muscle rupture. Prolonged period of immobilization results in muscle wasting which leads to knee joint instability so the muscle should be repaired as soon as possible.

Ectopic Thyroid Tissue With Hashimoto's Thyroiditis

OBJECTIVE

Ectopic thyroid gland is a rare occurrence with a prevalence of 1 per 100,000 to 300,000 people. Hashimoto's thyroiditis involving ectopic thyroid tissue is particularly unusual. We describe the presentation, workup, surgical management, and brief review of the literature.

METHODS

Retroactive review of an 83-year-old white female patient record. As a case report, this project was exempt from institutional review board approval.

RESULTS

We present a case of ectopic thyroid tissue located in the strap muscles with concurrent Hashimoto's thyroiditis. This tissue initially was believed to represent metastatic follicular thyroid carcinoma.

CONCLUSION

Whenever ectopic thyroid tissue is encountered, the gravest concern is metastatic thyroid cancer. The possibility of benign thyroid tissue should not be excluded even if the thyroid histology initially appears to be malignant in nature.

Soft tissue aneurysmal bone cyst: a rare case in a middle aged patient

Soft tissue aneurysmal bone cyst is a rare entity, with about 20 cases reported in literature, only 3 of which are in patients over 40 years of age. We present a case of a 41 year old Latin American female who presented for evaluation of atraumatic chest pain with radiation to the left shoulder. Her initial workup was negative, including radiographic imaging of the chest and left shoulder. 4 months later, she presented to her orthopedic surgeon with a palpable mass and mild left shoulder pain. Radiographs acquired at that time demonstrated a 7.0 × 5.5 × 6.7 cm mass with rim calcification in the region of the upper triceps muscle. Subsequent CT imaging showed central areas of hypodensity and thin septations, a few of which were calcified. MR evaluation showed hemorrhagic cystic spaces with multiple fluid-fluid levels and enhancing septations. Surgical biopsy was performed and pathology was preliminarily interpreted as cystic myositis ossificans, however on final review the diagnosis of soft tissue aneurysmal bone cyst was made. The lesion was then surgically excised and no evidence of recurrence was seen on a 3 year post-op radiograph. Following description of our case, we conduct a literature review of the imaging characteristics, diagnosis, and treatment of soft tissue aneurysmal bone cyst.

Simultaneous prosthetic mesh abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs

BACKGROUND

Standard abdominoplasty rectus plication techniques may not suffice for severe cases of rectus diastasis. In the authors' experience, prosthetic mesh facilitates the repair of severe rectus diastasis with or without concomitant ventral hernias.

METHODS

A retrospective review of all abdominal wall surgery patients treated in the past 8 years by the senior author (G.A.D.) was performed. Patients with abdominoplasty and either rectus diastasis repair with mesh or a combined ventral hernia repair were analyzed.

RESULTS

Thirty-two patients, 29 women and three men, underwent mesh-reinforced midline repair with horizontal or vertical abdominoplasty. Patient characteristics included the following: mean age, 53 years; mean body mass index, 26 kg/m; average width of diastasis or hernia, 6.7 cm; and average surgery time, 151 minutes. There were no surgical-site infections and two surgical-site occurrences-two seromas treated with drainage in the office. After an average of 471 days' follow-up, none of the patients had recurrence of a bulge or a hernia.

CONCLUSIONS

For patients with significant rectus diastasis, with or without concomitant hernias, the described mesh repair is both safe and durable. Although this operation requires additional dissection and placement of prosthetic mesh in the retrorectus plane, it may be safely combined with standard horizontal or vertical abdominoplasty skin excision techniques to provide an aesthetically pleasing overall result.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Surgical treatment of spinal tuberculosis complicated with extensive abscess

PURPOSE

Tuberculosis can be responsible for extensive spinal lesions. Despite the efficacy of medical treatment, surgery is indicated to avoid or correct significant deformity, treat spinal instability, prevent neurological compromise, and to eradicate an extensive tuberculous abscess. In this paper we present our experience in the surgical management of spinal tuberculosis complicated with large abscess.

PATIENTS AND METHODS

Fifteen patients with spinal tuberculosis complicated with extensive abscess were identified; and nine of those patients had extension of the infection into the epidural space. The average age at treatment was 34 years old. Seven patients had thoracic infection, seven patients had lumbar infection and one had thoracolumbar infection. Six patients had neurological deficit at presentation. All patients were surgically treated with abscess debridement, spinal stabilization and concurrent antituberculous chemotherapy. A single anterior surgical approach was used in three cases, a posterior approach was used in four others and a combined approach was performed in eight patients.

RESULTS

Surgical management allowed for effective abscess debridement and sspinal stabilization in this cohort. In combination with antituberculous drugs, surgical treatment resulted in infection eradication and bone fusion in all patients at 24 month average follow-up. Satisfactory neurological outcomes with improved American Spinal Injury Association (ASIA) scores were observed in 100% of patients.

CONCLUSION

Surgical treatment for spinal tuberculosis abscess can lead to satisfactory clinical outcomes.

Distal quadricepsplasty in children: 88 cases of retractile fibrosis following intramuscular injections treated in Benin

INTRODUCTION

Retractile fibrosis of the quadriceps (RFQ) is a physical and social handicap in children, and often results from a past history of quadriceps intramuscular injection. The aim of this study was to evaluate the therapeutic results of RFQ treated by distal quadricepsplasty using a modified Thompson-Payr procedure (DQPMTP).

HYPOTHESIS

Functional recovery will be good with DQPMTP.

PATIENTS AND METHODS

This is a descriptive retrospective 10-year study from 2002 to 2011, including 74 children (88 knees) less than 15 years old, admitted for RFQ and treated in Benin. The types of RFQ were: knee flexion loss of motion 16 cases (18.2%), lag of extension 54 cases (61.4%) and associated genu recurvatum, 18 cases (20.5%). Wasting of the thigh was found in all cases. An associated distal femoral osteotomy was performed to correct a bone deformity in 18 cases (20.5%).

RESULTS

There were 16 cases (18.2%) of poorly looking postoperative scars and 2 cases (2.3%) of fracture during physical therapy. Mean flexion ROM after surgery was 77.7°. Mean flexion increased from 77.7° to 108.5° following postoperative rehabilitation or a mean gain of 30.7°. The quadriceps muscle testing scores were at least 3/5. Results of DQPMTP were good in 80.7% of cases, as shown by mean active knee flexion of 108.5° with normal active extension. The results were satisfactory in 17 cases (19.3%).

DISCUSSION

DQPMTP has the advantage of cutting a minimum of blood vessels, thus limiting the risk of hematoma. Laterally placed incisions create less tension reducing the risk of skin necrosis. The clinical and radiological results of this series confirm those in the literature. Treatment of RFQ by DQPMTP provides satisfactory functional rehabilitation in patients, which confirms our hypothesis.

LEVEL OF EVIDENCE

Level IV, retrospective study without comparison.

[Soft tissue reconstruction after resection of musculoskeletal tumors]

OBJECTIVE

To evaluate the effectiveness of soft tissue reconstruction after resection of musculoskeletal tumor and to discuss the strategy of soft tissue reconstruction.

METHODS

Between June 2003 and December 2010, 90 patients with musculoskeletal tumor underwent tumor resection and soft tissue reconstruction. There were 59 males and 31 females with a median age of 37.2 years (range, 9-85 years), including 52 bone tumors and 38 soft tissue tumors. One stage reconstruction of soft tissue was performed after tumor resection in 75 cases; reconstruction of soft tissue was performed after debridement in 7 cases of wound dehiscence; and two stage reconstruction of soft tissue was performed after debridement and vacuum sealing drainage placement in 8 cases of infected wounds. The gastrocnemiums flap was used in 40 cases, the latissimus dorsi myocutaneous flap in 6 cases, rectus abdominis myocutaneous flap in 4 cases, gluteus maximus musculocutaneous flap in 1 case, pectoralis major muscle flap in 1 case, cross-abdominal flap in 1 case, local transfer flap in 27 cases, pedicled flaps in 5 cases, and skin grafts in 5 cases. The size of the flap ranged from 6.5 cm x 4.5 cm to 21.0 cm x 9.0 cm.

RESULTS

Eighty-seven flaps survived, and incisions healed by first intention in 81 cases. In 6 cases of healing by second intention, 2 had partial flap necrosis, which was cured by dressing change; 3 had delayed healing; 1 had mild infection, which was cured after conservative treatment. Wound of donor site healed primarily, and the grafted skin survived. Seventy-three patients were followed up 10-102 months (mean, 36.1 months). Local tumor recurrence was observed in 6 patients, who received second resection at 2-27 months (mean, 8.2 months) after operation. Thirteen patients dead of primary disease at 6-34 months (mean, 19.2 months) after operation.

CONCLUSION

The defects caused by resection of musculoskeletal tumor require soft tissue reconstructions. Optimal reconstruction can enhance wound closure, decrease incidence of wound complication, preserve limb function.

[Causes, diagnostics and therapy for paediatric ptosis]

BACKGROUND

The diagnosis of and therapy for paediatric ptosis present challenges because of difficulties in performing preoperative examinations and the inability of the patient to provide intraoperative cooperation for proper lid placement. The authors provide an overview of the different forms and findings in congenital ptosis patients and point out the difficulties of the surgical procedures.

DIAGNOSTICS AND THERAPY

The majority of paediatric ptosis cases is simple unilateral congenital ptosis with dysgenesis of the levator palpebrae superioris muscle. Other different forms exist due to neurological, neuro-myogenic, aponeurotic, sympathic, and mechanical reasons or syndromes. The relevant history is obtained, including birth history and family history, careful observation and full ophthalmological examination are necessary. Amblyopia because of ptosis, strabismus or anisometropia with corneal astigmatism should be recognised and treated early. The preoperative examination is vital for determining the appropriate diagnosis and is useful for selecting the appropriate procedure. Ptosis correction is based on ptosis severity, Bell phenomenon and levator function. The primary goal is symmetry of the upper lids. Most frequently a levator resection is performed between the 3rd and 5th year with a levator function of more than 3 mm. The most common complication is undercorrection, poor lid contour or amblyopia. Overcorrection may be associated with dry eye syndrome and keratopathy.

CONCLUSION

Levator resection is a useful procedure for the correction of mild to moderate ptosis. Frontalis suspension surgery is effective for congenital ptosis with poor levator function.

Clinical profile of musculoskeletal injuries associated with the 2008 Wenchuan earthquake in China

BACKGROUND

The Wenchuan earthquake was an enormous devastating disaster and caused mass casualties. The descriptive analysis presented here serves as a reference not only for present injury intervention but also for future earthquake disaster response.

METHODS

A total of 205 patients with a musculoskeletal injury were admitted in two teaching hospitals. We conducted a retrospective review of medical records to document the injury profile, chief complaints, damage locations and types, subsequent treatment, and prognosis.

RESULTS

Of the 205 patients, fracture was the major type of injury (78.0%). Forty patients were determined to have crush injuries and 19 patients had crush syndromes. Open fractures, multiple fractures and comminuted fractures were common. Fracture-associated neural injuries and trauma-associated infections were also common. Surgical treatments included debridement, bone traction, external fixation, open reduction and internal fixation, and spinal fixation. All the patients were effectively treated with few complications, a low deformity rate and no death.

CONCLUSION

For emergency conditions after a major earthquake, pre-hospital emergency care is highly important. After the patients are transported to the hospital, we should plan individualized treatment according to the patients' respective clinical features, and at the same time, prevent and cure the related complications in a timely manner in order to reduce mortality and disability rates.

Rectus sheath hematoma of the abdomen. Case report

BACKGROUND

Rectus sheath hematoma in the vast number of cases is due to an inferior epigastric artery tear occasionally due to trauma (not considered serious) or alterations in coagulation or use of anticoagulant therapy. It is an unlikely and difficult to diagnose pathology.

CLINICAL CASE

We present the case of a 61-year-old female patient. The patient presented in emergency service with sudden abdominal pain caused by coughing as a result of an upper respiratory tract infection. The culmination was a spontaneous rectus sheath hematoma.

CONCLUSIONS

Rectus sheath hematoma is a diagnosis to consider in a previously asymptomatic patient who presents with clinical features of acute pain and appearance of increase of volume in the abdominal wall involving the rectus muscles.

[Thyroid ectopia: problems in diagnosis and therapy]

The Authors report the cases of ectopic thyroid (n=22) observed among the thyroid pathologies that underwent surgical approach in the last 20 years (n=2670), to discuss their clinic characteristics other than the diagnostic and therapeutic approaches. Sometimes asymptomatic or emerged after thyroidectomy, the ectopic thyroid may generate functional troubles or, most frequently, local compression that require surgical approach that, in the opinion of these authors, is ever indicated also for asymptomatic forms. Based on author's experience, also if statistically rare, it is not possible to neglect the neoplastic degeneration, elapsed in two out of 22 cases analyzed.

Post-traumatic calcific myonecrosis of flexor hallucis longus. A case report and literature review

Calcific myonecrosis is a rare, late complication of compartment syndrome in the lower extremity. In this condition an entire single muscle of the leg is replaced by a fusiform mass with central liquefaction and peripheral calcification. Calcific myonecrosis presents a diagnostic dilemma to the clinician; it has to be considered in the differential diagnosis of a calcifying soft tissue tumour in the lower extremity. The purpose of this report is to highlight the importance of recognition of the lesion and its key clinico-pathological presenting features leading to appropriate management. We describe the unique presentation, diagnosis and surgical management of calcific myonecrosis involving only the flexor hallucis longus muscle of the leg in a middle-age adult. We found MRI Scan as the most useful method of investigation. Diagnosis can be confirmed by yellow-brown paste like material within the lesion intra-operatively or by aspiration and further by histology. We recommend complete excision of the lesion and closure of the wound with compression dressing, to avoid secondary infection.

Giant primary muscular hydatid cyst with a secondary bone localization

Primary musculoskeletal hydatidosis is less frequent than hydatidosis of the parenchymal organs. This localization has been little studied and so there is little information in the literature on the subsequent disease evolution. We present a case of primary hydatidosis of the abductor muscle that came to medical attention very late. After complete surgical removal of the huge mass, a secondary bone localization developed, causing a femoral pertrochanteric pathological fracture. The case described is exceptional in view of both the localization and the great size of the primary multi-lobed muscle hydatid cyst. We underline the difficulties of diagnosis and treatment of both the primary muscle localization and the secondary bone recurrence.

Endometriosis in the rectus abdominis muscle: case report and literature review

Endometriosis is characterized by the presence of histologically normal endometrial tissue outside the uterine cavity. Endometriosis occurs most commonly within the pelvis. Extrapelvic endometriosis is less common, but can involve nearly every organ in the body. We present a patient in whom endometriosis was discovered in the rectus abdominis muscle and discuss the imaging findings and histopathology.

[Posttraumatic muscular forearm hernia]

Symptomatic posttraumatic muscular herniation is a very rare complication of forearm fracture. We report a case of symptomatic musular herniation tretaed with an autologous fascia lata onlay graf.

[Autopsy case of PR3-ANCA-associated vasculitis complicated with rectus muscle hematoma]

A 80-year-old man was admitted to our hospital because of coughing, hemosputum and dyspnea. As a chest X-ray showed infiltrates of the right lung, he was diagnosed as bacterial pneumonia and treated with antibiotics. However, after a few days, he exhibited hemoptysis and developed severe dyspnea, while laboratory findings showed rapid elevation of the serum creatinine level (5.55 mg dL). Computed tomography (CT) revealed large areas of ground glass opacity in the right lung, hence the hemoptysis was considered to be due to alveolar hemorrhage. As he had been diagnosed as chronic renal failure a few years before this admission and we also noticed that interstitial pneumonia with a slightly elevated level of C-reactive protein had existed from that time, ANCA-associated vasculitis was suspected to be the underlying pathogenesis. Accordingly, he was started on methylprednisolone pulse therapy and temporary hemodialysis resulted in improvement of dyspnea and renal function. PR3-ANCA was 12.4 EU, so he was diagnosed as PR3-ANCA-associated vasculitis. After a few days, he suddenly complained of abdominal pain, developing hypotension and anemia. Abdominal CT showed an irregular low-density mass in the right muscle, so he was diagnosed as rectus muscle hematoma. Surgery was performed and a massive hematoma was found in the rectus muscle without any ruptures of macroscopic vessels in the abdomen. Bleeding could not be stopped followed by multiple organ failure and the patient died four days postoperatively. Rectus muscle hematoma is an uncommon cause of acute abdomen, and has been reported in about 100 cases in Japan. It occurs because of a tear in epigastric vessels and is usually managed conservatively with a good prognosis, although hemodynamically unstable cases require surgery. To the best of the authors' knowledge, this is the first case of rectus muscle hematoma complicated with ANCA-associated vasculitis.

[Anesthetic management of patients with muscular disease?]

The past two decades has been characterized by important advances in symptomatic care to the muscular patient. In particular, the development of home mechanical ventilation was associated by a substantial improvement in life expectancy. The presence of a muscular disease is less frequently a contra-indication of surgery and subsequently the issue of anesthetizing these patients has become a routine question. A growing number of muscular disorders have been subjected to specific guidelines for anesthetic procedures.

[Muscular compartment syndrome of the forearm in a haemophilia inhibitor patient]

Acute compartment syndrome is a complication in which microcirculation is impaired due to increased tissue pressure within a confined (osteo-fibrous) space and leads to neuromuscular dysfunction. A serious complication of haemophilia is the development of inhibitors. In this case the immune system produces antibodies to factor VIII or IX during substitution therapy of haemophilia A or B. These antibodies are directed against both, the substituted and the endogenous factors.

CASE REPORT

A man (age: 81 years) with originally moderate haemophilia A who at the age of 63 developed an inhibitor during treatment of a bleeding event. Painful swelling in the left forearm occurred without any recollection of trauma, and failed to subside under factor substitution initially performed by the patient. This finding necessitated emergency fasciotomy of the forearm flexor compartment.

CONCLUSION

In order to keep the complication rate as low as possible in the presence of hemophilia with inhibitors, the patients should only be treated in a specially equipped interdisciplinary treatment center.

Heat shock treatment increases engraftment of transplanted human myoblasts into immunodeficient mice

Myoblast transfer therapy (MTT) is a strategy that has been proposed to treat some striated muscle pathologies. However, the first therapeutic trials using this technique were unsuccessful due to the limited migration and early cell death of the injected myoblasts. Various strategies have been considered to increase myoblast survival in the host muscle after MTT. Overexpression of heat shock proteins (HSPs) in mouse myoblasts has been shown to improve cell resistance against apoptosis in vitro and in vivo. Our objective was to determine whether heat shock (HS) treatment increased the survival of human myoblasts leading to better participation of the injected cells in muscle regeneration. For this study, HS-treated human myoblasts were injected into the tibialis anterior (TA) muscles of immunodeficient RAG-/- gammaC-/- mice. TA muscles were excised at 24 hour and at 1 month after injection. Our results showed that HS treatment increased the expression of the hsp70 protein and protected the cells from apoptosis in vitro. HS treatment dramatically increased the number of human fibers present at 1 month after injection when compared with nontreated cells. Interestingly, HS treatment decreased apoptosis at 24 hour after human myoblast injection, but no differences were observed concerning proliferation, suggesting that the increased fiber formation among the HS-treated group was probably due to decreased cell death. These data suggested that HS treatment might be used in the clinical context to improve the success of MTT.

Surgery for rotator cuff disease

BACKGROUND

This review is one in a series of Cochrane reviews of interventions for shoulder disorders.

OBJECTIVES

To determine the effectiveness and safety of surgery for rotator cuff disease.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, CINAHL, Sports Discus, Science Citation Index (Web of Science) in March 2006 unrestricted by date or language.

SELECTION CRITERIA

Only studies described as randomised or quasi-randomised clinical trials (RCTs) studying participants with rotator cuff disease and surgical interventions compared to placebo, no treatment, or any other treatment were included.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed methodological quality of each included trial and extracted data.

MAIN RESULTS

We included 14 RCTs involving 829 participants. Eleven trials included participants with impingement, two trials included participants with rotator cuff tear and one trial included participants with calcific tendinitis. No study met all methodological quality criteria and minimal pooling could be performed. Three trials compared either open or arthroscopic subacromial decompression with active non operative treatment (exercise programme, physiotherapy regimen of exercise and education, or graded physiotherapy strengthening program). No differences in outcome between these treatment groups were reported in any of these trials. One trial which also included a placebo arm (12 sessions detuned soft laser) reported that the Neer score of participants in both active treatment arms improved significantly more than those who received placebo at six months. Six trials that compared arthroscopic with open subacromial decompression reported no significant differences in outcome between groups at any time point although four trials reported a quicker recovery and/or return to work with arthroscopic decompression. Adverse events, which occurred in three trials and included infection, capsulitis, pain, deltoid atrophy, and reoperation, did not differ between surgical groups.

AUTHORS' CONCLUSIONS

Based upon our review of 14 trials examining heterogeneous interventions and all susceptible to bias, we cannot draw firm conclusions about the effectiveness or safety of surgery for rotator cuff disease. There is "Silver" (www.cochranemsk.org) level evidence from three trials that there are no significant differences in outcome between open or arthroscopic subacromial decompression and active non-operative treatment for impingement. There is also "Silver" level evidence from six trials that there are no significant differences in outcome between arthroscopic and open subacromial decompression although four trials reported earlier recovery with arthroscopic decompression.

Tibialis anterior rupture: acute and chronic

Rupture of the tibialis anterior tendon is an unusual injury. Most ruptures occur in elderly men with a history of minor trauma. The sudden occurrence of a "foot drop" is often the presenting symptom. The diagnosis is frequently delayed. The acute rupture is best treated by direct repair. Treatment of the chronic rupture is tailored to the patient. In relatively inactive patients, either a polypropylene ankle-foot orthosis or no treatment at all is indicated. In the more active patient, a reconstruction using extensor hallucis longus helps restore dorsiflexion function.