Citations

Summary: Soft tissue wounds overlying the dorsum of the foot and ankle are difficult to treat, and historically have been treated with free tissue transfer. Advances in surgical technique have expanded the use of pedicle perforator flaps to avoid free tissue transfer in certain situations. The authors describe a technique for using an extensor digitorum brevis flap to provide soft tissue coverage for wounds of the ankle and foot. In the senior authors’ experience, the use of this flap has achieved wound coverage in 100% of patients with smaller wounds (≤45 cm2) of the ankle.

PurposeOur objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results.MethodsFifty‐one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with >1 year follow‐up. The primary outcome measured was shoulder ER. The outcomes we utilized included “clinically useful ER” (motion ≥ −35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation.ResultsEMG evidence of re‐innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow‐up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: −60° to 90°) and MRC grade 2.2 (2–4). The only predictor of ER improvement was an isolated upper trunk (C5‐C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5‐C6‐C7 and panplexus injuries, respectively (P < 0.03).ConclusionsAlthough 85% had EMG signs of recovery, the SAN to SSN transfer failed to provide useful recovery of ER through reinnervation of the infraspinatus muscle in injuries involving more levels than a C5‐C6 root/upper trunk pattern. In patients with greater than C5‐6 level injuries alternatives to SAN to SSN transfer should be considered to restore shoulder ER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:365–370, 2017.

Objective The aim of this study was to compare 2-dimensional (2D) gradient recalled echo (GRE) and 2D spin echo echoplanar imaging (SE-EPI) magnetic resonance elastography (MRE) sequences of the liver in terms of image quality and quantitative liver stiffness (LS) measurement. Materials and Methods This prospective study involved 50 consecutive subjects (male/female, 33/17; mean age, 58 years) who underwent liver magnetic resonance imaging at 3.0 T including 2 MRE sequences, 2D GRE, and 2D SE-EPI (acquisition time 56 vs 16 seconds, respectively). Image quality scores were assessed by 2 independent observers based on wave propagation and organ coverage on the confidence map (range, 0–15). A third observer measured LS on stiffness maps (in kilopascal). Mean LS values, regions of interest size (based on confidence map), and image quality scores between SE-EPI and GRE-MRE were compared using paired nonparametric Wilcoxon test. Reproducibility of LS values between the 2 sequences was assessed using intraclass coefficient correlation, coefficient of variation, and Bland-Altman limits of agreement. T2* effect on image quality was assessed using partial Spearman correlation. Results There were 4 cases of failure with GRE-MRE and none with SE-EPI-MRE. Image quality scores and region of interest size were significantly higher using SE-EPI-MRE versus GRE-MRE (P < 0.0001 for both measurements and observers). Liver stiffness measurements were not significantly different between the 2 sequences (3.75 ± 1.87 kPa vs 3.55 ± 1.51 kPa, P = 0.062), were significantly correlated (intraclass coefficient correlation, 0.909), and had excellent reproducibility (coefficient of variation, 10.2%; bias, 0.023; Bland-Altman limits of agreement, −1.19; 1.66 kPa). Image quality scores using GRE-MRE were significantly correlated with T2* while there was no correlation for SE-EPI-MRE. Conclusions Our data suggest that SE-EPI-MRE may be a better alternative to GRE-MRE. The diagnostic performance of SE-EPI-MRE for detection of liver fibrosis needs to be assessed in a future study.

SummaryThe rituximab extended schedule or retreatment trial (RESORT; E4402) was a phase 3 randomized prospective trial comparing maintenance rituximab (MR) versus a retreatment (RR) dosing strategy in asymptomatic, low tumour burden indolent lymphoma. A planned exploratory sub‐study compared the two strategies for small lymphocytic (SLL) and marginal zone lymphomas (MZL). Patients responding to rituximab weekly × 4 were randomized to MR (single dose rituximab every 3 months until treatment failure) or RR (rituximab weekly × 4) at the time of each progression until treatment failure. The primary endpoint was time to treatment failure (TTTF). Patients with SLL (n = 57), MZL (n = 71) and unclassifiable small B‐cell lymphoma (n = 3) received induction rituximab. The overall response rate (ORR) was 40% [95% confidence interval (CI) 31–49%; SLL ORR 22·8%; MZL ORR 52·1%]; all 52 responders were randomized. At a median of 4·3 years from randomization, treatment failure occurred in 18/23 RR and 15/29 MR. The median TTTF was 1·4 years for RR and 4·8 years for MR (P = 0·012); median time to first cytotoxic therapy was 6·3 years for RR and not reached for MR (P = 0·0002). Survival did not differ (P = 0·72). In low tumour burden SLL and MZL patients responding to rituximab induction, MR significantly improved TTTF as compared with RR.

PurposeTo assess interplatform reproducibility of liver stiffness (LS) and spleen stiffness (SS) measured with magnetic resonance elastography (MRE) based on a 2D gradient echo (GRE) sequence.Materials and MethodsThis prospective Health Insurance Portability and Accountability Act (HIPAA)‐compliant and Institutional Review Board (IRB)‐approved study involved 12 subjects (five healthy volunteers and seven patients with liver disease). A multislice 2D‐GRE‐based MRE sequence was performed using two systems from different vendors (3.0T GE and 1.5T Siemens) on the same day. Two independent observers measured LS and SS on confidence maps. Bland–Altman analysis (with coefficient of reproducibility, CR), coefficient of variability (CV), and intraclass correlation (ICC) were used to analyze interplatform, intra‐ and interobserver variability. Human data were validated using a gelatin‐based phantom.ResultsThere was excellent reproducibility of phantom stiffness measurement (CV 4.4%). Mean LS values were 3.44–3.48 kPa and 3.62–3.63 kPa, and mean SS values were 7.54–7.91 kPa and 8.40–8.85 kPa at 3.0T and 1.5T for observers 1 and 2, respectively. The mean CVs between platforms were 9.2%–11.5% and 13.1%–14.4% for LS and SS, respectively, for observers 1 and 2. There was excellent interplatform reproducibility (ICC >0.88 and CR <36.2%) for both LS and SS, and excellent intra‐ and interobserver reproducibility (intraobserver: ICC >0.99, CV <2.1%, CR <6.6%; interobserver: ICC >0.97, CV and CR <16%).ConclusionThis study demonstrates that 2D‐GRE MRE provides platform‐ and observer‐independent LS and SS measurements. J. Magn. Reson. Imaging 2016;43:1064–1072.

Purpose In order to achieve an oncological margin during limb salvage surgery for tumours around the hip, part or the entire hip joint is frequently sacrificed. Hip arthroplasty restores a functional extremity and achieves limb salvage. Currently there is a paucity of data concerning the late complications, long-term survival, and the risks of re-revision following aseptic revision of a total hip arthroplasty (THA) performed following an oncological resection. Methods We identified 78 patients who underwent aseptic revision of a THA which was performed for an oncological process involving the hip from 1972 to 2006. All patients had a minimum 5 years of follow-up with a mean of 13 years. Outcomes were compared to 1,378 patients undergoing aseptic revision of a THA that was performed for a diagnosis of osteoarthritis. Results The mean 5-, 10-, 15-, and 20-year re-revision-free survival for an oncologic process of the hip was 100%, 85%, 69%, and 57%. Within this cohort, younger patients were at an increased risk of revision surgery. There was no difference in survivorship of the revision implant at any of the aforementioned time points between the oncologic and osteoarthritis cohorts. Patients with an oncologic diagnosis had a higher rate of dislocations, component wear, and loosening compared to the osteoarthritis group. Conclusion Late complications following revision surgery of THA performed for an oncologic resection are common. The results of this study provide information for counselling patients on implant survivorship and complications following aseptic revision THA after index surgery for an oncologic indication.

Abstract Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of PMR. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology as a framework for the project. Accordingly, the direction and strength of the recommendations are based on the quality of evidence, the balance between desirable and undesirable effects, patients’ and clinicians’ values and preferences, and resource use. Eight overarching principles and nine specific recommendations were developed covering several aspects of PMR, including basic and follow‐up investigations of patients under treatment, risk factor assessment, medical access for patients and specialist referral, treatment strategies such as initial glucocorticoid (GC) doses and subsequent tapering regimens, use of intramuscular GCs and disease modifying anti‐rheumatic drugs (DMARDs), as well as the roles of non‐steroidal anti‐rheumatic drugs and non‐pharmacological interventions. These recommendations will inform primary, secondary and tertiary care physicians about an international consensus on the management of PMR. These recommendations should serve to inform clinicians about best practices in the care of patients with PMR.