Objective

A prospective study was performed comparing conventional radiography, 3-phase bone scintigraphy, ultrasound, and magnetic resonance imaging (MRI) with precontrast and dynamic postcontrast examinations in 60 patients with various forms of arthritis including rheumatoid arthritis (RA), spondylarthropathy, and arthritis associated with connective tissue disease.



Methods

A total of 840 finger joints were examined clinically and by all 4 imaging methods. Experienced investigators blinded to the clinical findings and diagnoses analyzed all methods independently of each other. The patients were divided into 2 groups. Group 1 included 32 patients (448 finger joints) without radiologic signs of destructive arthritis (Larsen grades 0–1) of the evaluated hand and wrist and group 2 included 28 patients (392 finger joints) with radiographs revealing erosions (Larsen grade 2) of the evaluated hand and/or wrist.



Results

Clinical evaluation, scintigraphy, MRI, and ultrasound were each more sensitive than conventional radiography in detecting inflammatory soft tissue lesions as well as destructive joint processes in arthritis patients in group 1. All differences were statistically significant. We found ultrasound to be even more sensitive than MRI in the detection of synovitis. MRI detected erosions in 92 finger joints (20%; 26 patients) in group 1 that had not been detected by conventional radiography.



Conclusion

Our data indicate that MRI and ultrasound are valuable diagnostic methods in patients with arthritis who have normal findings on radiologic evaluation.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/1529-0131%28199906%2942%3A6%3C1232%3A%3AAID-ANR21%3E3.0.CO%3B2-3

Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging.

Scalp reconstruction after ablative surgery can be challenging. A useful reconstructive algorithm is lacking. The purpose of this study was to evaluate the authors' experience and to identify an appropriate reconstructive strategy. This was a retrospective review of all patients treated by the authors' service for scalp defects during a 15-year period. Reconstructive methods, independent factors, and outcomes were analyzed. A total of 73 procedures were performed in 64 patients. Techniques for reconstruction included primary closure, grafts, and local and distal flaps. A correlation between reconstructive technique and complications could not be demonstrated. However, an increased incidence of complications was correlated with a history of radiation, chemotherapy, cerebrospinal fluid leaks, and an anterior location of the ablative defect (P < 0.05). Important tenets for successful management of scalp defects are durable coverage, adequate debridement, preservation of blood supply, and proper wound drainage. Local scalp flaps with skin grafts, and free tissue transfer remain the mainstay of reconstruction in most instances.

https://www.shanahq.com/main/shana_forum/download/file.php?id=22

Scalp reconstruction: a 15-year experience.

The antiinflammatory and immune-modulating effects of glucocorticoids (GCs) have been known for decades and have found extensive therapeutic use in a wide range of diseases of which inflammatory responses are a main feature. A surgical operation elicits a stress response of combined endocrine and inflammatory origin, where an excessive response can lead to increased functional demands on various organic systems, which subsequently might contribute to postoperative morbidity. Increased attention has evolved toward modulating potential deleterious responses. Because GCs might modulate several components of the inflammatory response to surgery, the aim of this review was to update knowledge on the effect of perioperative administration of a single dose of GC on surgical stress responses, postoperative organ dysfunctions, and morbidity in elective surgery with potential implications for clinical practice. Data were obtained by examining randomized clinical trials (RCTs) in which a single dose of GC was administrated systemically in immediate relation to surgery. We do not intend to discuss in depth either the molecular or cellular basis of action of GCs, recently reviewed elsewhere, nor to provide an overview of GC administration in septic or traumatized patients, or in GC-treated surgical patients. A recent metaanalysis concluded that perioperative administration of highdose methylprednisolone was not associated with major side effects. But the trials included consisted of major surgical procedures only, combined with studies in trauma and spinal cord injury, and only methylprednisolone administration was evaluated, including multiple administrations within 3 days of surgery. METHODS A Medline search (1966 to May 2001) was performed to identify all randomized, clinical trials published in English-language journals, in which a single dose of GC was administered systemically and perioperatively (defined as 12 hours before surgery, until the end of surgery; ie, before completion of incision closure) in elective surgical procedures, and where perioperative organ function, morbidity, or both were primary outcomes parameters. The search string consisted of the free text terms “glucocorticoid,” “glucocorticoids,” “dexamethasone,” “methylprednisolone,” “surgery,” and the medical subject headings “glucocorticoids” and “surgical procedures, operative.” All of the above search criteria were combined. The searches were limited to “English” in the language field and “randomized controlled trial” in the publication-type field. Additional studies were identified from review articles and articles cited in original papers. Abstracts, letters to the editor, and nonpublished data were not considered. No related Cochrane review relevant to this subject exists. Studies in patients with chronic GC treatment, patients receiving perioperative immune-suppressive therapy, multiple-dosage GC regimens, and patients receiving a local (at the surgical site) GC application were excluded. We evaluate the evidence of trials comparing GC administration to placebo treatment. In studies evaluating GC treatment against other active treatment and a placebo, only the GC-treated group versus the placebo group was considered.

https://www.journalacs.org/article/S1072-7515(02)01491-6/pdf

Perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications

Radiofrequency Volumetric Tissue Reduction of the Palate in Subjects With Sleep-Disordered Breathing

In 246 hands in which the carpal tunnel was explored at operation, 29 variations in the course of the median nerve were found. Accessory branches at the distal portion of the tunnel were found in 18 hands, a high division of the median nerve in seven, and accessory branches proximal to the tunnel in four. Based upon these findings and including published reports of others, the variations were classified into four groups: I-variation in the course of the thenar branch; II-accessory branches at the distal portion of the carpal tunnel; Ill-high divisions of the median nerve; and IV-accessory branches proximal to the carpal canal. The thenar branch variations in 100 cadaver hands (Poisel) were extraligamentous in 46 percent, subligamentous in 31 percent, and transligamentous in 23 percent. The findings emphasize the importance of approaching the median nerve from the ulnar side when opening the carpal tunnel.

Anatomical variations of the median nerve in the carpal tunnel

"Stretch-back" is a phenomenon which to a considerable extent reduces the benefits of scalp excisions for reduction of male pattern baldness. Tattoo marks placed on the scalp have revealed that about one-third to one-half the effect of the excision of the bald area of the scalp is lost postoperatively. Most of this stretch-back occurs during the first 8 postoperative weeks and is completed at 12 weeks. Most of the stretch-back originates from the wound area. It is important to be aware of the stretch-back for correct planning of the surgical program and for being able to predict the final result.

"Stretch-back" in scalp reductions for male pattern baldness.

The authors show a way of reconstruction of scalp defects with excellent results using a tissue expander. This method creates "new" scalp tissue for coverage of defects with normal hair-bearing skin having a dense and even growth of hair. The hairs grow in the correct direction. The authors also show that almost all of the "new" hair-bearing scalp gained by the tissue expander is a result of stretching the scalp over the expander and its close surroundings and that only a very minute portion is gained by migration of the scalp from farther away.

Scalp stretching with a tissue expander for closure of scalp defects

The aim of the present study was to evaluate how much a relaxing incision of the galea aponeurotica affects the biomechanical properties of a scalp flap to quantify the surgery-related advantages provided by this procedure. Twenty scalp flaps, created by a reverse-Y incision down to and through the galea aponeurotica together with undermining (in the layer between the galea and the pericranium) to within 1 cm of the external auditory canal were studied. Data were collected by stepwise loading the scalp flaps before and after performing three full-thickness galeotomies lengthwise and parallel to the sagittal scalp incision. The tension/ extension ratio characteristics were computed, and loading curves as well as mean stiffness values were measured. A statistically significant difference (-16.6 g per millimeter) was found between the slope (computed as Young's modulus) of the curves obtained before and after performing the galeotomies. This value corresponded to a mean 40% reduction of the closing tension attained with each galeotomy. In the closing-tension interval 500 g to 1,500 g, the mean gain of length of the flap per galeotomy was 1.67 mm. These data confirm the usefulness of galeotomies for lengthening the scalp flaps and for diminishing the tension on wound margins when closing scalp defects.

Effects of galeotomies on scalp flaps

The aim of the present study was to evaluate to what extent undermining affects the closing-tension of scalp defects to quantify. the surgery-related benefits provided by this procedure. Data were collected by stepwise loading in 10 patients, 20 scalp flaps (obtained by reversed Y scalp incision), and three different degrees of subgaleal undermining (1, 5, and 15 cm). The obtained data confirmed the value of undermining to diminish the tension on wound margins when closing a scalp defect. There was a progressive decrease in tension required to advance the wound edge when the amount of undermining was sequentially increased. Most of this reduction occurred with the 5-cm undermining, although statistically the 15-cm undermining also resulted in a significant decrease in the tension required to close the defect. Mean 83.3- and 92.2-percent reductions of the closing tension were obtained with 5 cm and 15 cm of undermining, respectively, compared with that achieved by the 1-cm undermining with the same width of defect.

Undermining of the scalp: quantitative effects.

In a material of 49 female patients with severe developmental breast asymmetry, Poland's syndrome and isolated unilateral hypoplasia were the most frequent etiological factors (69%). Prosthetic augmentation alone, transfer of the de-epithelialized latissimus dorsi musculocutaneous flap to fill up the infraclavicular hollow, combined with an expander prosthesis for the breast, or augmentation with tissue from the contralateral "healthy" hypertrophic breast were found to be the methods of choice in selected cases. In order to achieve optimum symmetry the contralateral ptotic/hypertrophic breast should be corrected in most patients.

Treatment of severe developmental asymmetry of the female breast.

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