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Introduction: The free anterolateral thigh (ALT) flap is a versatile reconstructive option for head and neck defects. Donor site complications are rare but severe; with wound dehiscence, need for secondary closure, and compartment syndrome reported., Objectives: We propose prophylactic thigh fasciotomy as a surgical technique to facilitate primary closure while preventing donor site complications during ALT flap harvest., Methods: We examined donor site wound characteristics, recipient site wound characteristics, and clinical outcomes for 24 consecutive ALT flaps performed for head and neck reconstruction from 2016 to 2018. All ALT donor sites underwent prophylactic fasciotomy., Results: There were no incidents of thigh compartment syndrome or wound dehiscence of donor site; one patient underwent primary donor site skin grafting., Conclusion: Prophylactic thigh fasciotomy allows mobilization of soft tissue to facilitate primary tension-free closure of the ALT donor site even for free flaps with a large skin component, while reducing the possibility of compartment syndrome., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Chronic exertional compartment syndrome (CECS) is a condition occurring most frequently in the lower limbs and often requires corrective surgery to alleviate symptoms. Amongst military personnel, the success rates of this surgery can be as low as 20%, presenting a challenge in determining whether surgery is worthwhile. In this study, the data of 132 fasciotomies for CECS was analysed and using combinatorial feature selection methods, coupled with input from clinicians, identified a set of key clinical features contributing to the occupational outcomes of surgery. Features were utilised to develop a machine learning model for predicting return-to-work outcomes 12-months post-surgery. An AUC of 0.85 ± 0.08 was achieved using a linear-SVM, trained using 6 features (height, mean arterial pressure, pre-surgical score on the exercise-induced leg pain questionnaire, time from initial presentation to surgery, and whether a patient had received a prior surgery for CECS). To facilitate trust and transparency, interrogation strategies were used to identify reasons why certain patients were misclassified, using instance hardness measures. Model interrogation revealed that patient difficulty was associated with an overlap in the clinical characteristics of surgical outcomes, which was best handled by XGBoost and SVM-based models. The methodology was compiled into a machine learning framework, termed AITIA, which can be applied to other clinical problems. AITIA extends the typical machine learning pipeline, integrating the proposed interrogation strategy, allowing to user to reason and decide whether to trust the developed model based on the sensibility of its decision-making., (© 2021. The Author(s).)

Objective: To explore the role of conjoint fascial sheath (CFS) suspension in the treatment of severe ptosis., Methods: A total of 110 patients with severe ptosis who were admitted to our hospital from May 2018 to December 2020 were included. Fifty-seven patients treated with frontalis suspension were assigned into group A, and the remaining 53 patients treated with CFS suspension were assigned into group B. The curative effect, ocular surface alterations, complications, and satisfaction in the two groups were compared., Results: Patients in group B suffered from severe upper eyelid retraction and lid lag than those in group A, as well as more limited range of motion (ROM) ( P < 0.05). The curative effect and patient satisfaction in group B were higher than those in group A ( P < 0.05). Postsurgical complications in group B were fewer than those in group A ( P < 0.05)., Conclusion: CFS suspension is effective in the treatment of severe ptosis., Competing Interests: No conflict of interest exists., (Copyright © 2021 Pengfei Sang et al.)

Case: Lumbar paraspinal compartment syndrome (LPCS) is a rare but potentially catastrophic pathology caused by increased intracompartmental pressures leading to potential ischemic necrosis of muscle, local denervation, and complications of rhabdomyolysis. A combination of unique clinical history and examination findings, laboratory findings, and radiologic imaging help in diagnosis., Conclusion: Early detection and intervention with minimally invasive percutaneous fasciotomy can minimize local soft tissue trauma while providing extensive fascial release with good clinical outcomes. Radiographic follow-up in this case suggests that the muscle at risk in LPCS can be spared with early surgical intervention., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B713)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The factors typically considered to be associated with Dupuytren disease have been described, such as those in the "Dupuytren diathesis." However, the quality of studies describing them has not been appraised. This systematic review aimed to analyze the evidence for all factors investigated for potential association with the development, progression, outcome of treatment, or recurrence of Dupuytren disease., Methods: A systematic review of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was conducted using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant methodology up to September of 2019. Articles were screened in duplicate. Prognostic studies were quality assessed using the Quality in Prognosis Study tool., Results: This study identified 2301 records; 51 met full inclusion criteria reporting data related to 54,491 patients with Dupuytren disease. In total, 46 candidate factors associated with the development of Dupuytren disease were identified. There was inconsistent evidence between the association of Dupuytren disease and the presence of "classic" diathesis factors. The quality of included studies varied, and the generalizability of studies was low. There was little evidence describing the factors associated with functional outcome., Conclusions: This systematic review challenges conventional notions of diathesis factors. Traditional diathesis factors are associated with disease development and recurrence, although they are not significantly associated with poor outcome following intervention based on the current evidence., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Subfascial breast augmentation is becoming popular because of a better understanding of breast anatomy. However, because the subglandular approach is also another popular method, it is critical to assess the influence of the superficial fascia of the pectoralis major muscle on the subfascial and subglandular pockets to determine if one method is superior to another. This study investigated whether there are clinical/radiological differences between subfascial and subglandular pockets following primary breast augmentation., Methods: Twenty patients were recruited, and each was randomly sorted to the subfascial and/or subglandular pocket per breast. Both patients and surgeons were blinded. Differences were evaluated through five independent surgeons and by magnetic resonance imaging scans. Subsequently, 1-year and 5-year follow-ups were conducted., Results: The results of the 5-year follow-up considering the aesthetics of the breast contour were significantly different between groups, with more good and excellent evaluations in the subfascial group. Regarding breast shape, there were also statistical differences, also with more good and excellent evaluations in the subfascial group. For breast consistency, subglandular had 84.20 percent of patients classified into Baker I and II, whereas subfascial had 100 percent. Magnetic resonance imaging scans showed a smaller implant base in the subglandular pockets, which was a significant result. There were no significant differences in implant projection. Comparison of the number of folds revealed significant differences between groups, with more folds in the subglandular group., Conclusion: Statistical differences between methods were found regarding breast shape and contour, capsular contracture, implant base, and the number of folds, showing that subfascial breast augmentation is superior to subglandular breast augmentation., Clinical Question/level of Evidence: Therapeutic, II., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Return to work is potentially an important factor in assessing the success of treatment. However, little is known about the return to work after treatment for Dupuytren's contracture. Therefore, the primary aim of this study was to assess return to work after limited fasciectomy and percutaneous needle fasciotomy., Methods: Patients who underwent either a limited fasciectomy or percutaneous needle fasciotomy were invited to complete a return-to-work questionnaire at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Median time to return to work was assessed using inverted Kaplan-Meier curves, and hazard ratios were calculated with Cox regression models. Finally, a cost analysis was carried out using the human capital method to determine indirect costs associated with loss of productivity., Results: The authors included 2698 patients in the study, of which 53 percent were employed at intake and included in the follow-up. After 1 year of follow-up, 90 percent of the patients had returned to work. Median time to return to work was 2 weeks after limited fasciectomy and within days after percutaneous needle fasciotomy. Furthermore, physically strenuous work, female sex, and higher age were associated with a longer time to return to work. Lost productivity per patient was estimated at €2614.43., Conclusions: The majority of patients returned to work after treatment for Dupuytren's disease. Return to work is much faster after percutaneous needle fasciotomy compared to limited fasciectomy. These findings can be used for more evidence-based preoperative counseling with patients with Dupuytren's disease., Competing Interests: Disclosure:The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no financial support for research, authorship, and/or publication of this article., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Acute extremity compartment syndrome is a surgical emergency for which timely diagnosis is essential., Objectives: To assess whether the time from the initial insult to the fasciotomy of compartment syndrome of the upper extremity affects outcomes and to examine the differences between compartment syndrome secondary to fractures and that resulting from a non-fracture etiology with regard to the time from insult to fasciotomy and the long-term patient outcomes., Methods: Patients presented with documented fasciotomy treatment following acute upper extremity compartment syndrome and a minimum of 6 months follow-up. Patient information included demographics, cause of compartment syndrome, method of diagnosis, and outcome on follow-up., Results: Our study was comprised of 25 patients. Fasciotomies were performed for compartment syndrome caused by fracture in 11 patients (44%), and due to insults other than fractures in 14 patients (56%). The average time to fasciotomy in patients without a fracture was 10.21 hours and 16.55 hours with a fracture. Fasciotomy performed more than 24 hours from the initial insult was not found to significantly affect long-term sequelae compared to fasciotomy performed earlier than 24 hours from the initial insult. The non-fracture group had more long-term sequelae than the fracture group (13/15 patients and 5/11 patients, respectively)., Conclusions: Most injuries treated for fasciotomy of compartment syndrome were non-fracture related, with more complications found in patients with non-fracture related injuries. Time interval from insult to fasciotomy did not affect outcome and was longer in the fracture group, suggesting longer monitoring in this group and supporting fasciotomy even with late presentation.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

The aim of this nonrandomized cohort study was to compare the clinical effectiveness of an elective fasciotomy with conservative treatment for chronic exertional compartment syndrome of the leg. Patients diagnosed with chronic exertional compartment syndrome who opted for surgery (n=188) completed a preoperative questionnaire and a 12-month postoperative questionnaire. Patients who continued conservative treatments (n=23) served as controls. Gender, age, sports activity or affected compartments were comparable, but intensity of pain was higher in the surgical group (at rest: 2.5±0.1 vs. 2.0±0.2, during exercise: 4.2±0.1 vs. 3.8±0.2; both p<0.05). Following treatment, surgical patients demonstrated a larger drop in intensity levels of pain (surgery 1.6±0.1, conservative 0.9±0.2, p=0.01) and tightness (surgery 1.4±0.1, conservative 0.4±0.3, p=0.00) during exercise. Success (good or excellent treatment effect) was attained in 42% of the surgical group compared to only 17% in the conservatively treated group (p=0.02). However, previous activity level was achieved in a mere 26% in the surgical treatment group and 35% in the conservative treatment group (p=0.33). A fasciotomy for chronic exertional compartment syndrome in the leg results in significantly decreased levels of pain and tightness and better satisfaction compared to patients who continued a conservative treatment regimen., Competing Interests: The authors declare no conflict of interest., (Thieme. All rights reserved.)

Aims: The results of surgery for Dupuytren's disease can be compromised by the potential for disease recurrence and loss of function. Selecting which patients will benefit from repeat surgery, when to operate, and what procedure to undertake requires judgement and an understanding of patient expectations and functional needs. We undertook this study to investigate patient outcomes and satisfaction following repeat limited fasciectomy for recurrent Dupuytren's disease., Methods: We prospectively identified all patients presenting with recurrence of Dupuytren's disease who were selected for surgical treatment with repeat limited fasciectomy surgery between January 2013 and February 2015. Patients were assessed preoperatively, and again at a minimum of five years postoperatively. We identified 43 patients who were carefully selected for repeat fasciectomy involving 54 fingers. Patients with severe or aggressive disease with extensive skin involvement were not included; in our practice, these patients are instead counselled and preferentially treated with dermofasciectomy. The primary outcome measured was change in the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were change in finger range of motion, flexion contracture, Semmes-Weinstein monofilament (SWM) values, and overall satisfaction., Results: There was a significant improvement in MHQ scores, across all domains, with a mean overall score increase of 24 points (p < 0.001). The summed flexion contracture across the metacarpophalangeal joint (MCPJ) and the proximal interphalangeal joint (PIPJ) reduced from means of 72.0° (SD 15.9°) to 5.6° (SD 6.8°) (p < 0.001). A significant increase in maximal flexion was seen at the MCPJ (p < 0.001) but not the PIPJ (p = 0.550). The mean overall satisfaction score from the visual analogue scale was 8.9 (7.9 to 10.0). Complications were uncommon although five fingers showed reduced sensibility at final follow-up., Conclusion: Our study shows that repeat limited fasciectomy for selected patients presenting with recurrence of Dupuytren's disease can be an effective and safe treatment resulting in excellent patient-reported outcomes and levels of satisfaction. Cite this article: Bone Joint J  2021;103-B(5):946-950.

Acute forearm compartment syndrome is damaging but rare. Early treatment reduces mid and long-term sequelae. The palmar compartment is most frequently involved but the dorsal compartment and mobile wad are also at risk. Multiple fasciotomies approaches have been described but are associated with long-term complications. In particular, wound management is important. Mini-invasive techniques are not available for acute forearm compartment syndrome. Acute leg release via a single approach has been developed and proven effective. Likewise, we present a lateral S-shaped approach for fasciotomies of the 3 forearm compartments in the case of acute forearm compartment syndrome., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Extraction site incisional hernia (IH) has been recognized as an important complication in minimally invasive procedures but has not been as well characterized following robotic-assisted laparoscopic prostatectomy (RALP). Approximately 29% of IH required surgical repair. A number of techniques have been utilized to reduce the rates of IH following minimally invasive procedures. First, off-midline extraction was investigated, this did not demonstrate a reduction in incisional hernia rates. Recently, supra-umbilical transverse incisions have been utilized to extract prostate specimen and this method decreased the extraction site IH rate compared to the vertical midline incision. In addition, the choice of fascial closure technique and choice of the suture may influence the incidence of extraction site IH. For example, studies showed that abdominal fascial closure using a nonabsorbable suture and a continuous running suture technique decreased IH rate from 32 to 17%. Finally, "the small bites technique" has been recommended to reduce hernia incidence after midline fascial closure following a randomized controlled trial (RCT) which demonstrated the superiority of the small-bite technique. In summary, a supra-umbilical transverse incision to extract the specimen was shown to decrease the rate of extraction site IH. In vertical midline incisional closure, the small bites technique with slowly- or non-absorbable suture, such as #0 or 2-0 PDS II with SH or CT-2 needle (26 mm arch length), reduces the IH rate. Urologists should consider this data to reduce the risk of IH following RALP.

Aim: To present 'bilateral iliococcygeal fixation of the pubocervical fascia' as an alternative vaginal surgical technique for anterior compartment repair with native tissue and the surgical outcomes of 30 cases., Materials-Methods: The consecutive 30 cases who admitted to urogynecology clinic with anterior vaginal prolapse/cystocele and underwent anterior compartment repair by bilateral iliococcgeal fixation of the pubocervical fascia by native tissue were included to the study. All cases attended to the postoperative follow-up visits at the sixth and the twelfth months., Results: There were no major or minor intraoperative complications. Overall, in 28 (93.3 %) patients surgical success was achieved at the postoperative 12th month when it was defined as the maximum descent of the anterior segment was proximal to the hymen. During the study period, none of the patients requested or admitted for re-treatment for anterior compartment prolapse. Subjective cure that was assessed by the absence of bulge symptoms was achieved in 29 cases (96.7 %) at first year follow-up. Lower urinary tract symptoms (LUTS) were found to be significantly lower at the first-year postoperative visit compared to pre-operative evaluation. A clinically significant improvement in the quality of life parameters were also noted (mean PFIQ-7 scores = 8.5, 5.6 and 50.8, respectively)., Conclusion: Bilateral iliococcygeal fixation of the pubocervical fascia seems to be effective in surgical correction of anterior vaginal prolapse according to our post-operative follow-up results. It is an easy to learn procedure with low complication rates and associated with high patient satisfaction., Competing Interests: Declaration of Competing Interest The authors declare no competing interest., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Military guidelines endorse early fasciotomy after revascularization of lower extremity injuries to prevent compartment syndrome, but the real-world impact is unknown. We assessed the association between fasciotomy and amputation and limb complications among lower extremitys with vascular injury., Methods: A retrospectively collected lower extremity injury database was queried for limbs undergoing attempted salvage with vascular procedure (2004-2012). Limbs were categorized as having undergone fasciotomy or not. Injury and treatment characteristics were collected, as were intervention timing data when available. The primary outcome measure was amputation. Multivariate models examined the impact of fasciotomy on limb outcomes., Results: Inclusion criteria were met by 515 limbs, 335 (65%) with fasciotomy (median 7.7 h postinjury). Of 212 limbs, 174 (84%) with timing data had fasciotomy within 30 min of initial surgery. Compartment syndrome and suspicion of elevated pressure was documented in 127 limbs (25%; 122 had fasciotomy). Tourniquet and shunt use, fracture, multiple arterial and combined arteriovenous injuries, popliteal involvement, and graft reconstruction were more common in fasciotomy limbs. Isolated venous injury and vascular ligation were more common in nonfasciotomy limbs. Fasciotomy timing was not associated with amputation. Controlling for limb injury severity, fasciotomy was not associated with amputation but was associated with limb infection, motor dysfunction, and contracture. Sixty-three percent of fasciotomies were open for >7 d, and 43% had multiple closure procedures. Fasciotomy revision (17%) was not associated with increased amputation or complications., Conclusions: Fasciotomy after military lower extremity vascular injury is predominantly performed early, frequently without documented compartment pressure elevation. Early fasciotomy is generally performed in severely injured limbs with a subsequent high rate of limb complications., (Published by Elsevier Inc.)

Background: Prevalence of abdominal compartment syndrome (ACS) is estimated to be 4%-17% in severely burned patients. Although decompressive laparotomy can be lifesaving for ACS patients, severe complications are associated with this technique, especially in burn populations. This study outlines a new technique of releasing intraabdominal pressure without resorting to decompressive laparotomy., Materials and Methods: Ten fresh tissue cadavers were studied; none of whom had had prior abdominal surgery. Using Veress needles, abdomens were insufflated to 30 mm Hg and subsequently connected to arterial pressure transducers. Two techniques were then used to incise fascia. First, large skin flaps were raised from a midline incision (n = 5). Second, small 2 cm cutdowns at the proximal and distal extent of midaxillary, subcostal, and inguinal incisional sites were made, followed by tunneling a subfascial plane using an aortic clamp with fascial incisions made through the grooves of a tunneled vein stripper (n = 5). Pressures were recorded in the sequence of incisions mentioned previously., Results: The open midline flap technique decreased abdominal pressure from a mean pressure of 30 ± 1.8 mm Hg to 6.9 ± 5.0 mm Hg (P < 0.01). The minimally invasive technique decreased intraabdominal pressure from 30 ± 0.9 to 5.8 ± 5.2 mm Hg (P < 0.01). This technique significantly reduced intraabdominal pressure via extraperitoneal component separation and fascial release at the midaxillary, subxiphoid, and inguinal regions., Conclusions: This technique offers the benefit of reducing the morbidity, mortality, and complications associated with an open abdomen, which may be beneficial in the burn injury population., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Case: A newborn presented with necrotic skin lesions and contractures of the right upper extremity. Ultrasonography indicated the presence of a brachiocephalic artery thrombosis, and clinical examination demonstrated a neonatal forearm compartment syndrome. Surgical treatment included decompressive fasciotomy of the right forearm. The right-sided brachiocephalic thrombosis resulted in left hemiplegic cerebral palsy. At the 3-year follow-up, the patient had near-normal function of the right upper extremity. This case has detailed preoperative video and follow-up to illustrate this rare but modifiable condition., Conclusion: This case demonstrates a unique cause of neonatal forearm compartment syndrome (brachiocephalic arterial thrombosis) and the results of prompt surgical treatment., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (links.lww.com/JBJSCC/B283)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Summary: The updated knowledge of perforasome anatomy and the evolution of microsurgical techniques have enabled surgeons to safely harvest a thin flap. Recently, the anterolateral thigh perforator flap, the current workhorse in soft-tissue reconstruction, has started to be designed and harvested on the superficial fascia, which divides the deep from the superficial fat. This allows elevation of a very thin flap tailored to the defect. Faithful to the ultrathin concept, in an attempt to make flap dissection simpler and safer, the authors describe a revisited harvesting technique of superthin anterolateral thigh perforator flap. This study presents the outlined technique performed in 16 patients with complex soft-tissue defects after trauma or tumor ablation. All of them underwent primary reconstruction using superthin anterolateral thigh perforator free flaps by superficial fascia elevation harvested according to the described surgical procedure. Complications and functional outcomes were assessed. The authors' series of anterolateral thigh perforator superthin flaps demonstrated an overall 100 percent survival rate. Of 16 anterolateral thigh perforators, 12 (75 percent) had no complications and four (25 percent) had minor complications. No major complications such as total flap loss requiring additional salvage surgery were reported. In no case was secondary debulking performed. The superthin anterolateral thigh perforator flap harvested with the described approach was used successfully in microsurgical reconstruction, providing an excellent outer skin cover tailored to the defect. The dissection procedure was safe, quick, simple, and free of major complications. With minimal donor- and recipient-site morbidity, it provided great aesthetic results, avoiding secondary operations., Clinical Question/level of Evidence: Therapeutic, IV., Competing Interests: Disclosure:The authors declare that they have no conflicts of interest to disclose., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: This study aims to analyze the clinical outcome of a new ultrasound-guided surgery for partial plantar fasciotomy performed with a needle for treatment of plantar fasciitis., Methods: We performed a retrospective review of 107 patients diagnosed with plantar fasciitis who underwent ultrasound-guided release of the plantar fascia. The series included 62 males (57.9%) and 45 females (42.1%) treated between April 2014 and February 2018, with a mean follow-up of 21.05 ± 10.96 months (7-66) and a minimum follow-up of 24 months. The mean age was 48.10 ± 10.27 years (27-72). Clinical assessments and ultrasound examination were carried out before treatment, after 1 week, and then after 1, 3, 12, and 24 months. The clinical assessment was based on a visual analog scale and the Foot and Ankle Disability Index., Results: Heel pain improved in 92.5% (99) of patients, but not in 7.4% (8 patients). In the group of patients whose heel pain improved, 9 experienced overload on the lateral column and dorsum of the foot, which improved with the use of plantar orthoses and a rehabilitation program. We recorded no nerve complications (e.g., paresthesia), vascular injuries, or wound-related problems., Conclusion: Ultrasound-guided partial plantar fasciotomy with a needle is safe, since structures are under direct visualization of the surgeon and the risk of damage is minimal. Stitches are not necessary, and recovery is fast. Consequently, costs are low, and the patient can return to work quickly. This technique may represent a valid option for treatment of plantar fasciitis.

Introduction: Temporary abdominal closure is frequently used in several situations such as abbreviated surgery in damage control situations or when closing is impossible due to organ distention or increased abdominal pressure. The ultimate goal is to eventually close the fascia; however, little is known about factors predicting abdominal closure. The purpose of this study was to identify characteristics associated with the need for open abdomen as well as indicating the possibility of delayed fascial closure after a period of open abdominal treatment., Methods: A retrospective review of all patients that underwent midline laparotomy between January 2008 and December 2012 was performed. Both factors predicting open abdominal treatment and possibility to close the fascia afterwards were identified and analyzed by univariate and multivariate analyses., Results: 775 laparotomies in 525 patients (60% male) were included. 109 patients (21%) had an open abdomen with a mortality rate of 27%. Male gender and acidosis were associated with open abdominal treatment. In 54%, the open abdomen could be closed by delayed fascial closure. The number of laparotomies both before and during temporary abdominal treatment was associated with failure of closure., Conclusion: In this study, male sex and physiological derangement, reflected by acidosis, were independent predictors of open abdominal treatment. Furthermore, the success of delayed fascial closure depends on number of abdominal surgical procedures. Moreover, based on our experiences, we suggest to change modalities early on, to prevent multiple fruitless attempts to close the abdomen.

Purpose: Surgery is the first line treatment for congenital concealed penis but penile retraction is inevitable in some cases. We investigate the anatomical and histological characteristics of penile fasciae and describe a new technique for the correction of concealed penis., Materials and Methods: The anatomical structures of penile fasciae were observed in 10 adult cadaveric penises. Penile tissue samples were stained with hematoxylin-eosin, Masson's trichrome and Weigert's resorcin-fuchsin, respectively. From January 2017 to May 2019, 78 patients with congenital concealed penis were treated with the new surgical technique. Median patient age was 14 years (range 8 to 18)., Results: Dartos fascia had sublayers. The superficial layer was a well vascularized tissue composed of nonpolar collagen fibers intermixed with nerves and vessels. The deep layer was composed of a transverse arrangement of collagen fibers and elastic fibers, and there were fewer venules and nerve fibers. Based on this finding we performed anatomical resection of the deep layer of dartos fascia to correct concealed penis. During the operation dartos fascia was separated into 2 layers and a complete circular resection of the deep layer was made at the base of the penis. Mean followup was 14 months. All patients and their parents were satisfied with the outcomes. None of the patients underwent postoperative penile retraction., Conclusions: The anatomical resection of the deep layer of dartos fascia for correcting concealed penis is technically easy, safe and effective. It provides a good cosmetic appearance and functional outcomes.

Background: Cytoreductive surgery for resection of peritoneal metastases requires an incision from the xyphoid process to the pubic rami. Laboratory and clinical data from randomized trials have shown that small (0.5-1.0 cm) bites of a running suture closely spaced (0.5 cm) through an isolated midline fascia results in the lowest incidence of incisional hernia., Methods: Manuscripts were used to formulate criteria for optimal closure of a long midline abdominal incision. Using these conclusions as a starting point, surgical technology to achieve an optimal wound closure were formulated., Results: A fixed retractor was placed prior to performing an abdominal incision. Skin traction sutures elevate the skin and subcutaneous tissue to facilitate fascial incision directly through the linea alba. Peritoneum and preperitoneal fat beneath the posterior rectus sheath are resected. Separations of the anterior and posterior rectus sheath are repaired prior to fascial closure. When closing the incision, a running suture of closely spaced small bites is used to bring the fascial edges together in the absence of excess tension. During closure of the fascia exposure of the linea alba with the skin traction sutures facilitates accurate placement of fascia only sutures., Conclusions: Optimal exposure of abdominal wall structures while opening and closing a long midline abdominal incision will minimize the incidence of incisional hernia. A fixed retractor and skin traction sutures are required., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Chronic exertional compartment syndrome (CECS) presents with pain during exercise, most commonly within the anterior compartment of the lower limb. A diagnosis is classically made from a typical history and the measurement of intramuscular compartmental pressure (IMCP) testing. Improved, more specific diagnostic criteria for IMCP testing allow clinicians to now be more certain of a diagnosis of CECS. Outcomes following surgical treatment in patients diagnosed using these more robust criteria are unknown., Methods: All patients undergoing fasciectomy for anterior compartment CECS at a single rehabilitation unit were identified between 2014 and 2017. Wilcoxen signed-rank test was used to compare military fitness grading and paired t-test was used to compare Foot and Ankle Ability Measure, FAAM Sport Specific and Exercise-Induced LimbPain-G outcome measures, presurgery and postsurgery., Results: There was a significant difference in fitness grading between presurgical and postsurgical intervention (Z = -2.68, p < 0.01) with 46 % of patients improving their occupational medical grading. All secondary measures of outcome, looking at clinical symptoms, also improved., Conclusion: Almost half of the patients undergoing fasciectomy, following diagnosis using more specific criteria, will have an improvement in occupational medical grading. These outcomes represent the lower end of those reported in civilian populations. This is likely a result of a combination of factors, most notably the different diagnostic criteria followed and the more stringent criteria applied to military occupational grading, compared with civilian practice. Further work is now required to evaluate the impact of differing rehabilitation regimes on postoperative patients identified through this more specific diagnostic testing., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Chronic exertional compartment syndrome (CECS) is characterized by an excessive increase in intracompartmental muscle pressures after exercise. Athletes with CECS report pain, pressure, and occasionally neurologic symptoms in the affected compartment during exercise that abates with rest. Although many treatment options have been proposed, athletes often require a fasciotomy to return to unrestricted sports participation. Surgical success rates vary; complications are not uncommon; and after surgery, it usually takes athletes 6 or more weeks to return to unrestricted impact activities. This case report describes a new ultrasound-guided fasciotomy technique for the treatment of anterior leg compartment CECS. The procedure required a 3 mm incision, was performed in the office under local anesthesia, and allowed the athlete to resume running within 1 week of the procedure. Although the preliminary results of this study are promising, further translational research is required before the widespread adoption of this procedure is recommended.

Objective: Evaluate treatment and outcome of mini-open fasciotomy (MOF) in a population of adolescent motorcycling racers affected by forearm chronic exertional compartment syndrome (CECS)., Design: Prospective case series., Setting: University hospital/private practice., Patients: Nine professional motorcycling adolescents were diagnosed with forearm CECS. All were treated with MOF between 2007 and 2012 and followed for a minimum of 5 years (range 5-10 years). Age, sex, body mass index, laterality, and profession were recorded., Interventions: A MOF to obtain decompression of all compartments was performed in all patients., Main Outcome Measures: Visual analog scale; a subjective scale to measure strength; and Quick-DASH functional scores. Time to resume full riding capacities as the short-term evaluation., Results: A significant decrease in visual analog scale (P < 0.001) and Quick-DASH (P < 0.001) scores was observed in the first 3 months, stabilizing during follow-up (P = 0.521; P = 0.217). Average time to return to sport was 2.8 ± 1 week. No symptom recurrence was reported, but one patient suffered a minor complication. There were no cases of infection, hematoma, or peripheral nerve injury., Conclusions: We assess that MOF can be a valid alternative for the treatment of forearm CECS in adolescent competitive motorcycling racers, as demonstrated by the good success rate and minimal incidence of complications during follow-up., Level of Evidence: IV, case series.

Acute compartment syndrome (ACS) of the foot is one of the most severe injuries of the foot and typically results from a fracture, crush or vascular injury. ACS, isolated to a single foot compartment, is a rare complication following a simple twisting injury of the ankle. In this article, the authors present the case report of a 25-year-old man who developed ACS, isolated to the lateral compartment of the foot, secondary to rupture of the lateral ligament complex and subsequent haematoma formation. An emergency fasciotomy was performed and the patient had complete resolution of his symptoms. ACS is usually associated with significant trauma, however, there are reported cases in the literature associated with a minor injury. In this case report, the authors describe how ACS developed following a simple ankle sprain playing sports in the absence of a high-energy insult or fracture., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

To evaluate the risk of iatrogenic injury when using a dual-incision minimally invasive technique to decompress the anterior and peroneal compartments of the lower leg. Forty lower extremities from 20 adult cadavers, embalmed with Thiel's method, were subject to fasciotomy of the anterior and peroneal compartment using a dual-incision minimally invasive fasciotomy. The first incision was made 12 cm proximal to the lateral malleolus to identify and protect the superficial peroneal nerve (SPN). The second incision was made at the mid-point of the Fibula (half-way between the fibular head and the lateral malleolus). Release of the anterior and peroneal compartments was successful in all specimens. Two nerve injuries of the superficial peroneal nerve were reported. More precisely, in these cases the medial dorsal cutaneous nerve got injured during the fascial opening of the extensor compartment. Two incision minimally invasive fasciotomy to decompress the anterior and peroneal compartments of the lower leg appears to be safe with regard to the results of this study.

In our previous anatomic study, the authors could pull the platysma effectively in the medial direction, lateral direction, or both the medial and lateral directions. In this paper, the authors analyzed the results of our series of modified medial and lateral platysmaplasties, in which the technique was based on Hamra's platysmaplasty, modified in light of Feldman's corset platysmaplasty and Mendelson's concepts.In medial platysmaplasty, subcutaneous dissection was performed from the mandibular border to 2 or 3 finger breadths above the xiphoid process. Lateral platysmaplasty required only peri-lobular subcutaneous dissection for exposing and anchoring the lateral border of the platysma to the preauricular platysma auricular fascia (PAF). Lateral dissection does not go beyond the occipital hairline. During dissection, the zygomatic retaining ligaments were detached and repositioned and anchored to the lateral side of the PAF using 4-0 sutures. One hundred sixty-eight patients underwent platysmaplasty (87 medial platysmaplasty, 76 lateral platysmaplasty, 3 isolated neck lift).The follow-up period ranged from 1 month to 156 months. In general, medial platysmaplasty was more efficacious than simple lateral pulling back for various conditions involving neck deformities, especially midline bands and severe submental fullness with skin laxity. The complications were 1 case of neuropraxia of the cervical branch (0.6%), 3 cases of hematoma (1.8%), 2 cases of seroma (1.2%), and 2 cases of submental depression (1.2%). All patients had temporary paresthesia around the periauricular area, but fully recovered by 6 months.Using this modified medial and lateral platysmaplasty, we obtained satisfactory results with low complications.

Aims: In the UK, fasciectomy for Dupuytren's contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients., Methods: Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks., Results: The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block., Conclusion: This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354-1358.

The objective of this study was to evaluate our technique of ultrasonography and robotic-assisted sacrocervicopexy with pubocervical fascia reconstruction (u-RALS-PFR) versus standard robotic-assisted laparoscopic sacrocervicopexy (s-RALS) in the treatment of patients with symptomatic apical/anterior vaginal prolapse. A retrospective analysis was done using the data in two community hospitals. Thirty women presented with symptomatic vaginal apical prolapse and desired minimally invasive surgery (video): (a) standard robotic-assisted laparoscopic sacrocervicopexy (s-RALS) (n = 15) or (b) ultrasound and robotic-assisted sacrocervicopexy with pubocervical fascia reconstruction (u-RALS-PFR) (n = 15) were eligible to participate. All participants underwent a standardized evaluation, including a structured urogynecologic history and physical examination with pelvic organ prolapse quantitative staging. There was longer operating room time in the u-RALS-PFR group compared with the s-RALS group (average difference 35 min); however, sacral promontory dissection time was less in the u-RALS-PFR (average difference of 15 min). The anterior/posterior vaginal dissection and mesh tensioning time was longer in the u-RALS-PFR, as expected. There was only one surgical and anatomic failure (7%) in the s-RALS group after 6 months of surgery (POP Q = Aa + 1, Ba0, Ap-2, Bp-3, C-7). Our technique of ultrasonography and pubocervical fascia reconstruction during RALS appears to be feasible and safe. It aims to improve anterior and apical support, minimize the use of mesh and improve visualization during surgery. u-RALS-PFR approach will add some additional time during surgery but may provide better outcomes.

Purpose: Plantar fasciitis is a frequent and painful condition with a lifetime incidence of 10%. Good results have been reported for operative treatment of plantar fasciitis refractory to non-surgical interventions in uncontrolled studies. The aim of this study was to compare the results of operative treatment (endoscopic debridement, removal of the heel spur and partial resection of the plantar fascia) with those of a controlled and supervised non-operative rehabilitation program., Methods: Thirty consecutive patients with plantar fasciitis during more than 3 months were randomized to either (1) non-operative treatment with corticosteroid injections and a controlled strength training program or (2) an endoscopic 2-incision operation with partial fasciotomy and heel spur removal followed by the same strength training program. Patients were evaluated at entry and 3, 6, 12 and 24 months post-operatively with the foot function index (FFI) and pain score during activity on a 100 mm VAS scale (VAS activity). FFI at 6 and 12 months was defined a priori as primary endpoint., Results: Both groups improved significantly over time. The FFI score was significantly better in the operated group compared to the non-surgically treated group 12 months post-operatively (p = 0.033), at 24 months this was, however, not significant (p = 0.06). VAS activity at 24 months was significantly (p = 0.001) in favor of the operative group. More patients returned to running and jumping in the operative group (p = 0.04)., Conclusion: This randomized controlled trial found significant and clinically relevant superior results for the operative treatment of plantar fasciitis as measured by Foot Function Index at 1 year and by VAS activity at 2-year follow-up when compared to the results of a supervised rehabilitation program., Level of Evidence: I.

To investigate pain in patients with Dupuytren disease, we analyzed the literature on pre- and post-interventional pain and complex regional pain syndrome. The pre-interventional pain intensity score of primary Dupuytren ranged from 0.3/10 to 2.0/10. One year after surgery or needle fasciotomy, no significant change of pain could be found. Collagenase therapy significantly reduced the mean pain intensity score from 1.3/10 [SD 2.2] to 0.5/10 [1.5] (p<0.01) after one year. The prevalence of complex regional pain syndrome after fasciectomy ranged from 0% to 12.8%, after needle fasciotomy from 0% to 6.3%, and after collagenase therapy from 0% to 3.0%. We conclude that for most Dupuytren patients, pain is not an issue. A minority seems to suffer pain and collagenase treatment appears to reduce this complaint significantly. However, complex regional pain syndrome is a known complication of Dupuytren treatment, with a low incidence after minimal invasive treatment.

Background: Fasciotomy incision closure is often performed with skin grafts that can lead to cosmetic and functional complications after surgical intervention. Because fasciotomy incisions do not result in skin loss, the authors hypothesized that better closure can be achieved by reducing tissue edema with negative-pressure wound therapy (NPWT) and reducing stress on the skin with the shoelace surgical technique., Methods: This 1-year prospective study included eight patients with acute compartment syndrome after extremity fractures and/or blunt injuries. Patients were treated with fasciotomies closed with the shoelace technique and NPWT for wound margin approximation. The NPWT device was changed every second day; the shoelace traction tension was tightened at the same time., Main Results: The mean time from fasciotomy to wound closure was 11.8 days (range, 5-30 days). There was no need for a skin graft or flap in any patient., Conclusions: The shoelace technique plus NPWT may be successful in closing skin fasciotomies after acute compartment syndrome without causing additional morbidity.

Introduction: The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome., Methods: A retrospective cohort study was conducted of 546 patients with acute leg compartment syndrome treated with fasciotomies from January 2000 to June 2015 at two tertiary trauma centers. The main outcome measurement was clinical myonecrosis diagnosed by the treating surgeon at the time of fasciotomy., Results: Eighty-two patients (15.0%) with acute leg compartment syndrome had myonecrosis at time of fasciotomy. Multivariable logistic regression analyses showed that younger age (p = 0.004) and diabetes mellitus (p < 0.001) were associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. Serum creatine kinase at presentation greater than 2405 U/L was found to be associated with myonecrosis at time of fasciotomy in post hoc analysis (p < 0.001)., Conclusions: Myonecrosis is associated with patient-related factors. Younger age by 10 years is associated with a 1.3 times increase and diabetes mellitus with a 3-time increase in the odds of myonecrosis. Serum creatine kinase at presentation greater than 2405 U/L denotes an almost 3 times increase in odds of myonecrosis and may be useful for preoperative counseling.

Introduction: Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed., Methods: A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution., Results: The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome-including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair., Conclusions: While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons' opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.

Objective: To observe the anatomical architecture of rectosacral fascia and discuss the best plan for accurate peri-rectal dissection in laparoscopic/robotic total mesorectal resection (TME). Methods: A descriptive cohort study was carried out. A total of 127 patients with rectal cancer who underwent TME in the Department of Colorectal Surgery at the affiliated Union hospital of Fujian Medical University were included, patients' demographics with their pathological details and operation videos were collected for analysis. Another 20 high-definition images of post-TME surgical specimens were collected from our digital database. A total of 28 cadaveric models were examined at the Laboratory of Clinical Applied Anatomy, Fujian Medical University, to observe the anatomical details of rectosacral fascia. Results: (1) Anatomical observation showed that the pre-hypogastric fascia attaches to the proper fascia of the mesorectum in a horizontal arc posteriorly, forming the rectosacral fascia. If this fusion couldn't be identified and appropriately transected during posterior space dissection, it would be easy to destroy the proper fascia and dissect through the mesorectum resulting in residual mesorectum tissue. After the fascia transaction, the proper fascia of the mesorectum is still intact distally. The upper part of rectosacral fascia bilaterally re-separated again into the proper fascia and pre-hypogastric fascia. The pre-hypogastric fascia acts as a "fascia barrier" when dissecting the lateral space constantly from posterior to anterior. The right attachment of the rectosacral fascia was gradually transected. The pelvic plexus from the right S2-S4 was covered by the pre-hypogastric fascia which is considered the outer side layer of rectosacral fascia laterally. It was observed that the fascia continued with the anterior layer of the Denonvilliers' fascia, which has been transected during anterior space dissection. The proper fascia, which is the inner side layer of rectosacral fascia laterally, was still intact. The edge of the right rectosacral fascia attachment ran obliquely from the back and upward into the front direction. The left extension was similar to the right. (2) Cadaveric specimens: at the level of the lower edge of S4 vertebral body, the pre-hypogastric fascia fused with the proper fascia to form the rectosacral fascia. The right attachment margin of the rectosacral fascia was cut off step by step. The attachment margin of the rectosacral fascia went from the back and upward to the front downward direction. The right edge of rectosacral fascia attachment continued with the anterior layer of the Denonvilliers' fascia at the pre-rectal space and attached to the pre-hypogastric fascia laterally. The pelvic plexus sends out many tiny rectal branches on the anterolateral side, which pass through the transitional area between pre-hypogastric fascia and the anterior layer of the Denonvilliers' fascia to innervate the rectum. (3) TME specimens observation: the posterior attachment of rectosacral fascia was curved around the mesorectum with bilateral oblique attachments. The mesorectum was covered by fusion fascia below the posterior and bilateral attachment margin while it was covered only by the proper fascia above it. Conclusion: according to the morphological characteristics of rectosacral fascia, the rectosacral fascia should be dissected at the level of S4 vertebral body posterior to the rectum in an arc, shape and then enter the superior-levator space. Before dissecting the bilateral spaces, the anterior space of the rectum should be dissected first. The anterior layer of the Denonvilliers' fascia should be cut off into an inverted "U" shape, and then the lateral space should be dissected from anterior to posterior. Finally, the lateral attachment of rectosacral fascia was transected to ensure the integrity of the mesorectum without damaging the pelvic plexus branches and NVB.

Background: The purpose of the present study is to investigate the therapeutic effect of fasciotomy through multiple small skin incisions for the treatment of early osteofascial compartment syndrome in children., Methods: From January 2009 to May 2017, 56 pediatric patients with early osteofascial compartment syndrome in their limbs were admitted into our department and treated with multiple small skin incisions for decompression at the early stage. The skin incisions, function, and sensation of the limbs were followed up., Results: The osteofascial compartment syndrome was diagnosed at 7.4 ± 2.1 h after injury, and then fasciotomy was performed at 1.4 ± 0.4 h later. The average procedure time of fasciotomy was 12.7 ± 4.8 min. No postoperative incision infections or neurovascular injuries were observed in all the patients. The incisions completely healed in 7-10 days with an average healing time of 8 days without secondary suture. The patients were followed up for an average of 5.1 years. No Volkmann's contractures in the injured limbs were found. The appearance, electromyography, and nerve conduction velocity of the affected limbs were not significantly different from that of the contralateral limbs. All the patients were free of symptoms and were fully recovered of sensation and function, being an "excellent" outcome at the latest follow-up., Conclusion: Fasciotomy through multiple small skin incisions, which can be useful to decompress the compartment pressure with fewer complications, is a simple and effective strategy for the treatment of early osteofascial compartment syndrome in children.

Percutaneous fasciotomy is a safe, simple, and inexpensive treatment for mild to moderate Dupuytren contracture. The decrease in extension deficit in the metacarpophalangeal and proximal interphalangeal joints after release correlates with improvement in patient-reported outcomes. Complications are rare and primarily include skin tears, which occur in approximately 4% of patients. Most patients are satisfied with the outcomes of the procedure at 1 year., (Copyright © 2020 Elsevier Inc. All rights reserved.)

We present the case of three pediatric patients who presented with non-fracture acute lateral compartment syndrome after 'minor trauma'. All patients were male and sustained the inciting event during football. Two of the patients were able to resume play after their injury. All patients sustained intramuscular proximal avulsion ruptures of the peroneus longus muscle. At final follow-up, all but one patient had documented full neurologic recovery. A seemingly innocuous event may cause acute compartment syndrome in the adolescent male. Compartment syndrome in the absence of fracture should be promptly recognized to prevent delay in surgical treatment.

The optimal surgical approach for acute compartment syndrome (ACS) of the lower leg remains debatable. Although a majority of surgeons tend to use a 2-incision approach to 4-compartment fasciotomies, the authors have used a single-incision technique followed by protocolized, staged skin closure. The purpose of this study was to determine the safety, efficacy, and complication rate of this strategy. This retrospective study included all patients treated for ACS by a single surgeon during a 3-year period. A protocol was used including a single-incision technique followed by vacuum-assisted wound-closure dressing, periodic return to the operating room at 48- to 72-hour intervals, and sequential wound closure with vertical mattress sutures. Complications associated with this protocol were analyzed. Eleven patients were included in the study. Average length of follow-up was 12 months (range, 2-35 months). There were no instances of malunion, deep or superficial infection, intraoperative neurovascular injury, or progressive neurologic deficits-indicating adequate release of all 4 compartments through a single incision. All patients were closed primarily without need for skin grafting. Average time to primary closure was 4.5 days. One patient had a tibial fracture nonunion and 1 had distal wound breakdown, which healed by secondary intention. A single-incision approach to 4-compartment fasciotomies followed by protocolized skin closure is safe and effective and may reduce the need for skin grafting. [Orthopedics. 2020;43(4):e225-e230.]., (Copyright 2020, SLACK Incorporated.)

Case: Acute lumbar paraspinal compartment syndrome (APCS) is rare. This case report describes the clinical presentation and magnetic resonance imaging (MRI) findings of APCS in a young man after strenuous weight training. The patient underwent surgical decompression of the paraspinal muscles with fasciotomy 4 days after presentation and made a complete functional recovery at the 3-month follow-up postsurgery., Conclusion: This case report highlights the importance of MRI in facilitating the diagnosis of APCS and demonstrates that fasciotomy, even if delayed, can result in complete functional recovery. This supports current understanding that surgical fascial decompression is the preferred treatment over conservative measures for this condition.

Rationale: Acute compartment syndrome (ACS) is a feared complication following traumatic injuries. We describe the occurrence of silent ACS of the hand in a 2-year old patient with atypical symptoms., Patient Concerns: Our patient experienced massive swelling but minimal pain of the hand after a heavy bistro table with a stone tabletop had fallen on the right hand., Diagnosis: After monitoring the development of ACS for 1 night, we noted increased firmness of the swelling and impaired perfusion of the skin covering the palm and dorsum of the hand. Notably, the patient held the hand in an intrinsic minus position but did not complain of pain after administration of only a single (weight-matched) dose of ibuprofen. Our suspicion of ACS was confirmed intraoperatively because of the elevated intramuscular pressure (up to 60 mm Hg) in several hand compartments., Interventions: We performed surgical fasciotomy of all hand compartments, followed by temporary coverage of the wounds with Epigard synthetic skin substitute. The wounds were closed stepwise after 2 and 7 days, and occupational therapy was initiated after 3 weeks., Outcomes: At the 1-year follow-up, we noted unrestricted wrist and finger functions of the patient. The parents reported that there was no difference in the use of the 2 hands during daily activities., Lessons: The possible development of ACS should be borne in mind even in the absence of marked pain. Although the 3 A's (i.e., anxiety, agitation, and increased analgesic requirements) in the diagnosis of ACS in children are well established, some patients may experience only minimal pain. This challenges the correct and timely diagnosis of ACS in children, particularly if they are very young.

Background: The deep temporal fascia (DTF) is known to separate into two layers that descend to attach to the zygomatic arch. When surgeons reduce an isolated fracture of the zygomatic arch through a temporal approach, the temporal incision site needs to be superior to the split line of the DTF., Materials and Methods: Sixty-seven hemifacial cadavers were investigated after removing the skin, subcutaneous tissue, and superficial temporal fascia. The superficial layer of the DTF was exposed. We cut the superficial layer along the line along, which it adhered to the deep layer inseparably. The heights of the split line of the DTF from the superior border of the zygomatic arch and from the top of the helix were measured at three points: at the jugale, zygion, and 3 cm from the tragus., Results: In all cases there were thick identifiable deep layers of the DTF. The mean heights of the split line of the DTF from the superior border of the zygomatic arch were 49.8, 46.7, and 42.6 mm at the jugale, zygion, and 3 cm from the tragus, respectively; the corresponding mean heights of the split line from the top of the helix were 19.1, 15.6, and 11.4 mm., Conclusions: Knowledge of the mean height of the split line of the DTF will be helpful for surgeons to determine the temporal incision site for ensuring the safe reduction of a zygomatic arch fracture., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest concerning the materials or methods used in this study and no source of funding., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background and purpose - Percutaneous needle fasciotomy (PNF) is a minimally invasive treatment option for Dupuytren contracture, which has gained momentum worldwide in recent years. However, evidence regarding safety and severe complications associated with PNF is sparse. Thus, we evaluated safety of a specific PNF method in the largest cohort reported in literature.Patients and methods - This is a single-center, register-based, observational study on PNF treatments between 2007 and 2015. The study cohort was identified by the Danish National Patient Registry, and diagnosis codes and procedure codes were used to identify potential severe postoperative complications such as: tendon rupture, nerve damage, infection, amputation, and reflex dystrophy for all index treatments. The Danish National Prescription Registry was used to identify non-hospital-treated infections. All index treatments and postoperative complications were verified by review of medical records.Results - 2,257 patients received PNF treatment of 3,331 treated finger rays. Median follow-up was 7.2 years (interquartile range: 4.9-9.5 years, range 1-12 years). 4 patients sustained flexor tendon rupture. 1 patient had digital nerve damage. 2 patients had an infection treated in hospital, while 31 patients received antibiotics in the primary sector for an infection or based on suspicion of an infection after PNF. None of the infections required surgical intervention. No finger amputations or ipsilateral upper limb reflex dystrophy cases were registered in relation to the procedure.Interpretation - Percutaneous needle fasciotomy for Dupuytren contracture is a safe procedure with a low rate of severe postoperative complications when a specific PNF method is applied.