Long-term behaviour of the free vascularised fibula following reconstruction of large bony defects.

Thirty-two free vascularised fibula grafts performed at our unit have been assessed retrospectively with respect to success, bony union and percentage graft hypertrophy. Between 1981 and 1998, there were 21 males and 11 females (aged 8-61 years) with follow-up of 5 months to 14.6 years. The mean bony defect bridged was 12.0 cm (standard deviation 4.8; range 5.0-21.0 cm). Bony union and hypertrophy were assessed radiographically. Time to bony union was compared using the log-rank, Wilcoxon or likelihood ratio tests. Kaplan-Meier survival curves were constructed. Hypertrophy was compared with Wilcoxon's rank sum test.Three flaps failed. Seventy-four percent of patients healed primarily at a median time of 4.75 months; five patients required further surgery to heal by 18 months (interquartile range 14-20 months). Complication rate and donor site morbidity were low. The stress fracture rate was 21%. Ninety percent of patients regained a functional limb by 12 months.Hypertrophy was measured in 22 patients and ranged from 0 to 316% (median 71%; interquartile range 10-145%). Median hypertrophy in the lower limb was 76.5% (interquartile range 26.5-165%) compared to 33.5% in the upper limb (0-88%); p=0.16. Median hypertrophy in trauma cases was 80% (interquartile range 10-167%) compared to 70% in tumour cases (33-105%); p=0.62.Our findings confirm that the fibula responds physiologically to biomechanical loading. Our results compare well with other series and alternative reconstructive modalities. We conclude that the free fibula flap can provide excellent results in the salvage of limbs with large bony defects.

A 6 year prospective analysis of the diagnosis of malignant melanoma in a pigmented-lesion clinic: even the experts miss malignant melanomas, but not often.

We investigated whether the pigmented-lesion clinic (PLC) run by the Department of Plastic and Reconstructive Surgery at Frenchay Hospital was effective in making and excluding the diagnosis of malignant melanoma, by looking at the pattern of referrals over time, the number of melanomas excised and melanomas in which the diagnosis was delayed or missed. We also investigated whether the PLC was having an effect on the thicknesses of melanomas excised. All 9968 patients attending the PLC between 1 January 1993 and 31 December 1998 were included in the study and 586 malignant melanomas were diagnosed; 24.7% of excisions led to the diagnosis of malignant melanoma. Seven invasive melanomas and two lentigo malignas were missed. There was one histological false negative. The PLC has a sensitivity of 98.5% and specificity of 89.2% for the diagnosis of melanoma; the negative predictive value is 99.9%. The PLC is effective in rapidly making or excluding the diagnosis of malignant melanoma, but has had no effect on the average thickness of melanomas excised over the 6 year study period.

A pigmented lesion clinic: analysis of the first year's 1055 patients.

The Pigmented Lesion Clinic (PLC) at Frenchay Hospital was started in January 1993 to deal rapidly and effectively with a growing number of referrals of suspicious pigmented lesions. Its objectives were to offer expert assessment and either reassurance or excision at the first PLC following referral by the patient's general practitioner. During 1993, 1055 patients were seen in 37 PLCs and 357 excision biopsies were performed. We have compared the Breslow thicknesses of malignant melanomas diagnosed from the PLCs with those of all other (non-PLC) malignant melanomas referred to our unit over the same period. We discuss the development and results of the first year of our PLC and the advantages it confers.

Incontinentia pigmenti (Bloch-Sulzberger syndrome) manifesting as painful periungual and subungual tumours.

A 25-year-old lady presented with painful periungual tumours which were associated with lytic changes of underlying terminal phalanges. She had been previously treated as a case of chronic paronychia but the problem recurred. She was subsequently diagnosed as a case of Incontinentia pigmenti which is a rare genodermatosis with mixed ectodermal and mesodermal polydysplasias, onchychodystrophy being a very rare manifestation. She was treated by excision of painful finger lesions, but there is no specific treatment for the underlying condition.

The morbidity of the free vascularised fibula flap.

Twenty patients who had undergone free vascularised fibula flap transfers were reviewed to determine the incidence of peri and postoperative complications. The mean follow-up was 3.2 years (0.2-10); 18 grafts were successful, but required 10 re-operations for complications including 5 haematoma evacuations and 3 bone grafts and plates for delayed or non-union. The two unsuccessful fibula grafts required 11 re-operations, the majority for infections and non-union. Technical details of the operative procedure are reviewed for their part in the complications.

Use of a pedicled fascial flap based on septocutaneous perforators of the posterior tibial artery for repair of distal lower limb defects.

A distally based fascial flap raised on perforating vessels of the posterior tibial artery is described. Its successful application in the repair of distal soft tissue defects of the lower limb in two patients is reported.

Vascularised fibular graft using reverse peroneal flow in the treatment of congenital pseudarthrosis of the tibia.

Pseudarthrosis of the tibia represents one of the more difficult conditions to treat, often resulting in delayed amputation or shortening. A technique is described where the central segment of the fibula containing the nutrient artery can be mobilised based on retrograde peroneal artery flow. This can then be transposed and slotted into the tibial defect after resection of the pseudarthrosis, allowing bone replacement and correction of length. In the initial two cases presented the bone behaved in the same way as a successful microvascular transfer.

Comparison of the safety and efficacy of parenteral ticarcillin/clavulanate and clindamycin/gentamicin in serious intra-abdominal infections.

One hundred and twelve patients with proven or suspected serious intra-abdominal infections were randomized for treatment with either ticarcillin/clavulanate (3.1 g every 4 h) or gentamicin (dosage schedule adjusted according to serum concentrations) plus clindamycin (in most cases 900 mg every 8 h). Positive intraperitoneal and/or blood cultures were available in 47 cases. Considering only fully evaluable cases, 15/20 (75%) were clinically cured or improved in the ticarcillin/clavulanate group and 16/25 (64%) in the gentamicin/clindamycin group, the difference not being significant (P greater than 0.05). Bacteraemia was documented in nine of 45 fully evaluable cases. During the course of the study, the serum creatinine concentration increased by more than 5 mg/l in only one patient (ticarcillin/clavulanate group). Two patients (one in each group) had apparent allergic reactions. No other drug-related adverse effects were noted. In-vitro sensitivity testing of anaerobic isolates revealed that, of those tested, 5/38, 1/38 and 2/37 were resistant to ticarcillin, ticarcillin/clavulanate and clindamycin, respectively. Among aerobic Gram-negative isolates, 34/78, 6/78 and 4/78 were resistant to ticarcillin, ticarcillin/clavulanate, and gentamicin, respectively. Among aerobic Gram-positive isolates, 2/32, 2/32, and 5/14 were resistant to ticarcillin, ticarcillin/clavulanate, and clindamycin, respectively. We conclude that ticarcillin/clavulanate is a safe and efficacious preparation for treating serious intra-abdominal infections.

Aminoglycoside pharmacokinetics: dosage requirements and nephrotoxicity in trauma patients.

We evaluated prospectively gentamicin and tobramycin pharmacokinetics in 37 patients with multiple system trauma and seven patients with isolated closed head trauma. The mean apparent volume of distribution (Vd) was 0.38 +/- 0.10 and 0.27 +/- 0.04 L/kg actual body weight (ABW) in patients with multiple trauma and closed head trauma, respectively. The difference in Vd between the two groups of patients was significant (p less than .002). Vd was not predictable on the basis of age, sex, weight, trauma score, or hospital day that therapy was initiated. Mean aminoglycoside clearance (Cl) was 123 +/- 46 ml/min. Neither serum creatinine nor estimated creatinine Cl predicted aminoglycoside Cl with sufficient accuracy to be clinically useful (r = .33 and .67, respectively). The mean daily dose was 6.1 +/- 1.6 mg/kg. The mean peak serum level was 5.8 +/- 1.3 micrograms/ml. Only one patient developed clinically significant renal dysfunction. Our data indicate that a loading dose of gentamicin or tobramycin of 3 mg/kg ABW in patients with multiple trauma and 2.5 mg/kg ABW in patients with isolated head trauma will obtain a mean initial peak serum level of 6.6 micrograms/ml. Although adequate maintenance dosing requires individualization based on pharmacokinetic analyses, large aminoglycoside doses can be used safely in patients with blunt trauma if appropriate monitoring is employed.

Indications and long-term assessment of 10 cases of cross-leg free DCIA flaps.

Compound fractures of the lower limb with skin and bone loss are difficult repair problems, especially in multiple level injuries. With bone loss between 6 and 12 cms, the deep circumflex iliac artery (DCIA) flap is usually the flap of choice in reconstruction; the aim is to carry out microvascular anastomosis of the flap vessels to vessels on the damaged leg. However, this may be difficult or even impossible. Experience of 10 cross-leg DCIA flaps is outlined, with indications and surgical technique. The long-term bone healing is compared with 13 cases with anastomosis based on the same leg. There appears to be no difference in callus formation and remodelling of bone, indicating that despite subsequently dividing the original main vascular supply the bone in the DCIA flap remains vascularized and behaves as such.

Pharmacokinetics and dosage requirements of netilmicin in cystic fibrosis patients.

The pharmacokinetics of netilmicin were determined in 10 patients with cystic fibrosis. Mean (+/- standard error of the mean) values for total body clearance and volume of distribution were 2.62 (+/- 0.18) ml/min per kg of body weight and 0.38 (+/- 0.01) liter/kg, respectively, and were considerably larger than the same parameters reported for patients without cystic fibrosis.

Microvascular surgery of the lower limb.

Microvascular surgery is now an essential ingredient in the range of reconstructional techniques available in lower limb surgery. It has a particular application in composite problems following trauma but wider applications are becoming apparent.

The development of a dynamic model for microvascular research and practice using human placenta: a preliminary report.

Human placenta has been investigated in an attempt to develop a non-animal model for microvascular research and practice, with a dynamic artificial circulation. Initial work has been encouraging and further development is in progress.

Functional association of class II antigens with cell surface binding of Epstein-Barr virus.

A functional role of class II antigen in the binding of Epstein-Barr virus (EBV) was deduced from the study of membrane proteins on Jijoye, an EBV receptor (EBVR)-positive B cell line, and its mutant, EBVR-negative daughter cell line, P3HR-1. From gel electrophoresis of radiolabeled microsomal membrane proteins and immunoprecipitates, we identified class II antigen on Jijoye but not on P3HR-1 cells and the presence of Ii on both cell lines. The role of these molecules in EBVR function was tested by antibody blocking of virus adsorption. Anti-p23,30 serum (to class II antigen) was found to block binding of EBV to B lymphoblasts under conditions in which normal rabbit serum, rabbit antiserum to butyrate-treated P3HR-1 cells (with ample anti-Ii antibodies), and rabbit anti-p44,12 (to class I antigen and beta 2-microglobulin) serum did not block virus binding. Only one of four commercial monoclonal antibodies (MoAb) to framework epitopes on class II antigens blocked binding of EBV, whereas all four MoAb demonstrated immunofluorescent reactivity with the EBVR+ Raji cells. In previous studies of binding of EBV to hairy leukemic cells, a substantial subpopulation of HLA-DR+, EBVR- cells was identified, in addition to HLA-DR+, EBVR+ cells. These findings were consistent with the view that the HLA-DR complex has a role in the binding of EBV but that other components are also needed for the expression of EBVR function.

Lengthening of a short traumatic femoral stump.

A case is reported in which a severe open injury of the thigh eventually required amputation of the lower limb. Lengthening of the short proximal femoral stump was achieved by turning over a flap comprising bone and soft tissue, with sensation, from the ipsilateral leg.

Free vascularized fibular graft to reconstruct early a traumatic humeral defect.

A case is reported in which a free, vascularized fibular graft was used to reconstruct early a traumatic 16-cm defect in a humerus. A description of a cast-brace used postoperatively is included. A brief review is presented of the literature with respect to the use of free vascularized fibular graft for defects in the upper extremity.

Lower limb salvage using an extended free radial forearm flap.

A case is reported of an unusual double injury, in which a lower limb salvage procedure employed a free radial forearm flap from an amputated upper limb. The use of amputated parts for salvage procedures is well documented but none has previously involved a free forearm flap. This clinical case shows that the entire forearm and hand skin can be adequately perfused on the radial artery along with the superficial palmar arch.

Vascularised nerve grafts using composite arterialised neuro-venous systems.

The rationale for the use of revascularised nerve grafts is well established and has been proved both experimentally and clinically. It is a technique that is particularly useful if one wishes to transfer large thick grafts to repair major nerves or insert vascularised cable grafts to bridge long defects in a poorly vascularised fibrous bed of tissue. An experimental technique has been devised to raise a composite neuro-venous graft and by reversing the vein component provide an arterialised composite nerve graft that can be safely transferred to different parts of the body. Experimental work in cadavers and dogs has confirmed these observations and details of seven clinical cases are given. The results are encouraging and in patients with nerve injuries where there are associated vascular and nerve defects, as in the forearm and hand, the technique of a composite reversed neuro-venous graft which is arterialised, should be seriously considered.