Calcium sulphate delivery system with tobramycin for the treatment of chronic calcaneal osteomyelitis.

The case of a 24-year-old woman with Pseudomonas aeruginosa and Proteus mirabilis chronic calcaneal osteomyelitis is presented. Extensive debridement of the necrotic bone and application of tobramycin-loaded polymethylmethacrylate beads was performed and ciprofloxacin was given post-operatively. Three months later, laboratory tests, including complete blood cell count, erythrocyte sedimentation rate and C-reactive protein, were normal. At this time, extensive surgical debridement and filling of the osseous defect with autologous iliac cancellous bone graft and tobramycin-impregnated calcium sulphate pellets and paste were performed. Oral ciprofloxacin was administered for 3 months after surgery. At the latest follow-up, 2 years later, the patient had full weight-bearing function; there was no recurrence of the infection, and complete incorporation of the autologous bone and calcium sulphate graft with the host bone was observed. This case demonstrates that two-stage surgical treatment with extensive debridement and tobramycin-impregnated calcium sulphate was effective in treating chronic calcaneal osteomyelitis.

Extraluminal or intraluminal inferior vena cava occlusion in pulmonary embolism.

Twenty-five cases of extraluminal and 47 of intraluminal inferior vena caval (IVC) occlusion for management of pulmonary embolism were reviewed. A comparison of results obtained with both methods suggests that the IVC umbrella filter provides the safer, more reliable means of IVC interruption in patients whose condition fulfills the criteria for caval occlusion. The simplicity of this technique and the fact that it can be performed under local anesthesia justify its consideration as the procedure of choice for IVC occlusion and permit its use in severely ill patients. On the basis of our positive findings, we now recommend that extraluminal occlusion be reserved for patients in whom insertion of the IVC umbrella is technically impossible.

Congenital arteriovenous malformation of the head and neck.

A discussion of congenital arteriovenous malformation of the head and neck based on five patients followed from three to twenty years is presented. Definition of the lesion and its progression as followed by angiography is described. The poor response to surgery is ascribed to the ischemic nature of the area of involvement. The concept of supplying normal tissue with normal vascularity to the involved area is advocated.

Long-term results after chemoradiotherapy for locally confined squamous-cell head and neck cancer.

The long-term results after simultaneous chemoradiotherapy in 54 patients with previously untreated or minimally treated, locally confined (M0) squamous-cell carcinoma of the head and neck are presented. Multiple concurrent courses of radiation therapy and chemotherapy with cisplatin and a four-day 5-fluorouracil infusion were given. Twenty-eight patients underwent definitive surgery and 26 were treated without surgical resection. Treatment-associated toxicity was significant, including mucositis, myelosuppression, and a mean 12% loss of initial body weight. Of the 54 patients, 51 were ultimately rendered disease free by this combined modality protocol. With a follow-up ranging from 42-68 months, the projected Kaplan-Meier relapse-free survival for the entire patient cohort is 70%, with all relapses occurring within 17 months of patient entry. The projected Kaplan-Meier relapse-free survival for patients with Stage IV disease is 62%. The durability of these remissions suggests that there is a significant likelihood of cure in all patients with locally confined disease, and justifies comparative trials with standard treatment.

Peripheral vascular trauma: a civilian experience.

A detailed review of 106 vascular injuries seen at the Mt. Sinai Hospital of Cleveland in a period of six-and-a-half years is presented. The type and location of the vascular injuries, the concomitant injuries, the preoperative evaluation, operative and post operative management, the complications and their management are discussed. The overall amputation rate in our cases was 4.7%, and for popliteal artery injuries 20%. The mortality rate was 5.6%.

Vascular impairment and free tissue transfer in the lower extremity.

Fourteen patients with arteriosclerotic peripheral vascular disease and extensive tissue defects of the lower extremity, underwent microsurgical reconstruction using free tissue ("free flap") transfer. It was possible to provide coverage in ten of these patients. Analysis of this small series showed that only six of these ten patients were able to resume unassisted ambulation. The authors discuss technical aspects of microsurgical reconstruction in this unfavorable group of patients. Analysis of this small series suggest that: (1) inadequate patient motivation, and (2) inability to form granulation tissue in the soft tissue defect, either before or after a vascular reconstructive procedure, are both strong contraindications to microvascular free flap reconstruction in patients with arteriosclerotic peripheral vascular insufficiency of the lower extremity.

Alternatives in soft tissue reconstruction of the ankle and foot.

Reconstruction of soft tissue defects of the ankle and foot still presents a challenge. This is related to both the lack of large soft tissue flaps in this part of the body suitable for transfer to adjacent injured areas and to of the unique characteristics of the soft tissues of the sole of the foot. Microsurgery has solved some of these problems with the transfer of soft tissue from more distal areas. Several small arterialized and sometimes innervated flaps from the intrinsic tissues of the foot are also available for reconstruction of defects of limited size. The present report assesses 49 flaps, 15 local and 34 microsurgical transfers which were performed in 46 patients. The results suggest that there are several effective alternatives for coverage of soft tissue defects of the ankle and foot.

Beyond replantation: microsurgical salvage of complex hand injuries.

The authors believe that certain complex hand injuries so severe as to be considered for amputation or simple proximal revision, may under some circumstances be salvaged with the use of appropriate microsurgical techniques. They present three examples of severely injured hands to illustrate the reconstructive potential of microsurgery. Salvage techniques are considered in some detail including debridement, evaluation and planning, fixation, restoration of circulation, reconstruction of tendons, joints and nerves, and provision of coverage. The importance of vein grafts for successful salvage of complex hand injuries is emphasized.

Avulsion injuries of the thumb.

Similar findings in a series of seven avulsions of the thumb suggest that this injury is a well-defined entity. In all cases avulsion was the result of catching the digit in a rotating machine. In most cases a glove was worn. The usual clinical findings included extrinsic tendon avulsion from the forearm, nerve avulsion from the median nerve within the carpal tunnel, extensive arterial damage in the amputated thumb, and partial degloving of soft tissues. Successful replantation was possible in every case. We believe that vein grafts should be used routinely, anastomosed to normal distal vessels. The site of nerve injury should be identified by dissection of the median nerve within the carpal tunnel. Retrograde flaps should not be sutured for wound closure. We believe that replantation should be attempted in all cases of thumb amputation in which the part is available.

Short saphenous vein grafts as an aid to microsurgical reconstruction of the lower extremity.

The authors present a method of free flap reconstruction using the short saphenous vein, when local vessels are not available in the lower extremity. Initially, a temporary arteriovenous fistula is created. This is subsequently divided to provide both arterial access and venous drainage for the flap. The use of the short saphenous vein has a number of advantages: 1) forty to 50 cm of length are available; 2) the vein is relatively thin-walled and has a nearly constant diameter throughout its length; 3) the vein may be left in situ at its upper end in some patients; 4) the vein drains into both the long saphenous and the popliteal veins. Thus, double drainage is provided. This may be of importance in patients with impaired outflow secondary to deep venous thrombosis or obstruction. 5) The separated vein graft components allow accurate ultrasonic monitoring of both arterial and venous circulation. Seven cases are presented of type IIIb and IIIc tibial fractures in which regional vessels were not accessible. Free flap reconstruction using in situ short saphenous vein grafts was successful in all seven patients. The anatomy of the short saphenous vein and surgical technique are considered.

Intraoperative heparin in replantation surgery--an experimental study.

An experimental study to define the usefulness of heparin in microvascular surgery was undertaken. Fifty-four rabbits underwent replantation of an amputated ear. The animals were randomly divided into two groups--"heparin" and "no heparin," with 27 animals in each group. Arterial patency was recorded based on direct microscopic observation of the anastomosed vessels prior to wound closure and on subsequent viability or necrosis of the ear during the surgical procedure was markedly enhanced by the use of intraoperative heparinization. The overall patency rate for the heparin group was 74%, whereas that of the no-heparin group was 44%--a statistically significant difference. This study confirms the value of intraoperative heparin in experimental replantation surgery using a rabbit ear model.

Crossed fingers and other tests of ulnar nerve motor function.

All tests for ulnar nerve motor function require demonstration and explanation if they are to be carried out reliably. The tests used most commonly may be difficult to elicit, particularly in children or in the presence of an acute injury. The authors have found that the ability to cross the middle over the index finger is a reliable test of ulnar nerve function. This maneuver of "crossing the fingers" is in common usage from childhood on as a good luck sign and is elicited easily in the presence of an intact ulnar nerve. An annotated table is included of other tests that may be useful in evaluating ulnar nerve integrity.

A simple method of controlling rotation in replanted digits.

A method of fixation for replanted digits is described. It consists of axial fixation with a wire passed longitudinally through the replanted digit, supplemented with a transverse wire passed across all the digits. In this way, splinting is provided and rotation is controlled. The method is simple, rapidly applied, and very effective.

Oral squamous cell carcinoma in children.

Squamous cell carcinoma of the oral cavity occurs very rarely in children and is particularly rare during the first decade of life. This article describes a case of squamous cell carcinoma of the maxillary alveolar ridge in a 7-year-old child. Subtotal maxillectomy was carried out with an apparent cure (33-month follow-up). A brief review of this disease as it occurs in children is included. Although this is an aggressive neoplasm, early and adequate surgical intervention may be curative.

Vein grafts in reconstructive microsurgery of the lower extremity.

This paper describes surgical techniques and results of lower extremity microsurgical reconstruction using vein grafts. During a 5 year period, free tissue transfers were used to reconstruct 118 lower extremity defects in 109 patients. In 28 of these cases (24%), saphenous vein grafts were used when reconstruction would otherwise have been difficult or impossible. A preliminary arteriovenous fistula was established between the proximal arterial source and the final venous drainage in the majority (26) of cases. Venous drainage was left intact at the point of entry into the deep venous system in 23 cases. Three complications included anastomotic clotting in 2 patients and postoperative blow-out of the vein graft in another; all were treated without flap loss. Flap survival was 86% in vein grafted patients and 94% in those cases in which vein grafts were not used. Flap loss was related in each case to the nature of the pre-existing condition, rather than to vein grafting per se.

Effect of nerve graft polarity on nerve regeneration and function.

To evaluate the effect of the polarity of nerve grafts, a 1.0 cm segment of sciatic nerve of 40 adult male Sprague-Dawley rats was excised. In 20 animals the nerve was sutured, maintaining the original polarity. In the order 20 the graft was reversed and sutured into place. Four to 6 months later, the nerves were exposed and directed conduction velocity and amplitude studies were done across the graft. No difference was found between the two groups. Comparison with the control side showed return of 70% to 75% of conduction velocity and amplitude. Nerve graft function was independent of nerve graft polarity.

A palmar cross-finger flap for coverage of thumb defects.

We have devised a method of covering tissue defects of the distal thumb using a flap elevated between the two flexion creases on the palmar skin over the proximal phalanx of the long finger. The advantages of this method over the usual dorsally based, distal, cross-finger flap include improved appearance of the donor finger, comfortable positioning, and avoidance of joint contractures. Although sensitivity of the palmar scar, contractures, or other disadvantages of this approach were sought during follow-up, none were found.

Munchausen's syndrome presenting as severe panniculitis.

Factitious disorders may trouble any physician during his/her career. A considerable number of cases of Munchausen's syndrome (self-induced disorder) are misdiagnosed in clinical practice. A 36-year-old woman was admitted to our hospital because of fever and abdominal pain. Physical examination showed signs of inflammation of the abdominal wall, and histological examination revealed severe panniculitis. We investigated various aetiologic factors that could probably be related to fat necrosis, but we found no explanation of the phenomenon until we verified the diagnosis of Munchausen's syndrome. 2 years later, the patient underwent surgery for removal of needles, which she herself had deliberately located under her skin. High index of suspicion and physician's persistence are necessary to make the correct diagnosis in the various protean manifestations of Munchausen's syndrome.

Treatment of oral squamous cell carcinoma with simultaneous chemotherapy and radiation: results and surgical implications.

Thirty-seven patients with oral squamous cell carcinoma, many with advanced disease, were treated initially with a protocol using simultaneous intravenous 5-fluorouracil (5-FU) cis-platinum, and radiation. Twenty-two patients (62%) experienced complete remission after one cycle of therapy. Fifteen patients (38%) demonstrated an incomplete response; surgical resection was possible in 14 of these 15 patients. A second cycle of chemoradiotherapy was administered to all 37 patients. After this treatment resection is possible for some patients who are initially inoperable, and surgery is necessary only for those patients (38%) who show an incomplete remission after the first cycle of therapy and for those who present initially with bony invasion. Furthermore, the treatment of cervical nodes and intraoral disease may be divorced and the extent of surgery may be reduced for many patients. A 5-year survival of 76% is predicted for this group of patients. The described protocol shows promise for treatment of oral squamous cell carcinoma.