Foucher first dorsal metacarpal artery flap versus littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects.

Our study aims to illustrate the advantages and disadvantages of Foucher's first dorsal metacarpal artery flap and Littler's heterodigital neurovascular flap in thumb pulp reconstruction, by assessing wound healing of donor and recipient sites, sensibility, and functional outcome of the reconstructed thumb. Fourteen male patients were reconstructed either with Foucher (n = 8) or Littler flap (n = 6). Dissection of Foucher's flap was faster than that of Littler's flap. All Littler flaps survived completely, but we experienced 1 partial Foucher flap necrosis. Thumb motility and stability was optimal in all patients. Wound healing of donor sites was achieved in both groups. Two patients reconstructed with Littler flap developed scar contractures and presented a reduced range of motion of donor finger and first webspace, respectively. Although Littler flap resulted in better sensibility and tactile gnosis of the reconstructed thumb-pulp, Foucher flap ensured negligible donor site morbidity, complete cortical reorientation, and better overall hand function.

Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients.

INTRODUCTION: Central venous cannulation is crucial in the management of the critical care patient. This study was designed to evaluate whether real-time ultrasound-guided cannulation of the internal jugular vein is superior to the standard landmark method. METHODS: In this randomised study, 450 critical care patients who underwent real-time ultrasound-guided cannulation of the internal jugular vein were prospectively compared with 450 critical care patients in whom the landmark technique was used. Randomisation was performed by means of a computer-generated random-numbers table, and patients were stratified with regard to age, gender, and body mass index. RESULTS: There were no significant differences in gender, age, body mass index, or side of cannulation (left or right) or in the presence of risk factors for difficult venous cannulation such as prior catheterisation, limited sites for access attempts, previous difficulties during catheterisation, previous mechanical complication, known vascular abnormality, untreated coagulopathy, skeletal deformity, and cannulation during cardiac arrest between the two groups of patients. Furthermore, the physicians who performed the procedures had comparable experience in the placement of central venous catheters (p = non-significant). Cannulation of the internal jugular vein was achieved in all patients by using ultrasound and in 425 of the patients (94.4%) by using the landmark technique (p < 0.001). Average access time (skin to vein) and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < 0.001). In the landmark group, puncture of the carotid artery occurred in 10.6% of patients, haematoma in 8.4%, haemothorax in 1.7%, pneumothorax in 2.4%, and central venous catheter-associated blood stream infection in 16%, which were all significantly increased compared with the ultrasound group (p < 0.001). CONCLUSION: The present data suggest that ultrasound-guided catheterisation of the internal jugular vein in critical care patients is superior to the landmark technique and therefore should be the method of choice in these patients.

The use of integra artificial dermis to minimize donor-site morbidity after suprafascial dissection of the radial forearm flap.

In an effort to minimize the radial forearm flap donor-site morbidity, the flap was elevated using the suprafascial dissection technique, in six patients with various facial defects. The donor site was covered primarily with Integra artificial skin and secondarily with an ultrathin split-thickness skin graft. The mean time to wound healing of the forearm donor site was 24 days. There were no flap failures, and all flaps healed uneventfully. At the end of the follow-up, all patients showed normal range of motion of the wrist and the fingers, normal power grip, and power pinch. All patients evaluated the esthetic appearance of the forearm donor site as very good. In conclusion, suprafascial dissection of the forearm flap creates a superior graft recipient site, and the use of Integra artificial dermis is a valuable advancement to further minimize the donor-site morbidity, resulting in excellent functional and aesthetic outcomes.

Application of the pedicled anterolateral thigh flap to defects from the pelvis to the knee.

The blood flow and the blood perfusion of pedicled anterolateral thigh (ALT) flap was evaluated in 11 patients with skin and soft tissue defects by means of color Doppler ultrasonography and of near-infrared spectroscopy, respectively. Also, the authors assessed the ability of the pedicled perforator flap to cover the above defects. A proximally based flap was used to cover defects at the lower abdominal wall (two patients), the suprapubic area, the penis (two patients), the greater trochanter (two patients), the lateral gluteal area, and the ischial tuberosity. A distally based flap was used to cover the exposed knee joint (two patients). Near-infrared spectroscopy revealed excellent oxygen saturation and Doppler ultrasonography documented increased blood flow and decreased vascular resistance in the pedicled ALT flap, postoperatively. All flaps survived completely and the wounds healed uneventfully, resulting in excellent esthetic and functional results. The vascular anatomy of ALT flap facilitates the design of versatile pedicled flaps with tremendous vascularity, two pivot points and large arc of rotation, able to cover defects from the lower abdominal wall to the knee joint.

Percutaneous versus Conventional Tracheostomy in Burned Patients with Inhalation Injury.

The aim of the study was to compare conventional tracheostomy with percutaneous dilatational tracheostomy in patients with inhalation burn injury. A total of 37 patients with severe burn injuries and associated inhalation injury, underwent percutaneous tracheostomy in our burn unit and were retrospectively compared with 22 patients who underwent conventional surgical tracheostomy. In the first group, 25 of 37 patients and in the second group 17 of 22 patients presented with partial or full-thickness burn injuries (or both) in the neck region. The cost of the procedure, operating time, complications, and incidence of pulmonary infection were recorded. There were no significant perioperative complications in the percutaneous tracheostomy group, and no patient required surgical revision or conversion to surgical tracheostomy. In the conventional tracheostomy group, 2 patients developed tracheal stenosis, 1 had a tracheoesophageal fistula, and 10 had stomal infections. The average procedure time in the first group was 9 minutes, and in the second group it was 22 minutes. The cost of the bedside percutaneous tracheostomy was one-fifth the cost of a conventional tracheostomy. The incidence of pulmonary sepsis was 45% after percutaneous tracheostomy compared to 68% after conventional tracheostomy. With the percutaneous technique, spontaneous closure of the stoma occurred within 1 to 3 days after removal of the tracheostomy tube, whereas with the conventional technique it was within 5 to 7 days. Percutaneous tracheostomy is associated with a lower complication rate and can be safely performed at the bedside. Moreover, it is faster and can be done at a lower cost than conventional open tracheostomy.

Penile resurfacing with vascularized fascia lata.

Penis resurfacing is a challenging procedure, and should simultaneously ensure erectile function, tactile sensibility, sexual satisfaction, and aesthetic integrity. This article presents three cases with penile skin defects treated by means of a pedicled fascia lata attached either to the tensor fascia lata (one case) or an anterolateral thigh flap (two cases). The cause of the wounds included electrical burn, Fournier's gangrene, and self-mutilation. The size of flaps ranged from 10-13 cm in width and 15-30 cm in length. All flaps included vascularized fascia lata, which covered part or the circumference of the penis. All flaps survived completely. The lateral cutaneous nerve of the thigh was included in the designed flaps in all instances, and normal protective sensation was recorded postoperatively. The patients reported normal erectile function and ability to perform intercourse. The flaps, though relatively bulky and hairy, had a good color and texture match with the penis and suprapubic region. Based on our limited experience, we believe that the anterolateral thigh flap has greater dimensions with a longer pedicle, and allows for greater flexibility in flap design compared to the tensor fascia lata flap. An anterolateral thigh flap can be safely thinned in a second stage, and it is our flap of choice for penis resurfacing.

Effect of genetically modified Schwann cells with increased motility in end-to-side nerve grafting.

Taking into account that Schwann-cell (SC) motility is a prerequisite for myelination during peripheral nerve regeneration, the present study was designed with the intention to increase SC motility in vitro and to evaluate the effect of transduced SC on nerve regeneration in vivo, through silicone tubes after end-to-side nerve repair. Our in vitro study demonstrated that SC transduction with the pREV-HW3 retrovirus, encoding for sialyl-transferase-X (STX), significantly increased their motility compared to the control. In the in vivo study, 45 Wistar rats were randomized into three groups of 15 each. In all animals, the left peroneal nerve was severed, and a 10-mm segment was removed. The distal stump of the peroneal nerve was connected end-to-side to a perineurial window in the ipsilateral tibial nerve with either a silicone tube lined with SC (group A) or a silicone tube lined with STX-transduced SC (groups B and C). Fluorescence and light microscopy in group C showed that SCs were viable the first critical 15 postoperative days. After 90 days, light microscopy in group B demonstrated that STX-transduced SCs with increased motility ensured nerve regeneration, through silicone tubes, in all cases. Furthermore, STX-transduced SCs increased significantly fiber diameter and myelin thickness, and most importantly enhanced significantly the functional outcome compared to non-transduced SCs.

Microvascular repair following crush-avulsion type injury with vein grafts: effect of direct inhibitors of thrombin on patency rate.

The aim of this study was to develop a standardized effective thrombogenic arterial anastomosis model, as usually encountered in clinical practice, and to offer a detailed evaluation of the antithrombotic effect of thrombin's direct inhibitors, antithrombin III and hirudin, as locally applied. Wistar rats were divided into four groups of 12 animals each. The carotid artery sustained a standardized crush-avulsion-type injury (groups B-D). A segment of the afflicted area was removed and replaced by a microvenous graft. Group A had no crush-avulsion injury inflicted; a microvenous graft replaced a simple resection from the center of the carotid artery. During microvascular anastomoses, normal saline (groups A and B), recombinant hirudin (group C), or antithrombin III (group D) were locally applied. Bleeding times were recorded, and patency tests were performed 20 min, 48 h, and 1 week after blood flow reestablishment. All grafts were harvested and examined histologically. Patency tests, 1 week postrevascularization, demonstrated that this experimental crush-avulsion injury model ensured low patency in group B (25%), whereas group A, which had no injury inflicted, achieved a 100% patency rate. The local application of hirudin and antithrombin III significantly increased bleeding times as well as the patency rate (92% and 75%, respectively) compared to group B. These findings indicate the efficiency of the experimental model and the potential use of thrombin's direct inhibitors in microvascular surgery.

Beneficial effect of nerve growth factor-7S on peripheral nerve regeneration through inside-out vein grafts: an experimental study.

This study investigated the effect of local administration of nerve growth factor-7S (NGF-7S) on the axonal regrowth of mixed peripheral nerves through inside-out vein grafts. Sixty male Wistar rats were randomized into two groups (n = 30). A defect 12 mm long in the right sciatic nerve was created and repaired with an inside-out vein graft from the right jugular vein. NGF-7S (group A) or phosphate-buffered saline (group B; control) was locally administered daily during the first 3 weeks. Walking-track analysis and electrophysiological and histological-morphometric studies were carried out 4, 6, 8, 10, and 12 weeks postoperatively (subgroups a, b, c, d, and e, respectively, n = 6 each). Data analysis showed that 1) the recovery of motor function, as measured by walk pattern analysis and evoked muscle action potential, and 2) the orientation, number, myelin thickness, and diameter of myelinated fibers were better in the NGF-7S than in the control group. These findings present strong evidence of the beneficial effect of NGF-7S on peripheral nerve regeneration through inside-out vein grafts.