Free intra-osseous muscle transfer for treatment of chronic osteomyelitis.

BACKGROUND: Chronic osteomyelitis is still a big reconstructive challenge. Even with standard care, therapeutic failures and recurrences are common. Multiple techniques of tissue transfer have increased the success rate. This study recommends free muscle transfers into the intramedullary bone cavities for treatment of chronic osteomyelitis. PATIENTS AND METHODS: The review included 29 patients that were treated for chronic osteomyelitis. Osteomyelitis was located at the femur in four patients, the tibia in 22 patients, and the foot in three patients. Dead bone and scar tissue were replaced with durable free muscle flap with special attention to fill the dead space. RESULTS: The average age of these patients was 48.5 years old (range = 23-70 years old). The average duration of osteomyelitis was 8.2 years (range = 1-45 years). Gracilis was applied in 20 cases (69%), latissimus dorsi was used in five cases (17.2%), and rectus abdominis was performed in four cases (13.8%). There was one flap failure, one partial superficial flap necrosis, two arterial thrombosis, and one venous thrombosis. All the remaining 28 muscle flaps survived. From 1-10 years follow-up, there was one recurrence of the osteomyelitis in the distal end of the intra-medullary cavity of a femur after reconstructing using the gracilis flap. CONCLUSION: The present study demonstrated that free intramedullary muscle transfers are effective in providing a high rate of success in the treatment of chronic osteomyelitis. The secondary filling of the intramedullary cavity after extensive removal of all infected bony sequesters has proven to give a long-term arrest of chronic osteomyelitis.

Evidence of insulin resistant lipid metabolism in adipose tissue in familial combined hyperlipidemia, but not type 2 diabetes mellitus.

In patients with familial combined hyperlipidemia (FCHL) and type 2 diabetes (DM2) organ-specific differences in insulin resistance may exist. In FCHL and DM2 in vivo insulin mediated muscle glucose uptake and inhibition of lipolysis were studied by euglycemic hyperinsulinemic clamp. Insulin mediated glucose uptake was impaired to the same extent in both FCHL and DM2. Only FCHL subjects showed no reduction in plasma glycerol concentrations during insulin infusion and incomplete suppression of plasma free fatty acid (FFA) concentrations combined. This finding indicated that insulin-induced suppression of lipolysis, or glycerol/FFA utilization, or both, were impaired in FCHL, in contrast to DM2 or control subjects. To analyze these possibilities in more detail, control, FCHL, and DM2 adipocytes were studied in vitro. In contrast to adipocytes from DM2 or control subjects, no reduction in medium FFA concentration was detected with FCHL adipocytes after incubation with insulin. This finding indicated impaired intracellular FFA utilization, most likely impaired FFA re-esterification. Genetic linkage analysis in 18 Dutch families with FCHL revealed no evidence for involvement of LIPE, the hormone sensitive lipase gene, indicating that genetic variation in adipocyte lipolysis by LIPE is not the key defect in FCHL. In conclusion, FCHL as well as DM2 subjects exhibited in vivo insulin resistance to glucose disposal, which occurs mainly in muscle. FCHL subjects showed insulin resistant adipose tissue lipid metabolism, in contrast to DM2 and controls. The different pattern of organ-specific insulin resistance in FCHL versus DM2 advances our understanding of differences and similarities in phenotypes between these disorders.

Toxic shock syndrome due to group A beta-hemolytic streptococcus presenting with purpura fulminans and limb ischemia in a pediatric patient treated with early microsurgical arteriolysis.

We describe a 2.5 year-old child with toxic shock syndrome due to group A beta-hemolytic streptococcus (GABHS) who presented with purpura fulminans and limb ischemia treated with early microsurgical arteriolysis. The clinical picture of toxic shock syndrome (TSS) presenting with purpura fulminans and limb ischemia is an exceptionally uncommon finding in sepsis due to GABHS. This is the first case of purpura fulminans caused by GABHS reported in Europe and the third one described in the literature (Dhodapkar et al., 2000[1]; Renaud et a., 2011[2]).

Minimizing limb amputations in meningococcal sepsis by early microsurgical arteriolysis.

PURPOSE: Surgical treatment of children with meningococcal sepsis has mainly involved debridement of necrotic skin and amputation of limbs. This resulted in major functional impairment. On the contrary, when early microsurgical arteriolysis was performed, freeing up the blood vessels, the impaired blood flow could be restored, thereby significantly reducing the amputation levels. METHODS: We prospectively evaluated 14 patients affected by meningococcal sepsis. In 7 patients, microsurgical arteriolysis was performed; standard sepsis treatment was performed on the remaining 7. Ischemia levels on admission were compared with permanent amputation levels after 1 year. RESULTS: Statistically significant decreases (P = .005) in ischemia values were achieved by the arteriolysis, in comparison with final amputation percentages. The functional impairment of the affected limbs was highly reduced compared with the probable loss of function observed on admission. CONCLUSIONS: Our findings show that early microsurgical arteriolysis is a reliable method to reduce the devastating amputations normally found in patients with meningococcal sepsis. This significantly improves the functional outcome in severely ischemic limbs in meningococcal induced septic children.

A study of perfusion of the distal free-TRAM flap using laser Doppler flowmetry.

The aim of this study was to characterise microcirculatory changes in the distal part of a flap and to evaluate whether measurement of the microcirculation may predict flap complications (FC). In this prospective study, 30 patients undergoing a delayed breast reconstruction were included. Perioperative data were recorded and with the laser Doppler flowmetry (LDF; Perimed) blood flow was recorded in the central part (zone I) and the distal part (zone IV) of the flap. A lower blood flow was observed in zone IV of patients with flap complications compared to patients without flap complications (P=0.013). In addition, LDF demonstrated different flow trends in zone I compared to zone IV indicating a delayed opening of the choke vessels connecting the angiosomes in the distal part of the flap. The LDF has proven to be a useful investigative tool to monitor microcirculatory changes. In future studies it will be used to evaluate interventions aimed at decreasing distal ischaemia and reducing flap complications.

Risk factors and blood flow in the free transverse rectus abdominis (TRAM) flap: smoking and high flap weight impair the free TRAM flap microcirculation.

Mastectomy patients may have significant psychologic-related problems. Breast reconstruction provides in these cases substantial benefits in restoring body image and health-related quality of live. Autologous free tissue transfer is the treatment of choice due to excellent outcome. The purpose of this study was to elucidate the effect of the risk factors on the microcirculation and clinical outcome. In this prospective study, 21 patients with a free transverse rectus abdominis (TRAM) flap breast reconstruction were included. Patient demographics and flap characteristics were recorded. Blood flow was recorded in the central part (zone I) and the distal part (zone IV) of the flap with the laser Doppler flowmetry (LDF; Perimed). In this study, increased flap complications were seen in smokers when compared with nonsmokers (P < 0.000). LDF was higher in the older patient population (P = 0.008) in zone IV. Smoking, especially in combination with a high flap weight (HFW), revealed lower blood-flow values (P = 0.020) in zone IV. Other possible influencing risk factors such as a HFW and history of radio- and chemotherapy did not alter the microcirculation. Patients with smoking and a HFW did also show decreased blood flow but also more severe flap complications.Smoking, especially in patients with a HFW, impairs the free TRAM flap microcirculation in zone IV. In our opinion, these patients can still be included for reconstruction. However, extra care has to be taken during flap design to minimize disturbed wound healing.

Is the treatment of keloid scars still a challenge in 2006?

BACKGROUND: Several options are described to treat keloid scars, none of them being 100% successful. Radiotherapy is suggested to have the most significant effect on recurrence rate. OBJECTIVES: The aim of the study is to confirm the effectiveness of iridium brachytherapy combined with surgery and to evaluate patient satisfaction. PATIENTS AND METHODS: We retrospectively enrolled 24 patients with 30 keloids, treated by surgical excision and iridium 192 high-dose-rate (HDR) brachytherapy. RESULTS: We observed a significant difference in scar thickness before and after the treatment (P < 0.001). With regard to patient satisfaction and complaints, 79.1% of them had no pain and irritation after treatment, 79.2% of patients would recommend this treatment to other patients, and 87.5% would undergo this treatment again if necessary. CONCLUSIONS: Our results confirm the effectiveness of surgical keloid excision followed by HDR brachytherapy in primary treatment or if other alternative methods have failed.

The role of free flaps in the treatment of persistent scalp osteomyelitis.

OBJECTIVE: To evaluate the efficacy of the combination of an extensive surgical debridement and simultaneous free flap repair in case of troublesome cranial osteomyelitis. METHODS: Five patients with persistent, frontal bone osteomyelitis were treated with surgical debridement of the infected bone and reconstruction with a free flap. In all patients, osteomyelitis occurred after neurosurgical procedures and lasted from 1 to 7 years. A latissimus dorsi muscle flap with a split skin graft has been performed. RESULTS: No flap failure occurred and donor site morbidity was negligible. No signs of osteomyelitis or soft tissue infection were observed during the mean follow-up period of 3.2 years. Furthermore, the contour of the cranium could be preserved without a need for bone grafts or implants. CONCLUSION: In our experience, the combination of an extensive surgical debridement and a free flap transfer is demonstrated to be an effective treatment for "chronic" osteomyelitis of the cranium.

Preservation of rat cremaster muscle microcirculation after prolonged cold storage and transplantation.

BACKGROUND: Microvascular surgery for the reconstruction of complex defects involves an ischemic period, which may cause flap failure as the result of ischemia/reperfusion injury. We assessed the microvascular consequences of rat cremaster muscle transplantation after prolonged periods of cold storage in HTK-Bretschneider solution (HTK). MATERIALS AND METHODS: Cremaster muscle transplantations were performed immediately or after 8 or 24 h of cold storage (4 degrees C) in HTK or saline. Intravital microscopy was used to quantify capillary perfusion and venular leukocyte-endothelium interactions following transplantation. RESULTS: The transplantation procedure itself resulted in 50-65 min of ischemia. After direct transplantation, capillary perfusion was 90% of control. Transplantation after 8 h of cold storage in either HTK or saline did not deteriorate capillary perfusion. When the tissue was stored for 24 h, HTK was superior to saline in preserving capillary perfusion (HTK: 76-83% of control, saline: 30%). Immediate transplantation induced a small increase in leukocyte adhesion. Prolonged cold storage in either fluid resulted in reduced flow velocities (qualitative observations) and edema formation, which hampered quantification of leukocyte-endothelium interactions. CONCLUSIONS: Even after 8 or 24 h of cold storage in HTK, transplantation of rat cremaster muscle was successful with good capillary perfusion. Capillary perfusion was better preserved in HTK than in saline.

Infected chronic wounds show different local and systemic arginine conversion compared with acute wounds.

BACKGROUND: Several experimental studies have shown the importance of arginine in wound healing. However, little is known about its role in human wound healing. In this study, we investigated arginine metabolism in impaired wound healing. MATERIALS AND METHODS: Twenty patients with chronic wounds and 10 patients with acute wounds were included in a prospective study. Amino acids, nitrate/nitrite, and arginase concentrations were determined in plasma and wound fluid using high-performance liquid chromatography and enzyme-linked immunosorbent assay. Chronic wounds were divided into two groups: noninfected chronic wounds (n = 11) and infected chronic wounds (n = 9), based on quantitative bacterial analysis of wound fluid samples. RESULTS: Plasma arginine levels, next to total plasma amino acid levels, were significantly decreased in patients with infected chronic wounds compared with patients having acute or noninfected wounds. Citrulline and ornithine levels were significantly increased in infected chronic wounds and related to decreased nitrate/nitrite levels, whereas wound fluid arginine levels were similar in all groups. In addition, wound fluid arginase levels of infected chronic wounds were significantly enhanced. CONCLUSIONS: This study demonstrates that patients with infected chronic wounds have decreased plasma arginine levels and suggests enhanced arginine conversion in the wound. In contrast to noninfected chronic wounds, arginine seems to be mainly metabolized by arginase in infected chronic wounds. In conclusion, our hypothesis is that impaired wound healing is related to an altered arginine usage.

Do preservation solutions protect rat cremaster microcirculation during ischemia and reperfusion?

BACKGROUND: Our aim was to investigate the potential of the preservation solution Celsior to protect rat cremaster muscle microcirculation during ischemia and reperfusion, and to compare its effects with those of HTK (histidine-tryptophan-ketoglutarate-Bretschneider solution). Because of its anti-oxidant contents, we expected Celsior to be more protective than HTK. MATERIALS AND METHODS: Capillary perfusion and leukocyte-endothelium interactions were examined in rat cremaster muscle using intravital microscopy. After perfusion with Celsior or HTK (4 degrees C), the cremaster was subjected to 4 or 6 h of warm (33-34 degrees C) ischemia and 2 h of reperfusion. Measurements were performed prior to perfusion and/or ischemia, and 0, 1, and 2 h after restoration of flow. RESULTS: Without Celsior or HTK, capillary perfusion transiently decreased to 50% of baseline after 4 h of ischemia; it remained low (45%) after 6 h of ischemia. Whereas HTK had no significant influence, Celsior deteriorated capillary perfusion: it remained low after 4 h of ischemia (39-48%) and decreased even further after 6 h of ischemia (18-8%). Both preservation solutions similarly reduced the increase in leukocyte-endothelium interactions after ischemia. CONCLUSIONS: Preischemic tissue perfusion with Celsior had an adverse effect on capillary perfusion in rat cremaster muscle after 4 and 6 h of ischemia, whereas HTK did not significantly influence this parameter. Both preservation solutions similarly prevented the increase in leukocyte-endothelium interactions after ischemia. These data suggest that HTK is more suited as a preservation solution for muscular tissue than Celsior, especially when the known protective effects of HTK on muscle function are taken into account.

Quality of life after breast reduction.

The purpose of this study is to compare health-related quality of life in women with symptomatic macromastia before and after breast reduction. Two comparable groups of women were enrolled in the study, those waiting for breast reduction (group 1) and those who underwent surgery approximately 2 years before (group 2). To evaluate the specific beneficial effects of breast reduction, we used a unique combination of general and specific questionnaires: the Short Form 36 Health Survey Questionnaire (SF-36), the European Quality of Life-5 Dimensions (EQ-5D), the Rosenberg Self-Esteem Scale (RSE), the Self-Consciousness Scale (SCS), and the Derriford Appearance Scale 59 (DAS-59). The esthetic appearance of the breast was also evaluated using a visual analog scale (VAS). In both groups, preoperative back pain was present in more than 50% of patients. Complaints were significantly reduced after surgery. SF-36 showed significant higher quality of life in group 2 with regard to 7 of 8 investigated domains. Increased self-esteem after surgery, increased personal and public self-consciousness were observed. Moreover, the condition-specific DAS-59 showed that insecurity, pain, shame, and unattractiveness were significantly scored higher in the nonoperated group. Subjective esthetic score was significantly higher in the operated group (2.5 vs. 7.1). The data of this study provide further evidence that women who have been operated for breast hypertrophy have a significant improvement in quality of life compared with those who are not yet operated. These data are further evidence that breast hypertrophy is not solely an esthetic problem.

Free fascia temporalis interpositioning as a treatment for wrist ankylosis.

The fascia temporalis is a thin and well-vascularized tissue and, for this reason, its use in reconstructive surgery is versatile. It can be used as an island flap in defects of the head and neck or as a free flap in reconstructions of different anatomic regions. As a "living" spacer in the treatment of wrist ankylosis, its use has not yet been described. The authors present the transfer of the free fascia temporalis into the wrist as a treatment of wrist ankylosis in patients affected by severe rheumatoid arthritis. Four flaps in three patients were performed. Preoperative flexion/extension in the wrist was absent or almost absent and painful, resulting in severely impaired daily activities. After resection of the distal ulna, distal radius, and the proximal surfaces of the proximal row of the carpal bones was performed, the free fascia was used to replace the wrist joint. Postoperative wrist flexion/extension was 45 to 50 degrees on average. In all patients, this procedure allowed painless motion of the wrist, and in all patients, daily activities were improved. A 2-year follow up showed no recurrence of wrist problems and a maintained articular space. In the treatment of wrist ankylosis, the use of the free fascia temporalis offers a good alternative to arthrodesis, maintaining sufficient function for daily activities.

Arterialized venous free flaps for soft-tissue reconstruction of digits: a 40-case series.

When there is not sufficient local tissue available for reconstruction of one or multiple digital defects, distant flap reconstructions are required. Available thin flaps with defined arterial inflow and venous outflow are limited and require the sacrifice of an arterial pedicle. In addition, a functional limitation can occur at the donor site. During the last decades, experimental and clinical attempts have been made in using venous flaps, based just on the venous network for in- and outflow. A 40-case series of arterialized venous free flaps in soft-tissue reconstruction of the digits and hand is presented. Neovessel formation induced by an intact venous plexus within the flap proved clinically to be the survival mechanism. Postoperative congestion was present in all flaps and subsided within 14 days; 92 percent of all flaps eventually survived. In 57.5 percent of cases, total flap survival was observed; in 17.5 percent of flaps, a superficial epidermolysis occurred, not requiring further surgery; in 17.5 percent of flaps, a full-thickness skin necrosis developed, requiring grafting (minor complication); in 7.5 percent of reconstructions, total flap necrosis was observed. Thus, in the authors' experience, when conventional local flaps are not available, arterialized venous free flaps proved to be a successful solution for soft-tissue reconstruction in digits and hands. The authors present the main indications and advantages of arterialized venous free flaps, emphasizing the essential technical steps and the most frequent pitfalls in treatment.

Identification of differentially expressed genes in subcutaneous adipose tissue from subjects with familial combined hyperlipidemia.

Subjects with familial combined hyperlipidemia (FCHL) are characterized by a complex metabolic phenotype with hyperlipidemia, insulin resistance, and central obesity. FCHL is due to impaired adipose tissue function superimposed on hepatic overproduction of lipoproteins. We investigated adipose tissue as an interesting target tissue for differential gene expression in FCHL. Human cDNA expression array analyses, in which adipose tissue from five FCHL patients was compared with that from four age, gender, and BMI matched controls, resulted in the identification of 22 up-regulated and three down-regulated genes. The genes differentially expressed imply activation of the adipocyte cell cycle genes. Furthermore, the differential expression of the genes coding for tumor necrosis factor alpha, interleukin 6, and intracellular adhesion molecule 1 support a role for adipose tissue in insulin resistance in FCHL subjects. The observed changes represent a primary genetic defect, an adaptive response, or a contribution of both.