Vertical Profunda Artery Perforator Flap for Plantar Foot Wound Closure: A New Application.

BACKGROUND: Plantar foot reconstruction requires special consideration of both form and function. There are several fasciocutaneous flap options, each with indications and reservations. CASE STUDY: This case presents a new application of the vertical profunda artery perforator flap for definitive closure of a neuropathic foot ulcer in a young woman with spina bifida. The postoperative course was uneventful, and the flap survived completely. The surgical and donor sites were without wound recurrence at 5-month follow-up. DISCUSSION: Understanding the variability of foot flap options is important because of unique cases such as the one presented where the wound was caused by specific and less commonly observed foot anatomy. The specific choice to use the vertical profunda artery perforator flap for this patient and her neuropathic wound type was made based on its excellent flexibility, durability, and donor site appeal. CONCLUSIONS: The vertical profunda artery perforator flap has adequate surface area and bulk and a favorable pedicle length and caliber, can be thinned, and leaves a donor scar in a less conspicuous area than other popular free flaps for lower-extremity reconstruction. For these reasons, it should be considered a first-line therapy for free flap coverage of selected foot wounds.

Beta-blockers for the treatment of problematic hemangiomas.

OBJECTIVE: To examine treatment indications, efficacy and side effects of oral beta-blockers for the treatment of problematic hemangiomas. METHODS: A retrospective review of patients with hemangiomas presenting to the Alberta Children's Hospital Vascular Birthmark Clinic (Calgary, Alberta) between 2009 and 2011 was conducted. The subset of patients treated with oral beta-blockers was further characterized, investigating indication for treatment, response to treatment, time to resolution of indication, duration of treatment, occurrence of rebound growth and side effects of therapy. RESULTS: Between 2009 and 2011, 311 new patients with hemangiomas were seen, of whom 105 were treated with oral beta-blockers. Forty-five patients completed beta-blocker treatment while the remainder continue to receive therapy. Indications for treatment were either functional concerns (68.6%) or disfigurement (31.4%). Functional concerns included ulceration (29.5%), periocular location with potential for visual interference (28.6%), airway interference (4.8%), PHACES syndrome (3.8%), auditory interference (0.95%) and visceral location with congestive heart failure (0.95%). The median age at beta-blocker initiation was 3.3 months; median duration of therapy was 10.6 months; and median maximal treatment dose was 1.5 mg/kg/day for propranolol and 1.6 mg/kg/day for atenolol. Ninety-nine patients (94.3%) responded to therapy with size reduction, colour changes, softened texture and/or healing of ulceration. Rebound growth requiring an additional course of therapy was observed in 23 patients. Side effects from beta-blockers included cool extremities (26.7%), irritability (17.1%), lower gastrointestinal upset (14.3%), emesis (11.4%), hypotension (10.5%), poor feeding (7.6%), lethargy (4.8%), bronchospasm (0.95%) and rash (0.95%). Side effects did not result in complete discontinuation of beta-blocker treatment in any case; however, they prompted a switch to a different beta-blocker preparation in some cases. Resolution of the primary indication, requiring a median time of three months, occurred in 87 individuals (82.9%). CONCLUSIONS: Treatment of infantile hemangiomas with oral beta-blocker therapy is highly effective and well tolerated, with more than 94% of patients demonstrating a response to treatment and 90% showing resolution of the primary functional indication for treatment.

OBJECTIF: Examiner les indications thérapeutiques, l'efficacité et les effets secondaires des bêtabloquants par voie orale pour traiter les hémangiomes problématiques. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des patients ayant des hémangiomes qui ont consulté à la clinique des angiomes vasculaires de l'Alberta Children's Hospital de Calgary, en Alberta, entre 2009 et 2011. Le sous-groupe de patients traités à l'aide de bêtabloquants par voie orale était caractérisé de manière plus détaillée, puisqu'on examinait l'indication thérapeutique, la réponse au traitement, le délai jusqu'à la résolution de l'indication, la durée du traitement, l'occurrence d'une excroissance de rebond et les effets secondaires du traitement. RÉSULTATS: Entre 2009 et 2011, 311 nouveaux patients ayant des hémangiomes ont consulté, dont 105 ont été traités à l'aide de bêtabloquants par voie orale. Quarante-cinq patients ont terminé le traitement, tandis que les autres continuent d'être traités. Les indications thérapeutiques étaient des préoccupations d'ordre fonctionnel (68,6 %) ou le préjudice esthétique (31,4 %). Les préoccupations d'ordre fonctionnel incluaient une ulcération (29,5 %), un foyer périoculaire avec un potentiel d'interférence visuelle (28,6 %), une interférence avec les voies aériennes (4,8 %), un syndrome PHACES (3,8 %), une interférence auditive (0,95 %) et un foyer viscéral avec une insuffisance cardiaque congestive (0,95 %). Les patients avaient un âge médian de 3,3 mois au début du traitement aux bêtabloquants, et le traitement avait une durée médiane de 10,6 mois. La dose maximale médiane du traitement était de 1,5 mg/kg/jour s'ils prenaient du propranolol et de 1,6 mg/kg/jour s'ils prenaient de l'aténolol. Quatre-vingt-dix-neuf patients (94,3 %) ont répondu au traitement par une diminution de la dimension, un changement de la couleur, une amélioration de la texture ou une guérison de l'ulcération. Chez 23 patients, une excroissance de rebond a exigé une cure supplémentaire. Les effets secondaires des bêtabloquants incluaient des membres froids (26,7 %), l'irritabilité (17,1 %), des troubles du bas de l'intestin (14,3 %), des vomissements (11,4 %), une hypotension (10,5 %), une alimentation insuffisante (7,6 %), une léthargie (4,8 %), un bronchospasme (0,95 %) et une éruption (0,95 %). Les effets secondaires n'ont jamais suscité l'interruption complète du traitement aux bêtabloquants, mais ont parfois donné lieu à un transfert vers une nouvelle préparation de bêtabloquants. Chez 87 patients (82,9 %), les chercheurs ont constaté la résolution de l'indication primaire, dans un délai médian de trois mois. CONCLUSIONS: Le traitement des hémangiomes infantiles à l'aide de bêtabloquants par voie orale est très efficace et bien toléré. En effet, plus de 94 % des patients répondent au traitement et 90 % présentent une résolution de l'indication thérapeutique fonctionnelle primaire.

The epidemiological profile of the Vascular Birthmark Clinic at the Alberta Children's Hospital.

BACKGROUND: The Vascular Birthmark (VBM) Clinic at the Alberta Children's Hospital (Calgary, Alberta) is a multidisciplinary clinic dedicated to the evaluation of children with vascular anomalies. OBJECTIVE: To review the characteristics of patients seen at the VBM Clinic. METHOD: A retrospective data analysis of all pediatric patients presenting to the VBM Clinic between 1998 and 2009 was performed. Data including demographic, referring, diagnostic and treatment information were obtained from the clinic's database. RESULTS: Of 932 patients, 621 with hemangiomas and 311 patients with vascular malformations were found in the database. Hemangiomas were more commonly found in girls (68.5%), and most commonly located on the head and neck (54%), with most patients (72.6%) having only one lesion. Of the patients with hemangiomas, 14.7% underwent diagnostic imaging investigation and 23.7% received treatment including medications, surgery, pulsed-dye laser or dressings. The sex distribution among the 311 patients with vascular malformations was almost equal. Venous malformations accounted for 38.9% of patients, isolated capillary malformations for 31.5%, lymphatic malformations for 11.6%, mixed low-flow malformations for 14.8% and arteriovenous malformations for 2.9%. Overall, 37.9% of patients underwent diagnostic imaging investigation and 42.4% received treatment - either pulsed-dye laser, surgical excision, sclerotherapy or other treatment. CONCLUSIONS: Hemangiomas and vascular malformations can occur at any anatomical site. There is a large variation in clinical presentation necessitating expertise in a variety of diagnostic approaches and treatment modalities. Vascular anomalies are best managed in a multidisciplinary setting.

HISTORIQUE: La clinique des angiomes de l'Alberta Children's Hospital de Calgary, en Alberta, est une clinique multidisciplinaire vouée à l'évaluation des enfants ayant des anomalies vasculaires. OBJECTIF: Analyser les caractéristiques des patients vus à la clinique des angiomes. MÉTHODOLOGIE: Les auteurs ont procédé à une analyse rétrospective des données de tous les patients pédiatriques qui ont consulté à la clinique des angiomes entre 1998 et 2009. Ils ont obtenu des renseignements sur la démographie, l'aiguillage, le diagnostic et le traitement dans la base de données de la clinique. RÉSULTATS: Des 932 patients, 621 ayant des hémangiomes et 311, des malformations vasculaires, faisaient partie de la base de données. Les hémangiomes s'observaient surtout chez les filles (68,5 %), sur la tête et dans le cou (54 %), et la plupart des patients (72,6 %) n'avaient qu'une lésion. Chez les patients présentant des hémangiomes, 14,7 % ont subi une exploration d'imagerie diagnostique et 23,7 % ont subi un traitement, y compris des médicaments, une opération, le laser à colorant pulsé ou des pansements. La distribution selon le sexe chez les 311 patients ayant des malformations vasculaires était presque égale. On observait des malformations veineuses chez 38,9 % des patients, des malformations capillaires isolées chez 31,5 % des patients, des malformations lymphatiques chez 11,6 % d'entre eux, des malformations mixtes à bas débit chez 14,8 % des patients et des malformations artérioveineuses, chez 2,9 % d'entre eux. Dans l'ensemble, 37,9 % des patients ont subi une exploration d'imagerie diagnostique et 42,4 % ont été traités par laser à colorant pulsé, excision chirurgicale, sclérothérapie ou un autre traitement. CONCLUSIONS: Des hémangiomes et des malformations vasculaires peuvent se manifester à n'importe quel foyer anatomique. On observe une vaste variation des présentations cliniques, qui exige des compétences à l'égard de diverses approches diagnostiques et modalités thérapeutiques. Les anomalies vasculaires sont mieux prises en charge en milieu multidisciplinaire.

The opportunities and obstacles in developing a vascular birthmark database for clinical and research use.

INTRODUCTION: Databases are useful tools in clinical settings. The authors review the benefits and challenges associated with the development and implementation of an efficient electronic database for the multidisciplinary Vascular Birthmark Clinic at the Alberta Children's Hospital, Calgary, Alberta. METHODS: The content and structure of the database were designed using the technical expertise of a data analyst from the Calgary Health Region. Relevant clinical and demographic data fields were included with the goal of documenting ongoing care of individual patients, and facilitating future epidemiological studies of this patient population. After completion of this database, 10 challenges encountered during development were retrospectively identified. Practical solutions for these challenges are presented. RESULTS: THE CHALLENGES IDENTIFIED DURING THE DATABASE DEVELOPMENT PROCESS INCLUDED: identification of relevant data fields; balancing simplicity and user-friendliness with complexity and comprehensive data storage; database expertise versus clinical expertise; software platform selection; linkage of data from the previous spreadsheet to a new data management system; ethics approval for the development of the database and its utilization for research studies; ensuring privacy and limited access to the database; integration of digital photographs into the database; adoption of the database by support staff in the clinic; and maintaining up-to-date entries in the database. CONCLUSIONS: There are several challenges involved in the development of a useful and efficient clinical database. Awareness of these potential obstacles, in advance, may simplify the development of clinical databases by others in various surgical settings.

A population-based study of the epidemiology of acute adult burn injuries in the Calgary Health Region and factors associated with mortality and hospital length of stay from 1995 to 2004.

INTRODUCTION: Trauma resulting from acute burns is relatively common and we wished to study the incidence, outcomes and factors related to mortality and hospital length of stay to identify potential areas of prevention and improve the care of burn-injured patients. To do so, we studied a population of adult burn injury patients from a large area of Canada (the Calgary Health Region (CHR) over a 10-year period. Burn data from this population-based sample has never been published and is not currently included in the American Burn Association Repository report. METHODS: We extracted data on all adult (>or=18 years) residents of the CHR who suffered a burn injury requiring hospital admission between January 1995 and December 2004. Of particular interest were patient demographics, incidence and mortality rates of the victims as well as any factors that were associated with mortality or increased length of hospital stay. RESULTS: A total of 928 burn-injured patients were identified. The highest incidence of burn injury admissions in the CHR occurred in 1996 (12.2 burn injury admissions per 100,000 population) and 2004 (12.3 admissions per 100,000 population). The largest number of burn injury admissions occurred during the months of July and August (23.3%), while the fewest occurred during the winter months of February and December (11.9%). Mean patient age was 45.2 years (range 18-97) and 658 (70.9%) were male. The majority of our patients were admitted with second-degree burns (48.7%) and burns of the head and neck were the most prevalent (22.2%). The mean length of hospital stay for burn patients was 20.4 days (range 1-312). Over the course of the 10 years of the study, 9 (1.0%) burn patients died during their hospital stay. In univariate analyses, burn survivors differed significantly from non-survivors with respect to mean age, burn degree, body part burned and year of admission. In adjusted analyses, survivors and non-survivors differed significantly with respect to year and month of admission, degree of burn, patient age and length of stay. Factors significantly associated with increase length of hospital stay included degree of burn, older patient age and hospital site. CONCLUSIONS: In this Canadian health region, patients who die from burns tend to be older, present to the hospital during the winter months, and suffer more acute burns to the torso or multiple body regions. Additionally, patient length of stay is influenced by older patient age and greater burn thickness.