Lower-Extremity Fillet Flap for Reconstruction of Complex Stage IV Pressure Sores and Plantar Flap for Lumbosacral Padding.

BACKGROUND: The lower-extremity fillet flap is a suitable option for the repair of complex (multiple or complicated with osteomyelitis) stage IV pressure sores. If prepared from a nonfunctional extremity, it can close complex wounds and avoid the unnecessary burden of a nonfunctional organ that restricts patient movement, thereby improving quality of life. METHODS: We used a lower extremity fillet flap for reconstruction in 5 patients with complex stage IV pressure sores. The flaps were prepared from the nonfunctional lower extremity with multiple lesions by using iliofemoral disarticulation. The mean age of the patients was 60 years old, and the mean follow-up period was 18 months. A plantar flap was used in 1 patient for prophylactic padding of the lumbosacral region. In another patient, the plantar flap was used as a sensate flap. RESULTS: No major complications, such as total or partial flap loss, occurred in these patients. In 1 patient, a hematoma developed under the flap that led to dehiscence; however, it healed uneventfully without flap loss. Patients developed minimal pelvic stability and balance loss because of iliofemoral disarticulation, but it did not affect their sitting ability and mobility. After the operation, all patients became increasingly active and mobile because of the absence of excess weight on their nonfunctional legs, allowing them to easily perform daily activities such as turning in bed, using a wheelchair, eating, and dressing. Pressure sores did not develop in any of the patients during the postoperative follow-up period. The patient who underwent lumbosacral padding with a sensate plantar flap began to perceive touch over the flap in the fifth postoperative month. CONCLUSIONS: These results suggest that a lower-extremity fillet flap can be a good repair option in complex stage IV pressure sores because it prevents recurrence and enables patients to perform daily activities more easily. Furthermore, plantar flaps can provide prophylactic padding in the lumbosacral region.

The Pedicled Sensate Osteocutaneous Groin Flap for Reconstruction of the Forearm and Hand.

BACKGROUND: The groin flap is axial pedicled and versatile. Until now, this flap has been used with many modifications for the reconstruction of forearm and hand defects. However, this flap has not been used in forearm, hand, and thumb reconstruction as a pedicled sensate osteocutaneous flap. In this study, a pedicled sensate osteocutaneous groin flap was used for the reconstruction of composite tissue defects on the forearm, hand, and thumb. PATIENTS AND METHODS: A pedicled sensate osteocutaneous groin flap was used to reconstruction composite tissue defects on the forearm, hand, and thumb in 7 patients. The mean age of the patients was 42 years. The defects were located on the dorsal surface of the forearm and hand in 2 patients, the dorsal surface of the hand and finger in 2 patients, and the thumb in 3 patients. The dimensions of the flap skin paddle ranged from 7 × 11 cm to 8 × 23 cm, and the dimensions of the bone component ranged from 1 × 1.5 × 3.5 cm to 1 × 1.5 × 5 cm. The mean follow-up duration was 26 months. RESULTS: All the flaps survived. Flap debulking was performed using 3 flaps. Sensory recovery in the flaps was completed approximately 18 months after the first operation. When the results of static 2-point discrimination test and Semmes-Weinstein monofilament test were evaluated at 18 months postoperatively, it showed that protective sensation was obtained. Except for 1 patient, motion restriction did not develop in the wrist, elbow, or shoulder joints. An acceptable aesthetic result, minimal donor site deformity, and protective sensation were obtained in all patients. CONCLUSIONS: The pedicled sensate osteocutaneous groin flap can be safely used in the reconstruction of forearm and hand composite tissue defects that do not have available vascular structures for free flaps in the recipient area and in thumb reconstruction where toe transfer and pollicization cannot be performed.

Scapular Bone Grafts: Good Options for Craniofacial Defects?

INTRODUCTION: There is still no consensus on the ideal material to be used in craniofacial defects. Autogenous bone grafts are mostly preferred owing to their use with fewer complications. The aim of this study was to evaluate whether the scapular bone graft can be used with equal or more advantages to other bone graft resources in orbital, maxillary sinus front wall, and frontal bone defects. PATIENTS AND METHODS: Twenty-four orbital, maxillary sinus front wall, and frontal bone defects were reconstructed with scapular bone grafts. Sixteen patients presented with complicated orbital fractures, 5 patients presented with isolated orbital floor fractures, and 3 patients presented with frontal bone fractures. The grafts were radiologically evaluated 1 day, 6 months, and 12 months postoperatively by 3-dimensional computed tomography scan. RESULTS: All orbital, maxillary sinus front wall, and frontal bone defects were reconstructed successfully with scapular bone grafts. Clinical evaluation of the patients at 6 to 24 months of follow-up was considered satisfactory. Minimal donor site morbidity was observed. Scapular bone grafts adapted nicely to the recipient area, and bony union was complete as demonstrated by 3-dimensional computed tomography scans. CONCLUSIONS: Reconstruction of orbital, maxillary sinus front wall, and frontal bone defects with scapular bone grafts is an easy and safe procedure with minimal donor site morbidity. Scapular bone graft is a good reconstructive option for orbital, maxillary sinus front wall, and frontal bone defects.

Failure of isoxsuprine HCl to increase sheep fertility after cervical versus laparoscopic AI using chilled semen at different durations.

To improve the fertility of cervical artificial insemination (AI) in sheep, we investigated isoxsuprine HCl usage on the cervical passage during cervical AI. We also compared cervical and laparoscopic AI fertility results of using chilled semen at different durations. Semen was collected from rams and diluted as 20 × 106 or 400 × 106 spermatozoa/straw for laparoscopic and cervical AI, respectively, and chilled to 4°C within 2 h. Sheep were inseminated with chilled semen for 8 or 24 h via the laparoscopic or cervical AI method. Moreover, some of the cervical inseminated sheep were injected intramuscularly with 0.5 mg/kg of isoxsuprine HCl 15 min before AI. As a result, the use of isoxsuprine HCl did not affect cervical transit and fertility. In addition, fertility was affected by the storage duration of the semen; laparoscopic AI was more successful than cervical AI in terms of fertility; if cervical AI is performed, the duration between semen collection and AI should be less than 8 h after chilling the semen at 4°C, and if laparoscopic AI is performed, the time between semen collection and insemination can be up to 24 h after chilling the semen at 4°C. Longer storage periods should be studied.

Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds.

The aim of this randomised clinical study was to evaluate the effectiveness and safety of gauze-based negative pressure wound therapy (NPWT) in patients with challenging wounds. A total of 50 consecutive patients who had wound drainage for more than 5 days, required open wound management and had existence of culture positive infection were included the study. In this study, gauze-based NPWT was compared with conventional dressing therapy in the treatment of patients with difficult-to-heal wounds. The patients were randomly divided into two groups. Group I (n = 25) was followed by conventional antiseptic (polyhexanide solution) dressings, and group II (n = 25) was treated with saline-soaked antibacterial gauze-based NPWT. The wounds' sizes, number of debridement, bacteriology and recurrence were compared between group I and group II. The mean age of the patients was 59·50 years (range 23-97). In group I, average wound sizes of pre- and post-treatment periods were 50·60 ± 55·35 and 42·50 ± 47·92 cm(2), respectively (P < 0·001). Average duration of treatment was 25·52 ± 16·99 days, and average wound size reduction following the treatment was 19·99% in this group. In group II, the wounds displayed considerable shrinkage, accelerated granulation tissue formation, decreased and cleared away exudate. The average wound sizes in the pre- and post-treatment periods were 98·44 ± 100·88 and 72·08 ± 75·78 cm(2) , respectively (P < 0·001). Average duration of treatment was 11·96 ± 2·48 days, and average wound size reduction following the treatment was 32·34%. The patients treated with antibacterial gauze-based NPWT had a significantly reduced recurrence (2 wounds versus 14 wounds, P = 0·001), and increased number of the culture-negative cases (22 wounds versus 16 wounds, P < 0·047) in a follow-up period of 12 months. There was a statistically significant difference between two groups in all measurements. As a result, we can say that the gauze-based NPWT is a safe and effective method in the treatment of challenging infective wounds when compared with conventional wound management.

The versatility of the reverse superior labial artery flap.

BACKGROUND: The reverse superior labial artery flap was introduced in 2015 as a reconstructive option for medial cheek defects. Notably, this flap can be redesigned as a more effective repair tool for large facial defect reconstruction. In this study, we redesigned the reverse superior labial artery flap to include the vascular territories of the infraorbital and transverse facial arteries in larger sizes for the repair of large facial defects. METHODS: A reverse superior labial artery flap was used to repair large facial defects in 17 patients with a mean age of 74 years. The defects were located in the orbital region and entirely nasal sidewall in patient two, buccal region in patient three, and in lower lip and malar areas in patient five. The flap sizes ranged from 3.5 × 10 to 7 × 15 cm. A sensory examination was performed on the flaps at 6 and 12 months postoperatively. The mean follow-up period was 12 months. RESULTS: All flaps survived without partial or total loss. In a small number of flaps minor complications such as venous congestion, epidermolysis, and dehiscence were seen. No functional disability was observed in the lower eyelid or lower lip, and the esthetic appearance was evaluated as satisfactory by the patients. In all the flaps, the protective sensation was recovered in the postoperative 12th month. CONCLUSIONS: The reverse superior labial artery flap has an extensive arc of rotation, a reliable vascular pedicle, and a large cutaneous paddle. Therefore, this flap may be a versatile surgical repair tool for large cheek defects.

COVID-19-Related Bilateral Avascular Necrosis of the Femoral Head.

Osteonecrosis is a pathologic process that involves focal bone infarction and death of bone tissue caused by trauma, infections, autoimmune conditions, and chronic steroid use; however, most cases go undiagnosed. The link between bilateral osteonecrosis and coronavirus disease 2019 (COVID-19) infections has not been fully investigated. This is the case of a 42-year-old Caucasian woman who presented to the emergency department for bilateral hip pain, which started three months prior. Initially, the pain was mild; however, her symptoms worsened, causing her to have difficulty ambulating. Co-incidentally she tested positive for COVID-19 10 days after the onset of pain. She denied any lower-extremity numbness, weakness, and loss of bowel or bladder function. X-ray of the hips showed significant sclerosis of bilateral femoral heads and acetabula, indicating avascular necrosis. She was given ketorolac injection intramuscularly for analgesia and remained in stable condition. Upon discharge, she was given a referral to orthopedic surgery for bilateral total hip arthroplasty. Atraumatic osteonecrosis of the femoral head can be caused by multiple etiologies, including exposure to medications, post-transplantation procedures, trauma, and hypercoagulable states. This condition is likely due to poor angiogenesis after an infarct, causing a domino effect of bone demineralization, trabecular thinning, and cortical collapse. A literature search demonstrated prior cases of unilateral femoral head necrosis associated with COVID-19 infection and steroid use. There have been no cases of bilateral osteonecrosis of the femoral head reported without long-term steroid use. Considering the disease severity in both hips and limited steroid use (only five days of prednisone), other common etiologies were sought and were ruled out. In our patient, the only event that was related to her initial onset of hip pain was a COVID-19 infection. We suggest a relationship between COVID-19 infection and avascular necrosis given the rapid progression of the disease. We acknowledge that this presentation of bilateral osteonecrosis is rare and warrants further investigation. More research should be performed to establish a tenable relationship between COVID-19 infection and osteonecrosis, with and without the use of steroids.

Adult Onset Hypertrophic Cardiomyopathy (HCM) Not Detected by Echocardiogram: A Case Presentation.

Hypertrophic cardiomyopathy (HCM) is a genetic myocardial disease of the sarcomere protein. The age of diagnosis of HCM tends to be between the second to third decades of life. However, the recent occurrence of HCM in the fifth and sixth decades of life has been seen in an increasing number of cases. In all cases, a transthoracic echocardiogram (TTE) is considered the gold standard of imaging. Here, we present a case of a 54-year-old Caucasian male who presented to the emergency department (ED) with dyspnea while on vacation. An electrocardiogram (ECG) taken at the time did not suggest any abnormalities. After returning home, a stress test conducted indicated left anterior descending (LAD) artery stenosis. Following treatment, symptoms improved temporarily but eventually came back. Repeat ECGs and TTEs done over the next two years indicated grade II diastolic dysfunction and mild left ventricular hypertrophy, which led to changes in the medication regime. Nevertheless, his condition progressively deteriorated over time. Repeat appearances to the ED led to the utilization of magnetic resonance imaging (MRI) to assess cardiac morphology function and velocity flow. The results were consistent with HCM. This case presents a unique obstacle for the diagnosis of adult-onset HCM. The change made to his medication regimen seemingly aggravated the patients' condition. This case highlights the need for further imaging, beyond the gold standard, in adult males with repeated complaints of dyspnea on exertion (DOE).

Blood prestin levels in COVID-19 patients.

BACKGROUND: Many studies have found that viral infections affect different tissues, including the inner ear. Coronavirus disease 2019 (COVID-19), a viral infection, is a significant health problem worldwide. Prestin is a motor protein with important functions both in the outer hair cells of the inner ear and in cardiac tissue. In addition, prestin is promising as an early biomarker in the detection of ototoxicity. To determine the severity of infection in COVID-19 patients and to determine whether other tissues are affected by the infection, lactate dehydrogenase (LDH), C-reactive protein (CRP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatine kinase MB (CK-MB), biochemical markers such as ferritin and D-dimer are used. This study aimed to compare prestin levels in patients with COVID-19 and healthy volunteers. METHODS: In blood samples taken from 45 patients diagnosed with COVID-19 and 40 healthy volunteers, prestin levels were determined with the kit that used an enzyme-linked immunosorbent assay method and was commercially available. At the same time, LDH, CRP, ALT, AST, CK-MB, ferritin, and D-dimer levels were also detected in both patients and healthy control groups and correlations with prestin levels were examined. RESULTS: The main result of our study is that serum prestin levels in COVID-19 patients are significantly higher than in healthy controls ( p < 0.001). In addition, a statistically significant strong positive correlation was found between prestin-LDL ( r = 0.537, p = 0.001), prestin-CRP ( r = 0.654, p = 0.001), and prestin-D-dimer ( r = 0.659, p = 0.001). CONCLUSION: The levels of prestin, a motor protein in inner ear outer hair cells and cardiac myocytes, were found to be higher in COVID-19 patients than in healthy volunteers. It also showed a positive correlation with CRP and D-dimer. This may be associated with systemic dysfunction.

Clinical Experience With the Use of Gauze-based Negative Pressure Wound Therapy.

UNLABELLED:  Purpose. In this preliminary study, gauze-based negative pressure wound therapy (NPWT) was used to accelerate granulation tissue forma- tion and promote closure in a number of wound types. The authors aimed to evaluate the efficacy of gauze-based NPWT using the Chariker-Jeter technique for wounds requiring delayed closure. METHODS: A retrospective review was conducted of 50 patients with wounds not suitable for imme- diate primary closure. After initial irrigation, debridement, and antibiotic therapy, Chariker-Jeter technique NPWT was used and dressings were changed at 24- to 48-hour intervals before secondary closure or primary closure. In addition, a 4-point category scoring system (severe, moderate, mild, and none) was used to evaluate pain. Semi-quantitative data also were obtained. RESULTS: Wound size decreased considerably, granulation tissue formation was accelerated, and exudate was reduced and removed by the end of the treatment. The patients were followed for 12 months. Pre- and post-treatment averages of the wound surface areas were 90.21 ± 74.97 cm2 and 35.71 ± 53.63 cm2, respectively (P < 0.001). Average duration of treatment was 12.98 ± 3.18 days and average wound size reduction following the treatment was 64.61% ± 30.42%. Granulation tissue was clinically observed in all wounds by day 5. Six cases healed without any operation; the others required various reconstructive methods to cover the wounds. After surgical intervention, only 3 patients treated with gauze-based NPWT had a recurrence. No infections were observed during the follow-up period. According to the pain form, only 2 patients had severe pain. CONCLUSION: The gauze-based NPWT was found to be a safe and cost-effective method in temporary soft-tissue management of chronic nonhealing wounds suitable delayed closure. .

Uses of scapular island flap in pediatric axillary burn contractures [correction of conractures].

Pediatric axillary post-burn contractures one of the most challenging problems which follow treatment of the upper extremity burns. We preferred to use scapular flaps for surgical treatment of pediatric axillary contractures instead of skin grafting or Z-plasties. In this clinical study we present 13 pediatric cases treated with scapular island flaps. In pediatric scapular flap cases, the technique which we used was to extend the flap's pedicle dissection was continued to the level of bifurcation of subscapular artery. Bypassing the flap triangular space allowed us to cover the anterior part of the axillary contractures. We observed that the scapular flap repairs have many benefits to skin grafting including no recurrence of contracture and stable coverage of the shoulder joint. The other advantages of scapular island flap are that the donor site is closed primarily, and it provides an adequate amount of pliable skin while not compromising the function and range of motion of joints. In conclusion, the island scapular flap is a good choice for reconstruction of various axillary contractures in pediatric population.

Pediatric Olecranon Fractures Associated With Radial Neck Fractures: Review and Report of Two Cases.

INTRODUCTION: The debate regarding the description on classification and nomenclature of the injury which includes olecranon fracture associated with radial neck fractures in children is ongoing. We report two pediatric cases that could not be classified in a Monteggia-equivalents system and were treated with open reduction and k-wire fixation. The aim of this study was to perform a systematic review regarding pediatric radial neck fractures associated with olecranon fractures and presentation of two pediatric cases of olecranon fractures associated with radial neck fractures with radiocapitellar dislocation. CASE PRESENTATION: Two boys, aged 7 and 12, came to two separate clinics on the same day after initial injury. On physical examination, the patients' elbow range of motion was limited and painful. Their upper extremities were intact. Radiographs revealed the radial neck fracture with prominent anterolateral radiocapitellar dislocation of radial head-associated with non-displaced olecranon fracture. Radial neck fracture was reduced easily by pushing posteromedially manually with the finger and secured with two K-wires .The olecranon fracture was visualized and confirmed that it was non-displaced and secured with two k-wires in the first case and one k-wire in the second case. After 2 months of follow-up, both patients had no pain in their elbow and a full functionality with a full range of motion of the elbow. The posterior intraosseous nerve functions were normal. CONCLUSIONS: The fracture of olecranon if it does not extend into the metaphyseal region; it could not fascilitate diastasis of the proximal radioulnar joint and radial head dislocation. So this type of fracture must not be addressed as a Monteggia-fracture dislocation. The description of radioulnar diastasis must be included when this type of injury is to be classified.

The Use of Vacuum-Assisted Closure and GranuFoam Silver® Dressing in the Management of Diabetic Foot Ulcer.

PURPOSE: The aim of this retrospective study was to evaluate the efficacy of vacuum-assisted closure (VAC) and GranuFoam Silver® dressing (KCI, San Antonio, TX) compared with conventional GranuFoam® dressing in the management of diabetic foot ulcers. PATIENTS AND METHODS: Twenty-one consecutive patients treated with conventional or silver-coated foam dressing were reviewed retrospectively. The wound duration was 6 mo. Group 1 (n=10) received conventional foam dressing (GranuFoam) and group 2 (n=11) received silver-coated foam dressing (GranuFoam Silver). The wound surface area, duration of treatment, bacteriology, and recurrence were compared between the groups. The mean age of the patients was 61.70±10.52 y in group 1 and 67.27±11.28 y in group 2. RESULTS: In group 1, the average surface area of the wounds was 45.30±46.96 cm2 and 18.40±23.48 cm2 in the pre-treatment and post-treatment periods, respectively. There was a statistically significant difference between two measurements (p=0.005). Average duration of the treatment was 25.50±27.13 d in this group. In group 2, average surface area of the wounds in the pre-treatment and post-treatment periods were 41.55±36.03 cm2 and 7.64±3.91 cm2, respectively. There was a statistically significant difference between two measurements (p=0.003). Average duration of the treatment was 10.09±3.51 d in this group. The patients treated with silver-impregnated polyurethane foam dressing had reduced recurrence (2 vs. 7 wounds, p=0.030) and increased number of the culture-negative cases at the end of the treatment. CONCLUSION: With the results of the study, it was concluded that VAC GranuFoam silver dressing can be superior to conventional GranuFoam dressing in reducing the recurrence rate of infected diabetic foot ulcers.

Diabetes care credit system: a model for comprehensive and optimal diabetes care.

OBJECTIVE: To introduce a "credit system," which empowers patients with diabetes to share in the implementation of guidelines with the health-care provider and provides credits for achievement of health variables considered essential for optimal diabetes care. METHODS: We describe the credit system and the points offered for achievement of variables that assess lifestyle, glycohemoglobin, blood pressure, lipid values, measurement of urinary albumin, annual physical examination, dilated eye examination, foot examination, and electrocardiogram, use of antiplatelet therapy, and use of angiotensin receptor blocker (ARB) or angiotensin-converting enzyme (ACE) inhibitor therapy. The patient's knowledge of diabetes and nutrition was also assessed. Patients with diabetes mellitus were enrolled in the credit program during their scheduled office visits. Results were compared with those in a control group. RESULTS: The study enrolled 613 patients (303 male and 310 female patients), with a mean age of 59.91 +/- 13.57 years (range, 16 to 90). The control group consisted of 119 patients with diabetes (63 men and 56 women; mean age, 55.94 +/- 14.83 years) not participating in the credit system. One year after initiation of the program, analysis of the study group demonstrated high rates of implementation of guidelines: complete physical examination, 94%; foot examination, 89%; dilated eye examination, 77%; blood pressure less than 135/85 mm Hg, 78%; hemoglobin A1c less than 6%, 7%, and 8%, 26%, 58%, and 82%, respectively; serum triglycerides less than 200 mg/dL, 61%; low-density lipoprotein cholesterol less than 100 mg/dL, 49%; high-density lipoprotein cholesterol more than 35 mg/dL, 76%; use of antiplatelet therapy, 60%; quantitative urinary albumin screening, 74%; and use of ACE inhibitors or ARB, 44%. These rates of achievement of established variables for hemoglobin A1c, serum lipids, blood pressure, antiplatelet therapy, and measurement of urinary albumin were significantly higher than those in the control subjects. CONCLUSION: The described credit system demonstrates an effective and practical means to implement and achieve the necessary guidelines and target variables that are intended to lead to optimal diabetes and cardiovascular outcomes.

Alternative nipple suspension technique in the treatment of inverted nipple: reverse s-shaped design.

The primary aim in the treatment of inverted nipple is to achieve a satisfactory and permanent projection of the nipple. The drawbacks of reported techniques include sensory disturbance of the nipple, marked scarring of the nipple and areola, destruction of breast function and incomplete correction. In the present study, the authors introduced a new modification of using two opposite nipple-based areolar dermal flap in the treatment of grades 2 and 3 inverted nipple cases. Nipple-based areolar flaps designed at 3 o'clock and 9 o'clock were raised by two linear incisions and the tip of each flap was sutured on the base of the nipple close to the base itself in a reverse S shape at 6 and 12 o'clock. Successful outcome was obtained due to a strongly suspending effect of the design of the flaps. The mean follow-up period was 6 months. The patients were satisfied with the result and the scars were minimal. The authors recommend the use of the technique that is a simple, reliable and with minimal scars for correcting grades 2 and 3 inverted nipples.

The use of temporalis muscle graft, fresh and cryopreserved amniotic membrane in preventing temporomandibular joint ankylosis after discectomy in rabbits.

PURPOSE: The aim of the study was to evaluate the efficacy of temporalis muscle-fascia graft, fresh and cryopreserved human amniotic membrane as an interpositional material in preventing temporomandibular joint ankylosis in a rabbit model. MATERIALS AND METHODS: In this experimental study, 21 New Zealand white rabbits were used. The condyle and the joint disc were removed to induce ankylosis in left TMJs. Reconstruction was immediately performed with temporalis muscle-fascia graft (tMFG) in group I (n = 7), fresh human amniotic membrane (fHAM) in group II (n = 7) and cryopreserved human amniotic membrane (cHAM) in group III (n = 7). All rabbits were sacrificed at 3 months after the operation. The comparison was made among three groups by means of vertical mouth opening and weight measurements, radiologic and histologic findings obtained before and after surgery. RESULTS: In all rabbits, there was no statistically significant difference in the jaw movements and weight among groups at commencement and 3 months after surgery. The condylar surfaces were more irregular in HAM groups. There were mild osteophyte formations, sclerosis, fibrosis and calcification around the condyle in all groups however the joint gap was more preserved in group I. All interpositional materials were also seen to be partially present in the joint gap at 3 months. Ankylosis was not seen in the joint gap in any group. CONCLUSION: With the results of this study it was concluded that interpositional arthroplasty with HAM and tMFG have an almost similar effect in preventing TMJ ankylosis after discectomy in the rabbit model.