Variety in diagnosis and treatment of periprosthetic joint infections in Belgium and the Netherlands.

Recently, guidelines regarding diagnosis and treatment of periprosthetic joint infection (PJI) have been published, but it is unknown how well these are -followed in the Netherlands and Belgium. Therefore, a survey study was performed in the Netherlands and Belgium. 81 orthopedic departments responded (54% in the Netherlands, 52% in Belgium). The majority used protocols for antibiotic and surgical treatment. To discriminate between early and late infection, differences in periods used were seen between respondents, and between countries. Empirical antibiotic treatment varied greatly. Debridement, antibiotics, irrigation and retention of the prosthesis (DAIR) is the -almost unanimous treatment of choice for early PJI. Guidelines are available, but seem not (yet) to be -followed accurately, and do not have answers to all possible treatment options. Perhaps, national guidelines might produce more standardized care, and -consequentially, easier comparison for research, more transparency for patients, and less health care costs.

Isolation and long-term culture of human hair-follicle melanocytes.

We report a method to establish long-term cultures of melanocytes derived from human hair follicles. Normal human scalp was transected 1 mm below the epidermis, and hair follicles in the remaining dermis were isolated by collagenase treatment. Hair-follicle cell suspensions were prepared by trypsin/ethylenediamine tetraacetic acid treatment and cultured in a mixture of Eagle's minimum essential medium (supplemented with 12-O-tetradecanoyl-phorbol-13-acetate and cholera toxin) and keratinocyte serum-free medium. After contaminating fibroblasts and keratinocytes were removed, cells with two distinct morphologies remained. These included large, dendritic and deeply pigmented cells, which did not proliferate and which disappeared by the third passage, and small bipolar cells, which initially were unpigmented, proliferated very rapidly, and became pigmented after the addition of 3-isobutyl-1-methylxanthine to the culture medium. Both cell types were melanocytes as confirmed by electron microscopy and by staining with antibodies to S-100, GD3, and melanosomal antigens. The availability of cultured hair-follicle melanocytes wil facilitate investigations of the role of these cells in normal and abnormal hair biology.

Selective microvascular procedures in oculoplastic surgery.

The aesthetic and functional reconstruction of the orbital and periorbital anatomy poses a complex challenge to the reconstructive surgeon. Four clinical cases are illustrated regarding the restoration of contour, and coverage of vital structures following tumor resections.

Dysplastic and congenital nevi.

The dysplastic nevus, both the sporadic and familial type, has a significant association with melanoma of the skin. The congenital nevus, which ranges in size from less than 1 cm to a giant hairy nevus, are treated primarily for aesthetic reasons and, in the giant variety, are also treated as a prophylaxis against the possibility of malignant change.

Sixty consecutive breast reconstructions with the inflatable expander: a critical appraisal.

Breast reconstruction using inflatable expanders has become an established and preferred technique. Although our knowledge of the biomechanical changes occurring in expanded skin has increased greatly, little information is available regarding average aesthetic results achieved with this technique. In order to eliminate the bias of best case selection reports, this study of 60 consecutive patients undergoing skin-expansion breast reconstruction was undertaken. Results of the study demonstrated a significant frequency and diversity of complications. In particular, immediate breast reconstruction with skin expanders was identified as a high-risk procedure because of its association with skin necrosis and delayed wound healing. Although two procedures--insertion and replacement--had been anticipated, patients from both the Boston and New York groups required approximately three operations to complete the expansion process. Average aesthetic results, often characterized by problems of symmetry, ptosis, and contour, need to be recognized and improved.

Review of the morbidity of 300 free-flap donor sites.

Donor-site morbidity in 300 consecutive free flaps was reviewed to identify their etiologies and potentially prevent their recurrence in future cases. An overall morbidity rate of 20 percent was seen in this series. Secondary surgical procedures specific for donor-site problems were required in 7.7 percent of patients. Major complications occurred in 2.3 percent of the donor sites. From this review it is apparent that major donor-site morbidity is uncommon and most donor-site problems could probably have been avoided. Our recommendations are as follows: closure of the donor site to avoid excessive tension must be carefully planned preoperatively, donor-site anatomy and flap elevation techniques must be precisely understood, surgical retractors must be carefully placed to avoid injury to nearby structures, the donor site should be closed immediately following pedicle division, thus minimizing wound exposures, and complete surgical hemostasis is mandatory.

Various methods of breast reconstruction after mastectomy: an economic comparison.

This study is an economic comparison of various methods of breast reconstruction after mastectomy. The hospital bills of 287 patients undergoing breast reconstruction at three institutions from June of 1988 to March of 1991 were analyzed. The procedures examined included mastectomy, implant and tissue-expander reconstruction, and TRAM and latissimus pedicle flaps, as well as free TRAM and free gluteal flaps. These procedures were subdivided into those which were performed at the time of mastectomy and those performed at a later admission. In addition, auxiliary procedures (i.e., revision, nipple reconstruction, tissue-expander exchange, and contralateral mastopexy/reduction) also were examined. Where appropriate, these procedures were subdivided into those performed under general or local anesthesia and by inpatient or outpatient status. Data from the three institutions were converted to N.Y.U. Medical Center costs for standardization. A table is presented that summarizes the costs of each individual procedure with all the pertinent variations. In addition, a unique and novel method of analyzing the data was developed. This paper describes a menu system whereby other data regarding morbidity, mortality, and revision rates may be superimposed. With this information, the final cost of reconstruction can be extrapolated and the various methods of reconstruction can be compared. This method can be applied to almost any complex series of multiple procedures. The most salient points elucidated by this study are as follows: The savings generated by performing immediate reconstruction varies between $5092 (p < 0.05) for free gluteal flaps and $10,616 (p < 0.05) for pedicled TRAM flaps.(ABSTRACT TRUNCATED AT 250 WORDS)

Microvascular free-flap salvage of the diabetic foot: a 5-year experience.

This study reviews 21 microvascular free flaps to the diabetic foot in 19 patients over a 65-month period. All flaps were either to the plantar surface of the foot or to cover exposed Achilles tendon. Twenty of the flaps survived. The operations required a long, costly hospitalization with frequent recipient- and donor-site complications. All patients eventually ambulated on their flaps. Five patients came to proximal amputation from 6 to 37 months after surgery. Only one amputation was for flap breakdown.

Reconstruction of mandibular and floor of mouth defects using the trapezius osteomyocutaneous flap.

The trapezius osteomyocutaneous island flap has evolved in postablative head and neck reconstruction as a versatile and hardy local flap which can provide intraoral lining, well-vascularized bone, and muscle bulk for the reconstruction of a complex defect. This investigative study examines the anatomy of 20 osteomyocutaneous flaps in 10 fresh cadavers and in 8 clinical patients. In our series, 80 percent (type I) of the major vascular pedicle arose from the thyrocervical trunk. In 20 percent (type II), the major pedicle arose separately from the subclavian artery. The regions perfused by the vascular trunk were further examined with microopaque and Prussian blue injections through the transverse cervical artery. Consistent areas of cutaneous staining as well as bony staining were noted over the shoulder, arm, and back and into the scapula itself. Experience with eight clinical applications of this osteomyocutaneous flap resulted in successful healing with an excellent aesthetic and functional result. Long-term follow-up was maintained on the patients for up to 36 months. Panorex radiographs and biopsies of the grafted bone were obtained on several patients. These disclosed evidence of bony remodeling and viable bone tissue. Tetracycline labeling also revealed evidence of active bony turnover.

Salvage of traumatic below-knee amputation stumps utilizing the filet of foot free flap: critical evaluation of six cases.

Over a 12-year period between 1979 and 1991, 27 patients were operated on at the New York University Medical Center for salvage of below-knee amputation stumps utilizing free flaps. Six different donor sites were used. In 6 patients, the amputated foot was the donor site for a free flap to cover the tibial stump. There were 3 males and 3 females in this group. Five of the patients underwent immediate filet of foot reconstructions, while 1 patient had a reconstruction performed 69 days after injury, electively, when it was determined that below-knee amputation was the best option. All foot flaps survived and ultimately provided the major soft-tissue coverage for the below-knee amputation stump. The length of hospitalization ranged from 24 to 118 days. The time required from foot filet procedure to ambulation was 2, 4, 6, 7, 9, and 12 months in the 6 patients. Five of the 6 patients have resumed work or school after their injury. Foot flaps were based on the posterior tibial artery, anterior tibial artery, or both vessels. Nerve anastomosis of the posterior tibial nerve was performed in 5 patients. In 1 patient it was possible to maintain the continuity of the posterior tibial nerve. Five of the 6 patients were tested over a year after the flap, and all have good cold, pressure, and vibration sensation. Two of the 5 patients have heat sensation, and all 5 patients have at least protective pressure sensation. All the patients ambulate well with a below-knee prosthesis.

Breast reduction with use of the free nipple graft technique.

In properly selected patients, the results of free nipple graft breast reduction may be equal or superior to a pedicle technique. A free nipple graft is clearly indicated for gigantomastia, but it is also useful in severe macromastia, when a large, bulky pedicle may impede adequate reduction and optimal contour, and in patients with fatty breasts and inverted nipples. Disadvantages include the loss of ability to breast-feed, loss of nipple sensation, and possible hypopigmentation in the nipple-areola. The author discusses patient selection and describes execution of this technique. (Aesthetic Surg J 2001;21:261-271.).

Evaluation of the enzyme-linked immunosorbent assay for the detection of antibodies against infectious bursal disease virus (IBDV) and the estimation of the optimal age for IBDV vaccination in broilers.

In order to evaluate the usefulness of the enzyme-linked immunosorbent assay (ELISA) in determining the optimal age for infectious bursal disease virus (IBDV) vaccination in broilers under field circumstances, the percentage of birds susceptible to vaccine at vaccination age was estimated in 12 flocks on the basis of ELISA titres in newborn chicks. The effective percentage of susceptible birds at the day of vaccination was checked by comparing virus neutralization (VN) titres measured in sera taken immediately before vaccine administration with the breakthrough titre of the vaccine used. In nine of the 12 flocks, the ELISA had largely overestimated the percentage of susceptible birds. Subsequently, to examine the performance of the ELISA kit, 815 chicken sera were comparatively examined in ELISA and VN tests. Results demonstrated a linear relationship between mean ELISA titres and VN titres. It was concluded that the ELISA could be a useful tool in IBDV vaccination timing, but that interpretation criteria should be adjusted to avoid vaccination at too early an age.

Localization of nonpalpable masses in patients with breast implants.

Nonpalpable nodules in patients with breast implants may represent silicone granulomas, fibrocystic mastopathy, or cancer. We describe a modified technique for needle localization which facilitates the surgical excision of these nodules while minimizing the possibility of rupture.

The role of microvascular free flaps in salvaging below-knee amputation stumps: a review of 22 cases.

Twenty-two cases of traumatic below-knee amputation stumps with inadequate soft-tissue coverage salvaged with microvascular free flaps were reviewed retrospectively. All patients would have required an above-knee amputation for prosthesis fitting had microvascular free flaps not bee utilized. A total of 24 flaps were used in 22 patients; parascapular 11 (46%), foot filet six (25%), latissimus dorsi four (17%), lateral thigh, tensor fascia lata, and groin one (4%). Free flaps were performed immediately after injury in five (21%) cases, within the first week in two (8%), between 1 and 3 months in 12 (50%), and after 3 months in five (21%). Fifty per cent of the patients had significant other injuries. The patients had a total of 107 operations (mean, 4.9) related to their injury: 33 (mean, 1.5) of those operations were after the free flap, 27 (25%) of which were either performed because of a complication of the free flap or for revision of the free flap. Complications included partial necrosis in five (21%), neuroma in three (13%), hematoma in two (8%), donor site complication in two (8%), thrombosis requiring reoperation in one (4%), and flap failure in one (4%). Patient followup ranged from 12 to 116 months. All patients maintained a functional below-knee prosthetic level. The mean time to ambulation was 5.75 months, and was not significantly affected by flap complications. Most patients employed before their injury were employed after their injury. Despite a protracted course in these severe injured trauma patients, a functional below-knee amputation level was preserved in all cases utilizing microvascular free flaps.

Dynamic computer tomography determining the patency of buried free flaps.

Numerous methods exist for monitoring the patency of cutaneous free flaps. Monitoring the patency of microvascular anastomosis in buried free flaps are limited. The present case report is of a 39-year-old female with Rhomberg's disease who underwent an abdominus rectus muscle free flap to correct the contour deformity of the right face. Dynamic CT scan was performed on the sixth postoperative day. Plots of the rate of change of density of the free flap were compared to an adjacent muscle of the face. Dynamic CT scanning provides a high degree of resolution of the free flap, the ability to examine the entire free flap, and the ability to determine the patency of buried free flap.

Reconstruction of a large chest wall defect with a musculocutaneous free flap using anterolateral thigh musculature.

Reconstruction of a large postmastectomy irradiated chest wall defect was accomplished with a large musculocutaneous free flap of anterolateral thigh musculature and skin. The vascular anatomy of the donor area allows a very substantial flap and skin island to be transferred, leaving a well-tolerated donor defect.

Pelvic floor reconstruction using the rectus abdominis muscle flap.

In the 2 cases reported the rectus abdominis muscle was used as a sling to construct the pelvic floor. In patient 1, a large squamous cell carcinoma of the perineum was treated with an abdominal perineal resection. Reconstruction was accomplished internally using a rectus abdominis muscle sling and externally with a gluteus maximus musculocutaneous flap. In the second case, the rectus abdominis muscle was used as a supportive sling to reinforce a perineal hernial repair and prevent recurrence.