Transformation of a prefabricated hydroxyapatite/osteogenic protein-1 implant into a vascularised pedicled bone flap in the human chest.

We describe the intramuscular transformation of a hydroxyapatite/osteogenic protein-1 (HA/OP-1) composite implant, into a vascularised pedicled bone flap useful for reconstruction of a hemi-mandible. Extraskeletal induction of a bone flap for transplantation was achieved without the addition of harvested bone, bone marrow, or stem cells. Five months after apparent clinical success, an MRSA infection of the graft led to its failure. The background to ectopically induced bone flaps is introduced, with our experience in a human case presented. The results from this emerging biotechnology are discussed in the light of limited human clinical experience.

Sagittal split osteotomy of a vascularised iliac crest free flap to correct residual asymmetry and malocclusion in the reconstructed mandible.

Reconstruction of the mandible with a vascularised bone graft from the iliac crest based on the deep circumflex iliac artery is an established and reliable technique. We report two cases in which mandibular asymmetry followed reconstruction with such grafts and was corrected by sagittal split osteotomies.

A phase III placebo-controlled study in advanced head and neck cancer using intratumoural cisplatin/epinephrine gel.

Patients with recurrent or refractory head and neck squamous cell carcinoma received cisplatin/epinephrine injectable gel or placebo gel injected directly into the clinically dominant tumour. The double-blind phase III trial comprised of up to 6 weekly treatments over 8 weeks, 4 weekly evaluation visits, and then monthly follow-up; open-label dosing began as needed after three blinded treatments. Tumour response was defined as complete (100% regression) or partial (50-99% regression) sustained for > or =28 day, and patient benefit as attainment of palliative or preventive goals prospectively selected by investigators and patients. With cisplatin/epinephrine gel, 25% (14 out of 57) of tumours responded (16% complete regression, 9% partial regression), vs 3% (one out of 35, complete regression) with placebo (P=0.007). Patient benefit was positively associated with target tumour response in the blinded period among cisplatin/epinephrine gel recipients (P=0.024): 43% (six out of 14) of responders benefited, vs 12% (five out of 43) of non-responders. The most frequent adverse event was pain during injection and the next most frequent was local cytotoxic effects consistent with the gel's mode of action. Systemic adverse events typical of intravenous cisplatin were uncommon. Intratumoural therapy with cisplatin/epinephrine gel provided safe, well-tolerated, effective palliative treatment for patients with locally advanced head and neck squamous cell carcinoma, who lack other satisfactory treatment options.

Management of Jehovah's Witness patients undergoing major head and neck surgery.

BACKGROUND: Several diverse strategies have been recommended to manage Jehovah's Witness patients undergoing surgery when significant blood loss is expected. However, many of the proposed management strategies cannot be used when the urgent nature of the disease precludes adequate preoperative preparation of the patient. We present our experience of the management of two Jehovah's Witnesses with oral carcinoma requiring extensive resection, neck dissection, and reconstruction with free tissue transfer. METHODS: Hypervolemic hemodilution, hypotensive anesthesia, meticulous surgical hemostasis, and antifibrinolytic therapy were used as an alternative to blood products or transfusion. RESULTS: Radical surgical ablation and state-of-the-art reconstruction were possible, as a single-stage procedure, even though blood transfusion or blood product replacement therapy was refused. CONCLUSION: Radical surgical ablation of oral carcinoma, with free tissue transfer reconstruction, is possible in this group of patients without the use of blood products or transfusion. There would have been no advantage in raising the red cell mass preoperatively, as the packed cell volume was ideal for free tissue transfer.

Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary?

Various clinical protocols for the management of warfarinised patients needing dental extractions have been suggested. This study was designed to compare two approaches in the management of these patients. A control group of 32 patients had their warfarin treatment stopped for 2-3 days prior to having dental extractions, resulting in a reduction in the average preoperative international normalised ratio (INR) from 2.6 to 1.6. The study group of 33 patients did not have their anticoagulant treatment altered before extractions, and had an average preoperative INR of 2.7. All patients were treated under local analgesia on an outpatient basis, and local measures-consisting of Surgicel pack and sutures-were used in all cases to control postoperative bleeding from extraction sockets. None of the patients had any immediate postoperative bleeding, and only 1 patient from each group had mild delayed haemorrhage, which was easily controlled with local measures. It is proposed that, provided the INR is within the therapeutic range of 2.0 to 4.0 and local measures are used to control postoperative bleeding, there is no justification in altering warfarin treatment prior to dental extractions in these patients, and thereby exposing them to the risk of thromboembolism.

Combined radial forearm and pharyngeal flap for soft palate reconstruction.

The use of a free vascularised fascio-cutaneous radial forearm flap in combination with a cranially based pharyngeal flap for soft palate reconstruction has not been previously reported. We present the technique and illustrate its use in two cases of total and one case of subtotal soft palate reconstruction. The functional outcome is discussed with particular reference to nasal airway patency, speech and swallowing.

Apocrine hidrocystoma: report of a case.

A case of apocrine hidrocystoma, mimicking a naso-labial cyst of the maxilla is reported. The histopathological features and treatment of these rare lesions is discussed.

Athletic Medical Insurance Practices at NCAA Division I Institutions.

As the cost of athletic medical insurance continues to rise, athletic departments are searching for ways to continue to provide quality insurance coverage while keeping costs contained. There are few published articles dealing with the specific topic of the daily operations of maintaining an athletic medical insurance program. We sent an 18-item questionnaire to the 295 active NCAA Division I head athletic trainers to ascertain the current trends in athletic medical insurance. Of these, 207 (70%) responded. Of the respondents, 85% were primarily responsible for the administration of their athletic department's insurance coverage, although they had received no formal training in insurance management. Most athletic departments carry secondary policies and many report having a deductible. A wide range of insurance coverage and premiums were reported.

Dexamethasone reduces pain and swelling following extraction of third molar teeth.

Extraction of multiple third molar teeth can cause significant postoperative pain, swelling and trismus, which may result in delayed hospital discharge. We have examined the effect of a single prophylactic dose of oral dexamethasone 8 mg on these complications, in a randomised double-blind study of 50 adult patients. The number of extractions performed and the operative approach were standardised. Dexamethasone resulted in a significant reduction in pain 4 h postoperatively, and eliminated the need for opioid analgesia in the postoperative period. The incidence of severe swelling was also reduced significantly, but there was no effect on trismus. Postoperative nausea and vomiting were significantly lower in the dexamethasone group. We conclude that the use of prophylactic oral dexamethasone is useful in reducing postoperative analgesia requirements in this group of patients, and may facilitate surgery performed on a day case basis.

Chondrosarcoma of the maxilla.

A patient was referred to us with a mass in her upper jaw. This was diagnosed to be a chondrosarcoma of the maxilla. The mass was removed surgically. We present the case here and discuss the salient features.

The transfacial approach to the postnasal space and retromaxillary structures.

Various surgical approaches to the region are discussed, and the procedure according to Hernandez Altemir (1986) described in detail. Six cases are presented to illustrate how this versatile osteoplastic technique may be adapted for individual patients.

Anteroinferior Tibiofibular Ligament Injury: Not Just Another Ankle Sprain.

In brief: Ankle sprains that primarily involve the anteroinferior tibiofibular ligament are reportedly uncommon, but the authors have recently seen several such injuries in their clinic. These high ankle sprains usually are caused by forced lateral rotation with the foot in dorsiflexion. Edema and ecchymosis are generally minimal, with pain and tenderness over the distal anterior tibiofibular syndesmosis. Pain and disability can persist for weeks. Rehabilitation consists of range-of-motion exercises leading up to weight-bearing and often takes much longer than the initial symptoms might suggest.

New intravenous sedative combinations in oral surgery: a comparative study of nalbuphine or pentazocine with midazolam.

A randomised, double blind study was conducted to compare the efficacy and safety of nalbuphine or pentazocine with midazolam in patients undergoing minor oral surgery under local analgesia. Forty patients, aged between 17 and 48 years and in American Society of Anesthesiologists A.S.A. Class I participated. The results confirmed that the use of either nalbuphine (0.2 mg/kg) or pentazocine (0.5 mg/kg) allowed for a significant reduction in the mean dosage of midazolam required to produce satisfactory sedation when compared with trials where midazolam was used alone. Thus a mean midazolam, 0.087 mg/kg (nalbuphine group) or 0.081 mg/kg (pentazocine group) was required compared with 0.17 mg/kg (Aun et al., 1984) and 0.19 mg/kg (Skelley et al., 1984). Inadvertent overdosage with midazolam is prevented as the onset of sedation and its end-point are more obvious. No adverse cardiovascular or respiratory side effects were noted. The recovery rate for both groups was similar. Ninety-five per cent (39 of 40) of patients were able to walk unaided at 2 h post operation. At this time significantly more patients in the nalbuphine group were pain free (p less than 0.001). Both combinations provided excellent operating conditions with a high degree of safety and high patient acceptability. As the nalbuphine group enjoyed a more comfortable post-operative period this combination is favoured.

Recurrent ameloblastoma of the maxillo-facial region. Clinical features and treatment.

21 recurrent cases of ameloblastoma in the maxillofacial region in Nigerian subjects are described. These had a typical age, sex and site distribution and characteristic clinical features. Extension of the disease into the cranial vault was seen in one individual but no metastasis was detected at presentation and follow-up review. The effective surgical treatment was en bloc excision with preservation of the lower border of the mandible or radical resection often including adherent soft tissues and skin. Follow-up data were recorded and all the patients were free from the disease for 6 months to 6 years.

The versatility of pectoralis major and latissimus dorsi myocutaneous flaps in the reconstruction of cancrum oris defects of children and adolescents.

The application of the recently described myocutaneous flaps in 7 cases of cancrum oris defects is shown and the consistency of the blood supply in children is stressed. The surgical anatomy is mentioned and the use of the flaps in the reconstruction of defects of the cheek, angle of mouth, lips and chin is illustrated. The excellence of the muscle island flap in preventing reankylosis if interposed into new joints in the body of the mandible is emphasised, together with the advantages over the forehead and delto-pectoral flaps when used for the same purpose.