Liver and vascularized posterior rectus sheath fascia composite tissue allotransplantation.

Abdominal wall closure in pediatric solid organ recipients may be confounded by donor size discrepancy and structural insults from previous surgery. Here we describe the novel use of vascularized donor abdominal wall posterior rectus sheath fascia, as a composite tissue allotransplant (CTA), to achieve abdominal wall closure in a liver and double kidney pediatric recipient who could not be closed primarily due to donor/recipient size mismatch. The posterior rectus sheath fascia was procured in continuity with the liver and falciform ligament. Blood supply was achieved using the single hepatic artery anastomosis as part of the standard liver transplantation procedure. Specimens of posterior rectus sheath fascia taken on postoperative days 3 and 30 showed no signs of acute rejection. The patient succumbed to an overwhelming fungal infection on day 51, with no signs of intraabdominal involvement. The patient received no additional immunosuppression in conjunction with the posterior rectus sheath fascia allotransplant.

Primary closure of complicated perineal wounds with myocutaneous and fasciocutaneous flaps after proctectomy for Crohn's disease.

BACKGROUND: The purpose of this study is to detail the use of advanced tissue transfer techniques to achieve primary closure of the perineal wound after proctectomy for Crohn's disease. METHODS: Between October 1984 and March 2000, we performed proctectomy with permanent intestinal stoma in 97 patients with Crohn's disease. Twelve of these patients (12.4%) required at least 1 myocutaneous flap to achieve primary closure of the perineal wound. Details of each patient's perioperative course were recorded prospectively. RESULTS: All 12 patients had fistulizing perineal Crohn's disease combined with Crohn's proctitis. Two patients had a simultaneous anal adenocarcinoma. Indications for flap closure included management of large perineal skin defects (n = 11), reconstruction of the posterior vaginal wall (n = 2), and the need to fill a large pelvic dead space (n = 3). (Three patients had a combination of the previous indications). In total, 6 rectus abdominis, 5 gluteus maximus, 1 posterior thigh, 3 chimeric posterior thigh, and 1 latissimus dorsi flaps were performed. Six patients required more than 1 flap. Three patients had complications develop related to the flaps (2 wound hematomas and 1 seroma). Complete perineal healing was achieved in all patients. CONCLUSIONS: Complex tissue flap closure of the perineal wound after proctectomy for perineal complications of Crohn's disease should be considered when simple closure is not possible or when reconstruction of the posterior wall of the vagina is necessary.

Frostbite of the upper extremity.

Human capacity for physiologic adaptation to cold is minimal; we survive by insulating ourselves with protective clothing. In addition to the irreversible direct injury caused by ice crystallization, the authors have outlined four possible mechanisms by which indirect injury may damage tissue. Other than rapid rewarming, there is no uniformly accepted protocol for the treatment of frostbite injury. Attempting to sort out the world's literature on frostbite in an effort to present a comprehensive treatment protocol is a daunting task. In addition to the probably irreversible direct injury caused by ice crystallization, the authors have outlined at least four possible mechanisms by which indirect injury may damage tissue. The literature is full of various treatment protocols that allegedly are beneficial despite addressing different mechanisms. Mills described 10 different categories of medications, each addressing one of four possible mechanisms, used in the clinical treatment of frostbite injury over a 30-year period. Analyzing this information is even more confusing when one realizes that there is little uniformity in animal models employed to generate these data. This is further complicated by the lack of clinical correlation with the most common experimental model--liquid nitrogen rapid freezing. The risk of frostbite is highest when psychiatric disturbance, intoxication, or unplanned circumstances lead to cold exposure without adequate protective clothing. As tissue freezes, both direct and indirect factors cause injury. Most therapies have been aimed at limiting indirect injury, in an attempt to limit progressive tissue loss. Rapid rewarming is universally accepted, but the benefits of other modalities are still controversial. Traditionally, observation and delayed amputation have been employed to manage frostbite. More recently, triple-phase bone scans have been used to distinguish between tissue that is irreversibly destined for necrosis and tissue that is at-risk for necrosis, but potentially salvageable. Early operation can be used to provide at-risk tissue with a new blood supply and preserve both function and length in the upper extremity.

Measured total energy requirements of adult patients with burns.

Adequate nutritional support is a primary concern in the treatment of patients with burns. Traditionally dietitians estimated energy requirements with the use of multifactorial equations that took into account anthropometric variables and burn severity. Recently, however, the availability of portable metabolic carts has reduced the need for dietitians to rely on predicted requirements. The use of metabolic carts, however, likely causes the underestimation of energy requirements because the carts do not always accurately measure the effects of surgery, dressing changes, and other related treatments. The aim of the current study was to determine the difference between resting energy expenditure and total daily energy expenditure. Seven adult patients whose burns ranged from 18% to 80% of their total body surface areas were studied. Total daily energy expenditure was measured with doubly labeled water, and resting energy expenditure was measured by studying respiratory gas exchange in the fed and fasted states. Total daily energy expenditure averaged 106% +/- 11% of average resting energy expenditure. Within the limits of the small data set studied, energy requirements could be measured with the use of the resting metabolic rate by allowing for an increase of 5% to 15% for nonrest activities and treatments.

Microsurgical replantation of the lip: a multi-institutional experience.

Traumatic amputation of the lip is a rare yet devastating event affecting both form and function. Considering the available methods for reconstruction, replantation may offer a reasonable solution. We sought to characterize the variables associated with lip replantation and to assess the outcome in a retrospective review of 13 lip replantations performed in 12 institutions utilizing a form database and clinical and photographic analysis. Lip replantation was successful in all 13 patients; partial flap loss occurred in one patient owing to iatrogenic injury. Follow-up averaged 3.1 years. Average patient age at the time of injury was 21.1 years. There were six male and seven female patients. Injuries in two patients were the result of a human bite, the remaining injuries resulted from dog bites. One patient had significant associated injuries. Average length of hospital stay was 11.9 days. Ten patients suffered amputations of the upper lip, and three suffered amputations of the lower lip. Average defect size was 10.6 cm2. Operative time averaged 5.7 hours (range 2.5 to 12 hours). Warm ischemia time averaged 2.9 hours, and cold ischemia time averaged 2.7 hours. Donor and recipient veins were often scarce; all patients had at least one arterial anastomosis, whereas no vein was available in 7 of 13 patients; vein grafts were required in one patient. Leech therapy was employed in 11 of 13 patients. Anticoagulant therapy was administered in the majority of patients. Systemic heparin was utilized in 10 of 13 patients, low molecular weight dextran was used in 7 of 13 patients, and aspirin was given to 7 of 13 patients. One bleeding complication was incurred. An average of 6.2 units of packed red blood cells was administered to 12 of 13 patients (adjusted to 250 cc/unit). Antispasmodic therapy was employed in six of eight patients intraoperatively and in two of eight patients postoperatively. Intraoperative complications included difficulty identifying veins in 7 of 13 patients, arterial spasm in 1 of 13 patients, and vessel diameter < 0.5 mm in 4 patients. Postoperatively, one patient suffered vein thrombosis requiring anastomotic revision. Broad spectrum antibiotics were administered to all patients, and there were no infections. Nearly one-third (4 of 13) patients suffered prolonged edema lasting > 4 months. Color match of the replanted lip segment was rated excellent in all cases. Hypertrophic scarring occurred in 6 of 13 patients. A total of 12 revision procedures was performed in six patients. Interestingly, leech therapy resulted in permanent visible scarring as a result of the leech bite in 6 of 11 patients treated. Ten patients demonstrated active orbicularis muscle contraction in the replanted lip segment. Stomal continence was present in all lips. Sensibility return in the replanted lip segment was quite good with 12 of 13 patients demonstrating at least protective moving two-point sensibility (> or = 10 mm). Partial replant necrosis in one patient resulted in significant scar and contraction that compromised the aesthetic appearance. Overall, however, all patients were uniformly pleased with their final results. This clinical study is one of the largest of its kind on lip replantation. Although this represents a multi-institutional experience, the data are remarkably consistent. Re-establishment of venous outflow seems to be the most problematic technical challenge. By incorporating the adjuncts of anticoagulation, leech therapy, and antispasmodics, a successful outcome can be expected despite the paucity of vessels and small vessel size. The risks of blood transfusion, lengthy operative time, and hospital stay must be weighed against the functional benefits.

The use of quantitative bacteriologic assessment of bone.

The purpose of this paper was to examine whether quantitative bacteriologic assessment of bone is a reliable indicator of the adequacy of debridement of draining wounds involving bone. This is a retrospective review of 31 consecutive patients treated for draining posttraumatic/ surgical wounds involving bone. Nineteen patients met the necessary criteria and were included in the study. These patients underwent radical debridement of bone and soft tissue, intraoperative assessment of the debrided wound by rapid slide quantitative bacteriologic assessment, and closure with well-vascularized tissue. Clinical assessment of vascularity and rapid slide quantitative bacteriologic assessment of cancellous bone and soft tissue were the only prerequisites used in determining the appropriateness of wound closure in this study. At the time of most recent follow-up, none of the 19 patients had recurrent wound drainage. Two patients required a second procedure to partially elevate their flaps and drain recurrent soft-tissue infections. None of the patients had recurrence of bony infection. Seventeen patients who presented initially with fractures or osteotomies all had successful bone unions. This study demonstrates that the technique of rapid slide quantitative bacteriologic assessment of cancellous bone is a useful adjunct to surgical judgment and allows one to close draining wounds (frequently with complex wound closure options) with a high level of confidence.

Medial gastrocnemius transposition flap for the treatment of disruption of the extensor mechanism after total knee arthroplasty.

We describe a modified technique for the salvage of a total knee arthroplasty after disruption of the extensor mechanism. Between January and December 1992, seven patients had reconstruction of the extensor mechanism with use of a medial or an extended medial gastrocnemius flap. Six of the seven patients were followed for a mean of thirty-three months (range, twenty-six to forty-one months) and were evaluated both preoperatively and postoperatively with regard to the knee and functional scores of The Knee Society as well as the range of motion, extensor lag, walking status, and patellar height. The seventh patient was lost to follow-up six months postoperatively and was excluded from the analysis of the results. Preoperatively, the knee and functional scores were 16 +/- 12.3 points and 12 +/- 12.1 points (mean and standard deviation), respectively; the mean range of motion was 70 +/- 44.0 degrees; and the mean extensor lag was 53 +/- 33.4 degrees. Postoperatively, the mean knee and functional scores improved to 82 +/- 12.4 points and 51 +/- 23.0 points, respectively; the mean range of motion improved to 100 +/- 21.8 degrees; and the mean extensor lag decreased to 24 +/- 18.8 degrees. After the procedure, all patients who previously had been dependent on a walker were able to walk about the community with or without a cane, and those who had been dependent on a wheelchair were able to walk with the assistance of a walker. Patellar height was measured according to the method of Insall and Salvati for the four patients who had a patella. Preoperatively, the patellar heights were grossly abnormal; postoperatively, they more closely approached accepted normal values for three of the four patients. Reconstruction of a complicated rupture of the extensor mechanism with use of a medial gastrocnemius transposition flap after total knee arthroplasty is a reliable option for treatment.

Reconstruction of the lower extremity after ablative resection for cancer.

Limb-sparing surgery for cancer of the lower extremity has ushered the development of composite, one-stage reconstructions that employ a combination of autologous tissues, bone allografts, and endoprosthetic devices. The success of these efforts in preserving limb function has been generally good, yet the ultimate level of function is less than normal. Microsurgery has assumed a progressively greater role in the reconstruction of composite defects and allows much latitude in the surgical planning and in the management of delayed complications. Although patients who opt for limb salvage reconstructions frequently require more operative procedures and have longer hospitalizations than patients undergoing primary amputation, their functional outcome surpasses that of the amputation group and thus justifies the surgical effort.

Distribution of pedal burns by source and depth.

The source and depth relationships of both isolated burns to the feet and pedal burns as part of multifocal thermal trauma are evaluated. Five years of cases at the University of Chicago Burn Center were selected at random and retrospectively reviewed. There were 33 isolated burns of the foot, with a source distribution of 70% scald, 9% grease, 9% hot solid, 6% flame, and 6% other. In patients with multifocal burns that included that foot, there were 89 cases, with a source distribution of 42% scald burns, 5% grease, 2% hot solid, 39% flame, 5% electrical, 1% frostbite, and 6% other. Source versus depth and grafting needs are presented. Admission to hospital which was delayed from the date of burn showed an increased need for grafting and a longer hospitalization than those admitted on the same day. Immediate admission for compliance of proper treatment protocol is advocated. Isolated pedal burns were most commonly sustained at home, indoors, and in the kitchen. A significant number of isolated burns to the feet were from a scald source, partial thickness in depth, and required no grafting. Much of the wound management involved treating elements found in traumatic, dysvascular, and diabetic pedal lesions.

Rigid internal fixation of the sternum in postoperative mediastinitis.

OBJECTIVE: The current standard treatment of mediastinitis following median sternotomy is radical sternal débridement and obliteration of anterior mediastinal dead space with muscle or omental flaps. This report describes and reviews our experiences with a new technique of sternal salvage based on osseous quantitative bacteriologic assessment and rigid fixation in patients with postoperative mediastinitis. DESIGN: A retrospective review of 29 patients treated with sternal rigid internal fixation. SETTING: Two tertiary care academic medical centers in Chicago, Ill, and Ann Arbor, Mich. PATIENTS: Patients with postoperative mediastinitis following median sternotomy who underwent rigid internal fixation of retained sternum. INTERVENTION: Following débridement, quantitative bacteriologic assessment and sternal vascularity were assessed. Sternal segments with good vascularity and in bacteriologic balance were anatomically reduced and rigidly fixed to each other with titanium miniplates in 24 patients with postoperative mediastinitis. Five of the 29 patients, at high risk for mediastinitis, underwent rigid internal fixation immediately after their cardiac procedure. MAIN OUTCOME MEASURES: Resolution of infection, wounds remaining closed, and stable sternums. RESULTS: Bony union was obtained in 27 (93%) of 29 patients. The postoperative hospital stay ranged from 5 to 84 days, with a mean stay of 17 days and a median stay of 7 days. Length of stay was directly related to pulmonary function, which correlated with preoperative intubation status. CONCLUSIONS: Radical sternal débridement may not be necessary in all patients with postoperative mediastinitis following median sternotomy. Sternal salvage can safely and reliably be performed with a combination of clinical assessment of vascularity and osseous quantitative bacteriologic assessment. Anatomic reduction of the viable sternal segments is possible even in severely osteoporotic bone.

Toxic shock syndrome associated with use of Biobrane in a scald burn victim.

Biobrane remains an excellent biosynthetic dressing for thermal injury coverage. The present report of a probable case of toxic shock syndrome associated with its use does not question its efficacy as temporary coverage for partial thickness thermal burns. Instead, attention is focused on raising the index of suspicion of toxic shock syndrome in burn patients treated with Biobrane, or other occlusive dressings, who develop early signs or symptoms which may be consistent with the diagnosis.

A new design for the radial forearm free-flap phallic construction.

One-stage phallic construction using the radial forearm free flap was originally reported in 1984. This potentially sensate, thin, minimally hair-bearing flap, whose design incorporated a vascularized urethra, provided significant advantages over previously described multistaged insensate phallic reconstructions. The original design, as described by Chang and Hwang, is limited in size and has the propensity to develop meatal stenosis. This article describes a new design of the radial forearm flap for phallic construction performed on four patients. The techniques described incorporates a centrally located neourethra in continuity with a neoglans. It eliminates the circumferential meatal suture line and, therefore, meatal stenosis without sacrificing phallic length.

Improved venous drainage of the radial artery forearm free flap: use of the profundus cubitalis vein.

The radial artery forearm free flap (RAFFF) is a versatile and popular flap used in various reconstructive procedures. This flap contains two venous drainage systems: a superficial (cephalic) route, and a deep (venae comitantes) route. Most surgeons use either the deep venous system alone or in combination with a superficial vessel, hence requiring two venous anastomoses. The authors describe a novel technique of providing venous drainage for the RAFFF, incorporating both deep and superficial systems, and using one venous anastomosis. From 10 consecutive operative and five cadaveric dissections, it was noted that paired venae comitantes, corresponding to the radial artery, coalesce into a single vein at the level of the brachial artery bifurcation. The profundus cubitalis vein (vena anastomotica) connects this coalesced (deep) vein to the cephalic (superficial) vein at the level of the cubital fossa. Both the deep and superficial venous systems are drained via one large anastomosis, situated proximal to the profundus cubitalis interconnection. Advantages of this technique include: 1) improved venous drainage of the RAFFF; 2) rendering the venous anastomosis technically easier, due to its larger size; and 3) more available versatility in designing the venous portion of the vascular pedicle.

Endogenous versus toxin-induced diabetes in rats: a mechanical comparison of two skin wound-healing models.

This study was designed to compare skin wound healing in three groups of Wistar rats: normal, genetically diabetic, and streptozotocin-induced diabetic. All diabetic animals received daily insulin. Full-thickness midline dorsal skin wounds were analyzed biomechanically for strength, toughness, and elasticity (Young's modulus) at 1 and 3 weeks after wounding. Wounds from normal controls were the strongest, toughest, and least compliant. Genetically diabetic rat wounds were the weakest and had the lowest elastic modulus. Wounds from the streptozotocin-induced rats were intermediate for all parameters measured (ANOVA, p = 0.001). Toxin-induced diabetes is less detrimental to skin wound healing than diabetes of endogenous origin. Whether this is due to basic differences in the models or to differences in duration of diabetes is unknown.

Prosthesis placement after total phallic reconstruction.

Total reconstruction of the phallus is now technically feasible. The successful reestablishment of sexual function in these patients is possible using the neurosensory radial forearm flap. The innervated neophallus develops tactile and erogenous sensation within 4 to 6 months of neurorrhaphy. Unperceived chronic pressure with subsequent tissue ischemia is the leading cause of delayed prosthesis extrusion. The development of protective sensation within this reconstructed neophallus allows for the safe placement of a penile prosthesis permitting intromission. The development of erogenous sensation allows for orgasm. We report on the successful implantation and long-term retention of penile prostheses in 4 patients after total phallic reconstruction.

Forequarter amputation wound coverage with an ipsilateral, lymphedematous, circumferential forearm fasciocutaneous free flap in patients undergoing palliative shoulder-girdle tumor resection.

Closure of massive soft-tissue defects in patients undergoing forequarter amputation for shoulder-girdle tumors may present a daunting challenge. This report describes two patients whose forequarter amputations were closed using ipsilateral, lymphedematous, circumferential forearm fasciocutaneous free flaps.

Full-thickness skin wound explants in tissue culture: a mechanical evaluation of healing.

This study was designed to evaluate biomechanically defined wound healing in full-thickness skin explants in tissue culture. The requirement for preculture incubation of wounds in situ was characterized. Full-thickness skin incisions were made in 44 rats and closed immediately. Wounds were incubated in situ for 0, 12, 24, 36, 48, 72, or 96 hours before harvesting and placement into tissue culture media for 6 weeks. Healing was evaluated by biomechanical criteria: tensiometric distraction to wound rupture generated true stress and energy absorption data. Burst-strength (maximum true stress) and toughness (energy absorption) were five times higher in the 48-hour group than in any other group; other groups were not different from each other. This study demonstrates long-term survival of full-thickness skin in culture and shows that full-thickness skin explants heal in tissue culture. Possible explanations for the narrow window of opportunity for harvest (48 hours, no more and no less) are discussed.