Double fillet of foot free flaps for emergency leg and hand coverage with ultimate great toe to thumb transfer.

A 42-year-old woman presented with avulsion amputation of her right leg 14 cm below the knee joint and a hemihand amputation of the opposite hand. Two free flaps, taken from the amputated foot, were used to cover the injured extremities. The sole fillet flap was used to preserve length and cover the injured leg, while the dorsal fillet flap covered the injured hand and provided ectopic storage for the great toe. The great toe was later transferred on a pedicle for thumb reconstruction. Spare parts surgery is now a well-accepted technique. This case demonstrates maximum utilization of amputated parts for functional and aesthetic reconstruction.

The extended V-Y flap.

The extended V-Y flap is a modification of the V-Y advancement flap, which is very useful in closing defects following excision of facial lesions. The modification involves the addition of an extension limb onto the advancing edge of the standard flap. This limb is located adjacent to the area requiring reconstruction and is hinged down as a transposition flap on the end of the V-Y advancement flap to close the most distal portion of the defect. The extended V-Y flap has been found to be very effective in closing large defects in areas that typically have inadequate subcutaneous tissue to allow extensive mobilization of the standard V-Y advancement flap. It has been used effectively with excellent cosmetic results in the temporal, scalp, forehead, and nasal areas, providing a well-contoured and aesthetically pleasing reconstruction.

Nonoperative management of full-thickness intravenous extravasation injuries in premature neonates using enzymatic debridement.

Peripheral intravenous fluid extravasation is a common occurrence among neonatal intensive care unit patients. Fifteen high-risk neonates, averaging less than 35 weeks' gestation and less than 1,500 g birth weight, with full-thickness extravasation injuries were successfully treated nonoperatively by a topical fibrinolysin/deoxyribonuclease ointment. All wounds healed without delaying hospital discharge, and no significant scar contractures were observed in patients followed up to 16 months after injury.

Successful combined medical and surgical treatment of a lower extremity sclerodermal ulcer.

Combined medical and surgical treatment of a chronic lower extremity ulcer in a patient with systemic scleroderma is described. Recent pharmacological advances including calcium channel blockers, meticulous surgical care, and skin grafting offer promise for more consistent wound closure in sclerodermal skin ulcerations.

Enterobacter bacteremia in surgical patients.

The records of 63 surgical patients with one or more positive blood cultures for Enterobacter organisms were reviewed to determine clinical, epidemiologic, and mortality risk factors. Enterobacter bacteremia occurred, on the average, on the twenty-third day of hospitalization, most frequently in male patients (47), after antibiotic therapy (48 patients), placement of central venous catheters (38 patients), gastrointestinal tract operations (36 patients), and respiratory failure (31 patients). Portals of entry were most commonly sputum (25 patients), open skin wounds (16 patients), and central venous lines (12 patients). Mortality risk (22 patients, 35%) was increased with Enterobacter bacteremia occurring after the fifteenth day of hospitalization (18 of 45 patients versus 4 of 28 patients, p less than 0.01), a preceding Enterobacter focus (13 of 22 patients versus 9 of 41 patients, p less than 0.05), preceding non-Enterobacter bacteremia (10 of 15 patients versus 12 of 48 patients, p less than 0.02), preceding total parenteral nutrition (11 of 21 patients versus 11 of 42 patients p less than 0.01), respiratory failure (19 of 36 patients versus 3 of 27 patients p less than 0.01), and renal failure (11 of 12 patients versus 11 of 51 patients p less than 0.01). The mortality risk was not diminished by specific antibiotic therapy. Enterobacter is emerging as an important pathogen in surgical patients. Prolonged antibiotic administration, particularly that of cephalosporins, may promote Enterobacter colonization of the tracheobronchial tree and skin with subsequent invasion enhanced by respiratory failure, open skin wounds, or central venous catheters traversing the skin. Mortality risk is determined primarily by factors associated with critical illness rather than effects of Enterobacter organisms and their specific treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Enterococcal bacteremia in surgical patients.

In 73 surgical patients enterococcal bacteremia was preceded by antibiotic administration (n = 58), central venous catheters (n = 52), other-organism bacteremia (n = 44), and gastrointestinal tract operations (n = 41). Surgical wounds and urinary tract infections were the most frequent portal of entry. The overall mortality was 42%. The mortality risk was significantly greater in patients with preceding or concomitant gram-positive bacteremia and four or more days of cephalosporin administration prior to enterococcemia. In 21 patients who had been given cephalosporins and who had gram-positive bacteremia, specific antienterococcal therapy resulted in survival in five of nine patients, compared with three of 12 who survived without therapy. Enterococcal bacteremia in surgical patients follows antibiotic administration, central venous catheter use, other-organism bacteremia, and intra-abdominal operations. Preceding or concomitant gram-positive bacteremia defines a subgroup of patients with high mortality who seem to respond to antienterococcal therapy.