Multidisciplinary management of thoracic esophageal fistula secondary to traumatic upper thoracic fracture (T3-4) with associated discitis/osteomyelitis and spinal epidural abscess: illustrative case.

BACKGROUND: An esophageal fistula secondary to a traumatic upper thoracic (T3-4) fracture with resultant thoracic discitis/osteomyelitis and an epidural abscess with neurological compromise is a rare clinical entity. Early diagnosis is critical for an optimal clinical outcome avoiding grave and progressive spinal dissemination with structural instability and neurological deterioration. OBSERVATIONS: The following case, not clearly described previously in the literature, highlights the clinical course and multidisciplinary approach to management including a single-stage posterior cervicothoracic (C3-T6) decompression with vertebral reconstruction with an expandable interbody cage (T2-4) and posterior cervicothoracic fusion and instrumentation (C3-T6), followed by direct esophageal fistula closure with AlloDerm and a vascularized latissimus dorsi muscle flap. LESSONS: Early diagnosis and the potential treatment of a posttraumatic esophageal fistula requires a multidisciplinary approach.

Mantle design: a composite construct for orbital floor reconstruction.

We present a unique case of orbital floor and wall reconstruction after complete destruction by a self-inflicted gunshot wound. The complex comminuted fracture was repaired using a composite construct design (the mantle design) that was fixed in place using mini plates and screws. The designed composite graft was shaped exactly to fit the area of the orbital floor and maxilla to create stability and support for the globe.The orbital floor and maxilla were repaired using this special design, which was created based on the basic physical principles of mantle constructs that have been known for many years to be strong, durable, and stable. After surgery, radiologic evaluation revealed excellent placement of our construct. This particular reconstruction method may be used in patients with severe orbital bony destruction with no surrounding stable bony support elements, which are required to reconstruct the orbital floor in patients with trauma using either an autologous or a biologic implant.

Nonarterialized venous replantation of part of amputated thumb-a case report and review of the literature.

Since the first successful replantation of a human thumb reported by Komatsu and Tamai in 1968, thousands of severed digits and body parts have been successfully salvaged. Restoration of anatomic form and function are the goals of replantation after traumatic tissue amputation. Regardless of anatomic location, methods include microsurgical replantation and nonmicrosurgical replantation, such as composite graft techniques. Numerous techniques to maximize tissue survival after revascularization have been described, including "pocket procedures" to salvage composite grafts, interposition vein grafts, and medicinal leeches to name a few. Artery-to-venous anastomoses have been performed with successful "arterialization" of the distal venous system in fingertip replantation. Although there is documented survival of free venous cutaneous flaps, to our knowledge this is the first report of a replanted composite body part (bone, tendon, soft tissues, and skin) utilizing exclusively multiple, microvascular, nonarterialized venous-venous anastomoses. We present a patient with an isolated band saw fillet amputation to the back of the thumb at the metacarpal-phalangeal joint region, resulting in a composite graft composed of bone, tendon, soft tissue, and skin. The hand wound provided no viable regional arterial inflow source, but there were multiple good caliber superficial veins present. The amputated tissues were replanted and revascularized by using only venous blood flow. The replanted part survival was 100% with excellent function of the digit. We conclude that a hand composite body part involving bone, tendon, soft tissues, and skin can survive replantation with a strict venous blood supply if sufficient good caliber, microvascular, venous-venous anastomoses are performed, granted that arterial inflow options are not available. This is an isolated case, yet introduces a new way of thinking regarding tissue replantation.