Hemicorporectomy.

Intractable decubitus ulcers and femoropelvic osteomyelitis are rare sequelae of paraplegia. Therapy for these conditions ranges from the simple to the complex, including wound debridement and care, alimentary and urinary tract diversion, hip disarticulation, and myofasciocutaneous rotational flaps. Should the condition be recalcitrant to these modalities the only curative therapy is hemicorporectomy. A 28-year-old rendered paraplegic 3 years ago presented manifesting sepsis; marasmus; hip and knee flexion contractures; suppurative sacral and femoropelvic decubitus ulcers, exposed bone, and osteomyelitis; and fecal and urinary incontinence. Pre-operative nutritional supplementation, wound debridement and care, and psychological counselling were provided. Hemicorporectomy was performed, including colostomy, ureteroileal conduit, gastrostomy, and translumbar amputation. Several anatomical, physiological, and operative-technical perspectives are emphasized: a two-staged approach may be preferable--at the first setting an intra-peritoneal exploratory celiotomy with alimentary and urinary tract diversion; and at the second setting an extra-peritoneal hemicorporectomy; preservation of abdominal wall musculature and fasciae to facilitate wound closure; sequential and bilateral ligation of the arteriae et venae iliaca communis; translumbar amputation between the fourth and fifth lumbar vertebrae; extirpation of the fourth lumbar processus spinosus vertebrarum; closure of the dura mater and translation of musculi sacrospinalis into the vertebral canal; avoidance of hypervolemia and hyperthermia; avoidance of wound pressure; testosterone replacement therapy for eunuchism; and physical and occupational rehabilitation including adaptation to a customized bucket prosthesis.

Concomitant renal endarterectomy and aortic reconstruction.

PURPOSE: This retrospective study is to determine the efficacy and durability of renal endarterectomy in patients undergoing simultaneous aortic reconstruction. In addition, the operative risk to patients with symptomatic and asymptomatic renal artery stenosis is evaluated. METHODS: The results of a retrospective study of 101 patients who underwent combined procedures are presented. All patients demonstrated at least a 75% stenosis of the renal artery ostium by arteriography and underwent surgical repair of aneurysmal (n = 33) or aortic occlusive (n = 68) disease. The indications for renal revascularization were hypertension necessitating multiple medications (47%), hypertension combined with renal insufficiency (18%), renal insufficiency alone (5%), and asymptomatic stenosis (30%). Blood pressure and antihypertension medications were monitored during the follow-up period (mean 3.3 years). RESULTS: The perioperative mortality rate was 1%, with a postoperative morbidity rate of 15%. The conditions of 74% of patients with hypertension were improved or cured, 23% were unchanged, and 3% were worse after surgery. Systolic and diastolic blood pressure in all patients remained significantly diminished during follow-up visits at 3 months, 6 months, 1 year, 3 years, and 6 years (p < 0.01). There was no significant improvement in serum creatinine levels in patients with preexisting renal insufficiency. A small but statistically significant decrease in systolic blood pressure and serum creatinine level was noted after operative intervention in the symptom-free patients (p < 0.005). There were no deaths in the asymptomatic subgroup, and significant azotemia did not develop in any of these patients after operation. CONCLUSIONS: Renal endarterectomy is an effective and durable method of renal revascularization. Furthermore, it is a technique that can be safely combined with aortic surgery and can be considered in the treatment of high-grade, asymptomatic lesions in patients undergoing aortic reconstruction.

Popliteal artery injury in a lumberjack.

We discuss the case of a patient with knee dislocation and popliteal artery injury. A high index of suspicion for vascular injury must be maintained in cases of blunt knee injury because more than one third of patients with knee dislocation will have an associated popliteal artery injury. Patients with a grossly unstable knee after blunt trauma often have had a knee dislocation; such patients should receive aggressive evaluation for popliteal artery injury. Arteriography should be done for all trauma patients with a grossly unstable knee joint or knee dislocation and palpable pedal pulses. For patients with severe limb ischemia, arteriograms may be done in the operating room to expedite revascularization. Without rapid recognition and revascularization, blunt injury to the popliteal artery results in a rate of limb loss of more than 30%.

Penetrating thermal vascular injury in a child: a case report.

Penetrating vascular trauma in children is most commonly seen in wartime settings or more recently as a result of attempts at invasive imaging. Treatment of these patients can be more complicated than treatment of trauma in adults and must include maintenance of symmetric limb growth, compensatory growth of the vascular graft and its anastomoses, and the need for very long-term graft patency. This report describes the care of a 5-year-old child who was impaled by a hot metal pipe and sustained a penetrating thermal injury to the distal external iliac artery and vein. Issues such as conduit choice, extraanatomic reconstruction, anastomotic suture technique, and soft tissue coverage are reviewed in the report.