Postoperative soft tissue defects in the ankle area : The etiology and methods of reconstruction

The risk is obvious for soft tissue complications after operative treatment of the Achilles tendon, calcaneal bone or after ankle arthroplasty. Such complications after malleolar fractures are, however, seldom seen. The reason behind these complications is that the soft tissue in this region is tight and does not allow much tension to the wound area after surgery. Furthermore the area of operation may be damaged by swelling after the injury, or can be affected by peripheral vascular disease. While complications in this area are unavoidable, they can be diminished. This study attempts to highlight the possible predisposing factors leading to complications in these operations and on the other hand, to determine the solutions to solve soft tissue problems in this region. The study consists of five papers. The first article is a reprint on the soft tissue reconstruction of 25 patients after their complicated Achilles tendon surgeries were analysed. The second study reviews a series of 126 patients after having undergone an operative treatment of calcaneal bone fractures and analyses the complications and possible reasons behind them. The third part analyses a series of corrections of 35 soft tissue complications after calcaneal fracture operations. The fourth part reviews a series of 7 patients who had undergone complicated ankle arthroplasties. The last article presents a series of post operative lateral defects of the ankle treated with a less frequently used distally based peroneus brevis muscle flap and analyses the results. What can be conducted from these studies is that in general, the results after the correction of even severe soft tissue complications in the ankle region are good. For the small defects around the Achilles tendon, the local flaps are useful, but the larger defects are best treated with a free flap. We found that a long delay from trauma to surgery and a long operating time were predisposing factors that lead to soft tissue complications after operatively treated calcaneal bone fractures. The more severe the injury, the greater the risk for wound complication. Surprisingly, the long-term results after infected calcaneal osteosyntheses were acceptable and the calcaneal bone seems to tolerate chronic infections very well if the soft tissue is reconstructed successfully. Behind the complicated ankle arthroplasties, unexpectedly high number of cases experiencing arteriosclerosis of the lower extremity was found. These complications lead to ankle fusion but can be solved with a free flap if the vascularity is intact or can be reconstructed. For this reason a vascular examination of the lower extremity arteries of the patients going to ankle arthroplasty is strongly recommended. Moreover postoperative lateral malleolar wound infections which typically create lateral ankle defects can successfully be treated with a peroneus brevis muscle flap covered with a free skin graft.

Microvascular reconstruction in extremity soft tissue sarcoma surgery

Soft tissue sarcomas (STS) are rare tumors of soft tissue occurring most frequently in the extremities. Modern treatment of extremity STS is based on limb-sparing surgery combined with radiotherapy. To prevent local recurrence, a healthy tissue margin of 2.5 cm around the resected tumor is required. This results in large defects of soft tissue and bone, necessitating the use of reconstructive surgery to achieve wound closure. When local or pedicled soft tissue flaps are unavailable, reconstruction with free flaps is used. Free flaps are elevated at a distant site, and have their blood flow restored at the recipient site through microvascular anastomosis. When limb-sparing surgery is made impossible, amputation is the only option. Proximal amputation such as forequarter amputation (FQA) causes considerable morbidity, but is nevertheless warranted for carefully selected patients for cure or palliation. 116 patients treated in 1985 - 2006 were included in the study. Of these, 93 patients treated with limb-sparing surgery and microvascular reconstructive surgery after resection of extremity STS. 25 patients who underwent FQA were also included. Patients were identified and their medical records retrospectively reviewed. In all, 105 free flap procedures were performed for 103 patients. A total of 95 curatively treated STS patients were included in survival analysis. The latissimus dorsi, used in 56% of cases, was the most frequently used free flap. Free flap success rate was 96%. There were 9% microvascular anastomosis complications and 15% wound complications. For curatively treated STS patients, local recurrence-free survival at 5 years was 73.1%, metastasis-free survival 58.3%, and overall disease-specific survival 68.9%. Functional results were good, with 75% of patients regaining normal or near-normal function after lower extremity, and 55% after upper extremity STS resection. Among curatively treated forequarter amputees, 5-year disease-free survival was 44%. In the palliatively treated group median time until disease death was 14 months. Microvascular reconstruction after extremity soft tissue sarcoma resection is safe and reliable, and produces well-healing wounds allowing early oncological treatment. Oncological outcome after these procedures is comparable to that of other extremity sarcoma patients. Functional results are generally good. Forequarter amputation is a useful treatment option for soft tissue tumors of the shoulder girdle and proximal upper extremity. When free flap coverage of extended forequarter amputation is required, the preferable flap is a fillet flap from the amputated extremity. Acceptable oncological outcome is achieved for curatively treated FQA patients. In the palliatively treated patient considerable periods of increased quality of life can be achieved.

Exclusion of an Exotic Top Quark with -4/3 Electric Charge Using Soft Lepton Tagging

We present a measurement of the electric charge of the top quark using $\ppbar$ collisions corresponding to an integrated luminosity of 2.7~fb$^{-1}$ at the CDF II detector. We reconstruct $\ttbar$ events in the lepton+jets final state and use kinematic information to determine which $b$-jet is associated with the leptonically- or hadronically-decaying $t$-quark. Soft lepton taggers are used to determine the $b$-jet flavor. Along with the charge of the $W$ boson decay lepton, this information permits the reconstruction of the top quark's electric charge. Out of 45 reconstructed events with $2.4\pm0.8$ expected background events, 29 are reconstructed as $\ttbar$ with the standard model $+$2/3 charge, whereas 16 are reconstructed as $\ttbar$ with an exotic $-4/3$ charge. This is consistent with the standard model and excludes the exotic scenario at 95\% confidence level. This is the strongest exclusion of the exotic charge scenario and the first to use soft leptons for this purpose.

Measurement of the tt̅ production cross section in pp̅ collisions at √s=1.96 TeV using soft electron b-tagging

We present a measurement of the top quark pair production cross section in ppbar collisions at sqrt(s)=1.96 TeV using a data sample corresponding to 1.7/fb of integrated luminosity collected with the Collider Detector at Fermilab. We reconstruct ttbar events in the lepton+jets channel. The dominant background is the production of W bosons in association with multiple jets. To suppress this background, we identify electrons from the semileptonic decay of heavy-flavor jets. We measure a production cross section of 7.8 +/- 2.4 (stat) +/- 1.6 (syst) +/- 0.5 (lumi) pb. This is the first measurement of the top pair production cross section with soft electron tags in Run II of the Tevatron.

Measurement of the tt̅ production cross section in 2 fb-1 of pp̅ collisions at √s=1.96 TeV using lepton plus jets events with soft muon b tagging

We present a measurement of the tt̅ production cross section in pp̅ collisions at √s=1.96  TeV using events containing a high transverse momentum electron or muon, three or more jets, and missing transverse energy. Events consistent with tt̅ decay are found by identifying jets containing candidate heavy-flavor semileptonic decays to muons. The measurement uses a CDF run II data sample corresponding to 2  fb-1 of integrated luminosity. Based on 248 candidate events with three or more jets and an expected background of 79.5±5.3 events, we measure a production cross section of 9.1±1.6  pb.

Measurement of the tt̅ production cross section in 2 fb-1 of pp̅ collisions at √s=1.96 TeV using lepton plus jets events with soft muon b tagging

We present a measurement of the tt̅ production cross section in pp̅ collisions at √s=1.96  TeV using events containing a high transverse momentum electron or muon, three or more jets, and missing transverse energy. Events consistent with tt̅ decay are found by identifying jets containing candidate heavy-flavor semileptonic decays to muons. The measurement uses a CDF run II data sample corresponding to 2  fb-1 of integrated luminosity. Based on 248 candidate events with three or more jets and an expected background of 79.5±5.3 events, we measure a production cross section of 9.1±1.6  pb.

Measurement of the tt̅ production cross section in 2 fb-1 of pp̅ collisions at √s=1.96 TeV using lepton plus jets events with soft muon b tagging

We present a measurement of the $\ttbar$ production cross section in $\ppbar$ collisions at $\sqrt{s}=1.96$ TeV using events containing a high transverse momentum electron or muon, three or more jets, and missing transverse energy. Events consistent with $\ttbar$ decay are found by identifying jets containing candidate heavy-flavor semileptonic decays to muons. The measurement uses a CDF Run II data sample corresponding to $2 \mathrm{fb^{-1}}$ of integrated luminosity. Based on 248 candidate events with three or more jets and an expected background of $79.5\pm5.3$ events, we measure a production cross section of $9.1\pm 1.6 \mathrm{pb}$.

Strategic Soft Human Resource Management - The Very Idea

On the one hand this thesis attempts to develop and empirically test an ethically defensible theorization of the relationship between human resource management (HRM) and competitive advantage. The specific empirical evidence indicates that at least part of HRM's causal influence on employee performance may operate indirectly through a social architecture and then through psychological empowerment. However, in particular the evidence concerning a potential influence of HRM on organizational performance seems to put in question some of the rhetorics within the HRM research community. On the other hand, the thesis tries to explicate and defend a certain attitude towards the philosophically oriented debates within organization science. This involves suggestions as to how we should understand meaning, reference, truth, justification and knowledge. In this understanding it is not fruitful to see either the problems or the solutions to the problems of empirical social science as fundamentally philosophical ones. It is argued that the notorious problems of social science, in this thesis exemplified by research on HRM, can be seen as related to dynamic complexity in combination with both the ethical and pragmatic difficulty of ”laboratory-like-experiments”. Solutions … can only be sought by informed trials and errors depending on the perceived familiarity with the object(s) of research. The odds are against anybody who hopes for clearly adequate social scientific answers to more complex questions. Social science is in particular unlikely to arrive at largely accepted knowledge of the kind ”if we do this, then that will happen”, or even ”if we do this, then that is likely to happen”. One of the problems probably facing most of the social scientific research communities is to specify and agree upon the ”this ” and the ”that” and provide convincing evidence of how they are (causally) related. On most more complex questions the role of social science seems largely to remain that of contributing to a (critical) conversation, rather than to arrive at more generally accepted knowledge. This is ultimately what is both argued and, in a sense, demonstrated using research on the relationship between HRM and organizational performance as an example.

Accurate mass-based analysis in human sport doping control : Application of liquid chromatography - time-of-flight mass spectrometry

Human sport doping control analysis is a complex and challenging task for anti-doping laboratories. The List of Prohibited Substances and Methods, updated annually by World Anti-Doping Agency (WADA), consists of hundreds of chemically and pharmacologically different low and high molecular weight compounds. This poses a considerable challenge for laboratories to analyze for them all in a limited amount of time from a limited sample aliquot. The continuous expansion of the Prohibited List obliges laboratories to keep their analytical methods updated and to research new available methodologies. In this thesis, an accurate mass-based analysis employing liquid chromatography - time-of-flight mass spectrometry (LC-TOFMS) was developed and validated to improve the power of doping control analysis. New analytical methods were developed utilizing the high mass accuracy and high information content obtained by TOFMS to generate comprehensive and generic screening procedures. The suitability of LC-TOFMS for comprehensive screening was demonstrated for the first time in the field with mass accuracies better than 1 mDa. Further attention was given to generic sample preparation, an essential part of screening analysis, to rationalize the whole work flow and minimize the need for several separate sample preparation methods. Utilizing both positive and negative ionization allowed the detection of almost 200 prohibited substances. Automatic data processing produced a Microsoft Excel based report highlighting the entries fulfilling the criteria of the reverse data base search (retention time (RT), mass accuracy, isotope match). The quantitative performance of LC-TOFMS was demonstrated with morphine, codeine and their intact glucuronide conjugates. After a straightforward sample preparation the compounds were analyzed directly without the need for hydrolysis, solvent transfer, evaporation or reconstitution. The hydrophilic interaction technique (HILIC) provided good chromatographic separation, which was critical for the morphine glucuronide isomers. A wide linear range (50-5000 ng/ml) with good precision (RSD<10%) and accuracy (±10%) was obtained, showing comparable or better performance to other methods used. In-source collision-induced dissociation (ISCID) allowed confirmation analysis with three diagnostic ions with a median mass accuracy of 1.08 mDa and repeatable ion ratios fulfilling WADA s identification criteria. The suitability of LC-TOFMS for screening of high molecular weight doping agents was demonstrated with plasma volume expanders (PVE), namely dextran and hydroxyethylstarch (HES). Specificity of the assay was improved, since interfering matrix compounds were removed by size exclusion chromatography (SEC). ISCID produced three characteristic ions with an excellent mean mass accuracy of 0.82 mDa at physiological concentration levels. In summary, by combining TOFMS with a proper sample preparation and chromatographic separation, the technique can be utilized extensively in doping control laboratories for comprehensive screening of chemically different low and high molecular weight compounds, for quantification of threshold substances and even for confirmation. LC-TOFMS rationalized the work flow in doping control laboratories by simplifying the screening scheme, expediting reporting and minimizing the analysis costs. Therefore LC-TOFMS can be exploited widely in doping control, and the need for several separate analysis techniques is reduced.

Optimal Use of Treatment Modalities and Treatment Results of Osteosarcoma and Soft Tissue Sarcomas

Soft tissue sarcomas are malignant tumours of mesenchymal origin. Because of infiltrative growth pattern, simple enucleation of the tumour causes a high rate of local recurrence. Instead, these tumours should be resected with a rim of normal tissue around the tumour. Data on the adequate margin width are scarce. At Helsinki University Central Hospital (HUCH) a multidisciplinary treatment group started in 1987. Surgical resection with a wide margin (2.5 cm) is the primary aim. In case of narrower margin radiation therapy is necessary. The role of adjuvant chemotherapy remains unclear. Our aims were to study local control by the surgical margin and to develop a new prognostic tool to aid decision-making on which patients should receive adjuvant chemotherapy. Patients with soft tissue sarcoma of the extremity or the trunk wall referred to HUCH during 1987-2002 form material in Studies I and II. External validation material comes from the Lund university sarcoma registry. The smallest surgical margin of at least 2.5 centimetres yielded local control of 89 per cent at five years. Amputation rate was 9 per cent. The proposed prognostic model with necrosis, vascular invasion, size on a continuous scale, depth, location and grade worked well both in Helsinki material and in the validation material, and it also showed good calibration. Based on the present study, we recommend the smallest surgical margin of 2-3 centimetres in soft tissue sarcoma irrespective of grade. Improvement in local control was present but modest in margins wider than 1 centimetre. In cases where gaining a wider margin would lead to a considerable loss of function, smaller margin is to be considered combined to radiation therapy. Patients treated with inadequate margins should be offered radiation therapy irrespective of tumour grade. Our new prognostic model to estimate 10-year survival probability in patients with soft tissue sarcoma of the extremities or trunk wall showed good dicscrimination and calibration. For time being the prognostic model is available for scientific use and further validations. In the future, the model may aid in clinical decision-making. For operable osteosarcoma, neoadjuvant multidrug chemotherapy followed by delayed surgery and multidrug adjuvant chemotherapy is the treatment of choice. Overall survival rates at five years are approximately 75 per cent in modern trials with classical osteosarcoma. All patients diagnosed and reported to the Finnish Cancer Registry with osteosarcoma in Finland during 1971-2005 form the material in Studies III and IV. Limb-salvage rate increased from 23 per cent to 78 per cent during 1971-2005. The 10-year sarcoma-specific survival for the whole study population improved from 32 per cent to 62 per cent. It was 75 per cent for patients with a local high-grade osteosarcoma of the extremity diagnosed during 1991-2005. This study outlines the improved prognosis of osteosarcoma patients in Finland with modern chemotherapy. The 10-year survival rates are good also in an international scale. Nonetheless, their limb-salvage rate remains inferior to those seen for highly selected patient series. Overall, the centralisation of osteosarcoma treatment would most likely improve both survival and limb-salvage rates even further.