Neurocutaneous sural flap in paraplegic patients.

Neurocutaneous flaps have been demonstrated to be a reliable option in different groups of patients but it remains unclear if distally-based sural flaps can be safely used in paraplegic patients because they suffer from significant nervous system alterations. The aim of this proof-of-concept study is to demonstrate that these flaps are reliable in paraplegic patients. We prospectively analysed a group (n=6) of paraplegic patients who underwent reversed sural flap surgery for ulcers on the lateral malleolus. Measurement of area and photographic documentation techniques have been employed to quantify the defect area. Sural nerve biopsies have been analysed histologically with several different staining techniques to assess the neurovascular network and the myelinisation of the nerve. The patients showed uneventful wound healing, except one case that suffered a partial flap necrosis that healed by secondary intention. Histologic analysis revealed an intact neurovascular network and myelinated nerve fibres. In this small series of paraplegic patients that underwent a distally-based sural flap, the complication rate was low, with only one case of superficial partial necrosis demonstrating the reliability and safety of the flap in this subset of patients. Histologic evaluation of sural nerve biopsies revealed an almost normal morphology. A possible explanation of this phenomenon is that the dorsal root ganglia remain intact in paraplegic patients and can preserve neural characteristics in the peripheral sensory nerve system.

Silicone moulding for pressure sore debridement.

The radicality of wound debridement is an important feature of the surgical treatment of pressure sores. Several methods such as injection of methylene blue or hydrogen peroxide have been proposed to facilitate and optimise the surgical debridement technique, but none of them proved to be sufficient. We present an innovative modification of the pseudo-tumour technique consisting in the injection of fluid silicone. Vulcanisation of the silicone leads to pressure-sore moulding, permitting a more radical and sterile excision. In a series of 10 paraplegic patients presenting with ischial pressure sores, silicone moulding was used to facilitate debridement. Radical en bloc debridement was achieved in all patients. After a minimal follow-up of 2 years, no complications and recurrences occurred. A three-dimensional (3D) analysis of the silicone prints objectified the pyramidal shape of ischial pressure sores. Our study showed that complete resection without capsular lesion can be easily achieved. Further, it allows the surgeon to analyse the shape and size of the resected defect, which might be helpful to select the appropriate defect coverage technique.

Tip anchor flap in decubital surgery.

Anchoring a flap remains a key procedure in decubital surgery because a flap needs to be stable against shearing forces. This allows an early mobilization and undisturbed primary wound healing. This study evaluated a uniform group of eight paraplegic patients with sacral decubital ulcers and covered the lesions using gluteal rotation flaps with a deepithelialized tip to anchor the flap subcutaneously on the contralateral ischial tuber. Initial wound healing and recurrence after one year were evaluated. All but one flap showed uneventful wound healing, and all the flaps presented without any signs of recurrence or instability. The authors suggest that sufficient anchoring using a deepithelialized part of the flap helps to integrate and stabilize sacral rotation flaps.

Management of Pharyngeal Fistulas After Anterior Cervical Spine Surgery: A Treatment Algorithm for Severe Complications.

STUDY DESIGN:: Retrospective database- query to identify all anterior spinal approaches. OBJECTIVES:: To assess all patients with pharyngo-cutaneous fistulas after anterior cervical spine surgery. SUMMARY OF BACKGROUND DATA:: Patients treated in University of Heidelberg Spine Medical Center, Spinal Cord Injury Unit and Department of Otolaryngology (Germany), between 2005 and 2011 with the diagnosis of pharyngo-cutaneous fistulas. METHODS:: We conducted a retrospective study on 5 patients between 2005 and 2011 with PCF after ACSS, their therapy management and outcome according to radiologic data and patient charts. RESULTS:: Upon presentation 4 patients were paraplegic. 2 had PCF arising from one piriform sinus, two patients from the posterior pharyngeal wall and piriform sinus combined and one patient only from the posterior pharyngeal wall. 2 had previous unsuccessful surgical repair elsewhere and 1 had prior radiation therapy. In 3 patients speech and swallowing could be completely restored, 2 patients died. Both were paraplegic. The patients needed an average of 2-3 procedures for complete functional recovery consisting of primary closure with various vascularised regional flaps and refining laser procedures supplemented with negative pressure wound therapy where needed. CONCLUSION:: Based on our experience we are able to provide a treatment algorithm that indicates that chronic as opposed to acute fistulas require a primary surgical closure combined with a vascularised flap that should be accompanied by the immediate application of a negative pressure wound therapy. We also conclude that particularly in paraplegic patients suffering this complication the risk for a fatal outcome is substantial.