Wide resection of the lateral malleolus and adjacent tibial, talar and calcanear bones with ankle fusion and allograft reconstruction for an osteosarcoma.

Introduction: Primary bone sarcomas around the ankle are rare. Due to the proximity of neurovascular structures and limited soft tissue reserves, limb salvage is often not possible. Case report: A 19 yo male presented with pain and a progressive swelling of his ankle. X-rays revealed cortical erosions and an extensive periosteal reaction (sunburst) of the distal fibula. MRI showed a large mass of the fibula invading adjacent soft tissue. The lesion appeared close to the ankle joint, but with the articular cartilage as a barrier and without joint effusion. Core-needle biopsy revealed a high-grade chondroblastic osteosarcoma. No metastases were detected. After presentation at our multidisciplinary sarcoma board, the patient was subjected to neo-adjuvant chemotherapy (AOST 03-331). Without any sign of intra-articular contamination of the ankle joint, surgical treatment consisted of wide resection of the lateral malleolus including a large skin patch, the distal third of the fibula, the lateral surfaces of the tibia and talus as well as the insertion of the lateral ligament on the calcaneus. The distal parts of the anterior, peroneal, and posterior muscular compartments were resected en bloc with the tumor. The defect was reconstructed with tibio-talar and talo-calcanear fusion, bony allograft and a plate. Soft-tissue coverage was achieved with a free fascio-cutaneous flap from the controlateral thigh. Histological analysis revealed clear margins and 50% of tumor necrosis. The oncologic treatment was completed with adjuvant chemotherapy. Conclusion: Wide resection and reconstruction of the lateral malleolus is technically demanding but possible in selected cases. Despite some important functional loss, limb salvage is superior to an amputation.

Mediastinal reinforcement after induction therapy and pneumonectomy: comparison of intercostal muscle versus diaphragm flaps.

OBJECTIVE: Prospective non-randomised comparison of full-thickness pedicled diaphragm flap with intercostal muscle flap in terms of morbidity and efficiency for bronchial stump coverage after induction therapy followed by pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: Between 1996 and 1998, a consecutive series of 26 patients underwent pneumonectomy following induction therapy. Half of the patients underwent mediastinal reinforcement by use of a pedicled intercostal muscle flap (IF) and half of the patients by use of a pedicled full-thickness diaphragm muscle flap (DF). Patients in both groups were matched according to age, gender, side of pneumonectomy and stage of NSCLC. Postoperative morbidity and mortality were recorded. Six months follow-up including physical examination and pulmonary function testing was performed to examine the incidence of bronchial stump fistulae, gastro-esophageal disorders or chest wall complaints. RESULTS: There was no 30-day mortality in both groups. Complications were observed in one of 13 patients after IF and five of 13 after DF including pneumonia in two (one IF and one DF), visceral herniations in three (DF) and bronchopleural fistula in one patient (DF). There were no symptoms of gastro-esophageal reflux disease (GERD). Postoperative pulmonary function testing revealed no significant differences between the two groups. CONCLUSIONS: Pedicled intercostal and diaphragmatic muscle flaps are both valuable and effective tools for prophylactic mediastinal reinforcement following induction therapy and pneumonectomy. In our series of patients, IF seemed to be associated with a smaller operation-related morbidity than DF, although the difference was not significant. Pedicled full-thickness diaphragmatic flaps may be indicated after induction therapy and extended pneumonectomy with pericardial resection in order to cover the stump and close the pericardial defect since they do not adversely influence pulmonary function.

Nasopalatine duct cyst: report of 22 cases and review of the literature

Objectives: Nasopalatine duct cysts (NPDCs) are the most common developmental, epithelial and non-odontogenic cysts of the maxillae. The present study describes the clinicopathological characteristics of 22 NPDCs and discusses their etiology, incidence, treatment and prognosis, with a review of the literature on the subject. Study design: A retrospective observational study was made comprising a period of 36 years (1970-2006), and yielding a series of 22 patients with histopathological confirmation of NPDC. Surgical treatment was carried out under local anesthesia and comprised the dissection and removal of the cyst adopting a usually palatine approach, with the preparation of an enveloping flap from 1.4 to 2.4. Results: No statistically significant correlation was observed between the size of the lesion and patient age, although the size of the cyst differed according to patient gender, with a mean NPDC diameter of 16 mm in males and 12 mm in females. In no case did we observe root reabsorption or loss of vitality of the upper incisors following surgery. The X-ray image was rounded in 15 cases and heart-shaped in the remaining 7 cases. In the majority of cases panoramic X-rays and periapical and occlusal X-rays sufficed to identify the lesion, though computed tomography was used in cases of doubt. Conclusions: The etiology of NPDC is unclear. Simple surgical resection is recommended, followed by clinical and radiological control to ensure correct resolution of the case.

Laser scanning evaluation of atrophy after autologous free muscle transfer.

Denervated muscle tissue undergoes morphologic changes that result in atrophy. The amount of muscle atrophy after denervation following free muscle transfer has not been measured so far. Therefore, the amount of muscle atrophy in human free muscle transfer for lower extremity reconstruction was measured in a series of 10 patients. Three-dimensional laser surface scanning was used to measure flap volume changes 2 weeks as well as 6 and 12 months after the operation. None of the muscles transferred was re-innervated.All muscles healed uneventfully without signs of compromised perfusion resulting in partial flap loss. The muscle volume decreased to 30 ± 4% and 19 ± 4% 6 and 12 months, respectively, after the operation, ie, the volume decreased by approximately 80% within a 12-month period.Denervated free muscle flap tissue undergoes massive atrophy of approximately 80%, mostly within the first 6 months.

Tracheo-carinal reconstructions using extrathoracic muscle flaps.

OBJECTIVES: Prospective evaluation of tracheo-carinal airway reconstructions using pedicled extrathoracic muscle flaps for closing airway defects after non-circumferential resections and after carinal resections as part of the reconstruction for alleviation of anastomotic tension. METHODS: From January 1996 to June 2006, 41 patients underwent tracheo-carinal airway reconstructions using 45 extrathoracic muscle flaps (latissimus dorsi, n=25; serratus anterior, n=18; pectoralis major, n=2) for closing airway defects resulting from (a) bronchopleural fistulas (BPF) with short desmoplastic bronchial stumps after right upper lobectomy (n=1) and right-sided (pleuro) pneumonectomy (n=13); (b) right (n=9) and left (n=3) associated with partial carinal resections for pre-treated centrally localised tumours; (c) partial non-circumferential tracheal resections for pre-treated tracheal tumours, tracheo-oesophageal fistulas (TEF) and chronic tracheal injury with tracheomalacia (n=11); (d) carinal resections with the integration of a muscle patch in specific parts of the anastomotic reconstruction for alleviation of anastomotic tension (n=4). The airway defects ranged from 2 x 1 cm to 8 x 4 cm and involved up to 50% of the airway circumference. The patients were followed by clinical examination, repeated bronchoscopy, pulmonary function testing and CT scans. The minimum follow-up time was 6 months. RESULTS: Ninety-day mortality was 7.3% (3/41 patients). Four patients (9.7%) sustained muscle flap necrosis requiring re-operation and flap replacement without subsequent mortality, airway dehiscence or stenosis. Airway dehiscence was observed in 1/41 patients (2.4%) and airway stenosis in 1/38 surviving patients (2.6%) responding well to topical mitomycin application. Follow-up on clinical grounds, by CT scans and repeated bronchoscopy, revealed airtight, stable and epithelialised airways and no recurrence of BPF or TEF in all surviving patients. CONCLUSIONS: Tracheo-carinal airway defects can be closed by use of pedicled extrathoracic muscle flaps after non-circumferential resections and after carinal resections with the muscle patch as part of the reconstruction for alleviation of anastomotic tension.

Repair of tracheal aspergillosis perforation causing tension pneumothorax.

Tracheobronchial aspergillosis is a rare entity mainly observed in immune-compromised patients or those who have undergone transplantation. It may cause airway ulcerations or bleeding. We report the case of a 17-year-old patient receiving chemotherapy for acute lymphoblastic leukemia who presented with right-sided tension pneumothorax. Chest tube drainage revealed a massive air leak without reexpansion of the lung, and bronchoscopy showed a 15- × 15-mm defect of the distal trachea related to aspergillosis infection. The defect was closed by an intrathoracic transposition of a pedicled latissimus dorsi muscle flap, which was sutured into the debrided defect followed by temporary endotracheal stenting and antifungal medication.

Nasopalatine duct cyst: report of 22 cases and review of the literature

Objectives: Nasopalatine duct cysts (NPDCs) are the most common developmental, epithelial and non-odontogenic cysts of the maxillae. The present study describes the clinicopathological characteristics of 22 NPDCs and discusses their etiology, incidence, treatment and prognosis, with a review of the literature on the subject. Study design: A retrospective observational study was made comprising a period of 36 years (1970-2006), and yielding a series of 22 patients with histopathological confirmation of NPDC. Surgical treatment was carried out under local anesthesia and comprised the dissection and removal of the cyst adopting a usually palatine approach, with the preparation of an enveloping flap from 1.4 to 2.4. Results: No statistically significant correlation was observed between the size of the lesion and patient age, although the size of the cyst differed according to patient gender, with a mean NPDC diameter of 16 mm in males and 12 mm in females. In no case did we observe root reabsorption or loss of vitality of the upper incisors following surgery. The X-ray image was rounded in 15 cases and heart-shaped in the remaining 7 cases. In the majority of cases panoramic X-rays and periapical and occlusal X-rays sufficed to identify the lesion, though computed tomography was used in cases of doubt. Conclusions: The etiology of NPDC is unclear. Simple surgical resection is recommended, followed by clinical and radiological control to ensure correct resolution of the case.

Analysis of the antibiotic prophylaxis prescribed by Spanish oral surgeons

Aim: To identify prophylactic antibiotic prescription practices among Spanish dentists with preferential dedication to Oral Surgery in different types of tooth extraction surgeries. Method: Members of the Spanish Oral Surgery Society were surveyed on antibiotic prophylaxis use in 4 different tooth extraction modalities scaled according to their surgical invasiveness. Results: Sixty-nine of the 105 distributed questionnaires were returned completed. Thirteen percent of the surveyed surgeons would prescribe antibiotics to prevent postoperative wound infection when confronted with conventional tooth extraction lasting less than 5 minutes. In the case of surgery lasting more than 5 minutes, the percentage of participants that would prescribe antibiotics increased to 39%. When a mucoperiosteal flap was elevated or an ostectomy was performed, 87% and 100%, respectively, would prescribe antibiotic prophylaxis. Amoxicillin and its combination with clavulanic acid were the most commonly prescribed antibiotics. All participants would prescribe the antibiotic orally, starting after surgery and with a duration that ranged from 2-8 days. Conclusions: The results obtained suggest that antibiotic prophylaxis for preventing local odontogenic infection is not being correctly implemented in Spain. This can generate new bacterial resistances, facilitate adverse drug reactions and favor opportunistic infections. Better designed studies are needed in order to clarify the role of antibiotics in the prevention of postsurgical wound infection

Real-time full field laser Doppler imaging.

We present a full field laser Doppler imaging instrument, which enables real-time in vivo assessment of blood flow in dermal tissue and skin. This instrument monitors the blood perfusion in an area of about 50 cm(2) with 480 × 480 pixels per frame at a rate of 12-14 frames per second. Smaller frames can be monitored at much higher frame rates. We recorded the microcirculation in healthy skin before, during and after arterial occlusion. In initial clinical case studies, we imaged the microcirculation in burned skin and monitored the recovery of blood flow in a skin flap during reconstructive surgery indicating the high potential of LDI for clinical applications. Small animal imaging in mouse ears clearly revealed the network of blood vessels and the corresponding blood perfusion.

Hidradenitis suppurativa of the groin treated by radical excision and defect closure by medial thigh lift: aesthetic surgery meets reconstructive surgery.

INTRODUCTION: Hidradenitis suppurativa of the groin is a chronic, relapsing inflammatory disease of the skin and subcutaneous tissues. Radical surgical excision is the treatment of choice. Often split-skin grafting or wound healing by secondary intention are used for defect closure, sometimes with disfiguring results. We describe our experience with radical excision of localised inguinal hidradenitis suppurativa and immediate defect closure with a medial thigh lift. PATIENTS AND METHODS: Our hospital database was searched for all patients presenting to our institution for surgical treatment of hidradenitis suppurativa between 2001 and 2006. Only patients with hidradenitis confined to the groin were included. Exclusion criteria were simple abscess incisions, recurrence after previous grafting or flap surgery and extension of the disease outside the groin and presence of clinical signs of infection at the time of surgery. We documented patient demographics, sizes of defects, complications, time of follow-up, recurrences and patient satisfaction. RESULTS: A total of 8 patients with localised inguinal hidradenitis suppurativa were identified and 15 thigh lifts were performed. Defect size assessed on pathologic examination of the excised specimens averaged 15.9 cm x 4.3 cm x 1.3 cm (length x width x depth). All wounds but one healed primarily. Functional and aesthetic results were satisfactory. No major complications and no irritations of the genital area were observed. No recurrences were observed either. CONCLUSION: We propose the medial thigh lift to be considered for immediate defect closure after radical excision of localised inguinal hidradenitis suppurativa provided that no perifocal signs of infection are present after debridement.

Body taping for contour surgery.

BACKGROUND: Preoperative marking is of primary importance in body contouring and when precise simulation of skin excisions is difficult. Because the "cut as you go" principle can be delicate, especially in patients after massive weight loss, a simple and quick method is needed for preoperative planning. We suggest an approach that helps visualize the optimal skin incision lines and simulates the postoperative result by body taping. METHODS: Twelve patients who underwent abdominal contouring, including classic and vertical abdominoplasties as well as dog ear and scar revision, were prospectively analyzed. The skin to be excised was preoperatively folded, taped, and then marked. The area marked was measured and compared with the actual intraoperatively resected area and the postoperative result was evaluated after 1 year by the patients and three surgeons. RESULTS: With body taping, an 83% congruence between the preoperative planning and the surgery was obtained and only two patients had additional skin resected. No wound dehiscence and flap necrosis occurred and patients as well as surgeons scored the final body contour positively. CONCLUSION: Body taping is a simple, quick, and economic method for planning contour surgery with high accuracy as demonstrated by the low rate of intraoperative changes of the planned resection and low complication rate.

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.

Spiral CT aortography: an efficient technique for the diagnosis of traumatic aortic injury.

The objective of this study was to assess the efficiency of spiral CT (SCT) aortography for diagnosing acute aortic lesions in blunt thoracic trauma patients. Between October 1992 and June 1997, 487 SCT scans of the chest were performed on blunt thoracic trauma patients. To assess aortic injury, the following SCT criteria were considered: hemomediastinum, peri-aortic hematoma, irregular aspect of the aortic wall, aortic pseudodiverticulum, intimal flap and traumatic dissection. Aortic injury was diagnosed on 14 SCT examinations (2.9 %), five of the patients having had an additional digital aortography that confirmed the aortic trauma. Twelve subjects underwent surgical repair of the thoracic aorta, which in all but one case confirmed the aortic injury. Two patients died before surgery from severe brain lesions. The aortic blunt lesions were confirmed at autopsy. According to the follow-up of the other 473 patients, we are aware of no false-negative SCT examination. Our limited series shows a sensitivity of 100 % and specificity of 99.8 % of SCT aortography in the diagnosis of aortic injury. It is concluded that SCT aortagraphy is an accurate diagnostic method for the assessment of aortic injury in blunt thoracic trauma patients.

Quality improvement for portal vein embolization.

Fibrin sealant is used in many areas of surgery. We present a novel aspect of flap insetting in the ischial region using fibrin spray to seal the transferred tissue. We analyzed 10 patients suffering from decubital ulcers and assessed drainage output, time of drain removal, as well as complications following fasciocutaneous flap surgery. Patients were randomized to receive sprayed fibrin glue (study group) or not (control group) before wound closure. The mean drainage time was 4 +/- 1 days in the study group and 6 +/- 1 days in the control group ( P = 0.06). The mean drainage volume was 100 +/- 20 mL in the study group and 168 +/- 30 mL in the control group ( P < 0.01). Fibrin sealant led to reduced drainage volumes and duration of drainage, indicating a beneficial effect of the application of fibrin glue in fasciocutaneous flap surgery for pressure sore coverage.

Vacuum-assisted closure device for the management of infected postpneumonectomy chest cavities.

BACKGROUND: Infected postpneumonectomy chest cavities may be related to chronic postpneumonectomy empyema or arise in rare situations of necrotizing pneumonia with complete lung destruction where pneumonectomy and pleural debridement are required. We evaluated the safety and efficacy of an intrathoracic vacuum-assisted closure device (VAC) for the treatment of infected postpneumonectomy chest cavities. METHOD: A retrospective single institution review of all patients with infected postpneumonectomy chest cavities treated by VAC between 2005 and 2013. Patients underwent surgical debridement of the thoracic cavity, muscle flap closure of the bronchial stump when a fistula was present, and repeated intrathoracic VAC dressings until granulation tissue covered the entire chest cavity. After this, the cavity was obliterated by a Clagett procedure and closed. RESULTS: Twenty-one patients (14 men and 7 women) underwent VAC treatment of their infected postpneumonectomy chest cavity. Twelve patients presented with a chronic postpneumonectomy empyema (10 of them with a bronchopleural fistula) and 9 patients with an empyema occurring in the context of necrotizing pneumonia treated by pneumonectomy. In-hospital mortality was 23%. The median duration of VAC therapy was 23 days (range, 4-61 days) and the median number of VAC changes per patient was 6 (range, 2-14 days). Infection control and successful chest cavity closure was achieved in all surviving patients. One adverse VAC treatment-related event was identified (5%). CONCLUSIONS: The intrathoracic VAC application is a safe and efficient treatment of infected postpneumonectomy chest cavities and allows the preservation of chest wall integrity.