Posterior interosseous free flap: various types

The posterior interosseous artery is located in the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi muscles. The posterior interosseous artery is anatomically united through two main anastomoses: one proximal (at the level of the distal border of the supinator muscle) and one distal (at the most distal part of the interosseous space). In the distal part, the posterior interosseous artery joins the anterior interosseous artery to form the distal anastomosis between them. The posterior interosseous flap can be widely used as a reverse flow island flap because it is perfused by anastomoses between the anterior and the posterior interosseous arteries at the level of the wrist. The flap is not reliable whenever there is injury to the distal forearm or the wrist. To circumvent this limitation and to increase the versatility of this flap, we have refined its use as a direct flow free flap. The three types of free flaps used were (1) fasciocutaneous, (2) fasciocutaneous-fascia, and (3) fascia only. Described are 23 posterior interosseous free flaps: 13 fasciocutaneous flaps, 6 fasciocutaneous-fascial flaps, and 4 fascial flaps. There were 13 sensory flaps using the posterior antebrachial cutaneous nerve. The length and external diameter of the pedicle were measured in 35 cases. The length of the pedicle was on average 3.5 cm (range, 3.0 to 4.0 cm) and the external diameter of the artery averaged 2.2 mm (range, 2.0 to 2.5 mm). The hand was the recipient in 21 patients, and the foot in 2. All 23 flaps covered the defect successfully.     

Posterior interosseous flap and its variations for coverage of hand wounds

Damage of large arteries is a major contributory factor to the high pulse pressure observed in patients with end-stage renal disease. Whether incremental modulus of elasticity (Einc), a classic marker of arterial stiffness, can predict cardiovascular mortality has never been investigated. A cohort of 79 patients with end-stage renal disease undergoing hemodialysis was studied between September 1995 and January 1998. Mean age at entry was 58+/-15 years. The duration of follow-up was 25+/-7 months, during which 10 cardiovascular and 8 noncardiovascular fatal events occurred. At entry, carotid Einc was calculated from measurements of diameter, thickness (echo-tracking technique), and pulse pressure (tonometry). Based on Cox analyses, 2 dominant factors emerged as predictors of all-cause and cardiovascular mortality: increased Einc and decreased diastolic blood pressure. Lipid abnormalities and the presence of previous cardiovascular events interfered to a smaller extent. After adjustment for confounding variables, the odds ratio for Einc >/=1 kPa-3 was 9.2 (95% confidence interval, 2.4 to 35.0) for all-cause mortality. These results provide the first direct evidence that in patients with end-stage renal disease undergoing hemodialysis, arterial alterations, as determined from carotid Einc, are strong independent predictors of all-cause and cardiovascular mortality.     

Penetrating stab wounds of the chest: experience with 200 consecutive cases

The incidence of penetrating wounds of the chest is rising rapidly. Opinions continue to differ on their management. Our experience with 200 consecutive cases of stab wounds of the chest between 1972 and 1975 were reviewed. There were 176 males and 24 females. The average age was 31 years; about two-thirds of the patients were under 30. About 74% presented with hemothorax or hemopneumothorax; 21 presented with pneumothorax. Eleven per cent had associated intra-abdominal injuries. Seventy-nine per cent were successfully treated with tube thoracostomy. About 15% underwent thoracotomy, with three deaths (mortality, 10%); the mortality for cardiac wounds was 16%; overall mortality was 1.5%. The overall complication rate was 5.5%, most occurring in patients with cardiac wounds and associated intra-abdominal injuries. The average period of hospitalization was 6.5 days. Treatment was individualized. Indications for each course of therapy are discussed.     

Posterior fossa meningiomas: surgical experience in 52 cases

The ability to discriminate between galactose and N- acetylgalactosamine, observed in some lectins, is crucial for their biological activity as well as their usefulness as tools in biology and medicine. However, the molecular basis of differential binding of lectins to these two sugars is poorly understood. Peanut agglutinin (PNA) is one of the few galactose-specific legume lectins which does not bind N- acetylgalactosamine at all and is, therefore, ideal for the study of the basis of specificity towards C-2 substituted derivatives of galactopyranosides. Examination of the three-dimensional structure of PNA in complex with lactose revealed the presence of both a longer loop and bulkier residues in the region surrounding the C-2 hydroxyl of the galactopyranoside ring, which can sterically prevent the accommodation of a bulky substituent in this position. One such residue, is a glutamic acid at position 129 which protrudes into the binding site and perhaps directly obstructs any substitution at the C-2 position. Two mutants in bacterially expressed PNA were therefore constructed. These were E129D and E129A, in which Glu129 was replaced by Asp and Ala, respectively. The specificity of the mutants for galactose, galactosamine, and N- acetylgalactosamine was examined through observing the inhibition of hemagglutination and binding of the lectin to immobilized asialofetuin. The results showed that the affinity of E129A and E129D for C-2-substituted derivatives of the galactose varies. The mutant E129D showed significant binding towards N- acetylgalactosamine, suggesting that the residue Glu 129 is crucial in imparting exclusive galactose-specificity upon PNA. This study not only attempts to provide an explanation for the inability of PNA to accommodate C-2-substituted derivatives at its primary subsite, but also seeks to present a basis for engineering lectins with altered specificities.     

Aesthetic rhinoplasty with maximum preservation of alar cartilages: experience with 52 consecutive cases

Historically, rhinoplasty has been conceptualized mainly as an excisional and reductional operation of the nasal framework; however, there is growing evidence showing that conservatism in terms of preserving as much skeleton as possible makes the final results more predictable and more physiologic. On the basis of this point of view and using modifications of Tebbetts' technique, a prospective study of 52 patients presenting for primary open rhinoplasty was made. In all the cases, the cephalic portion of the lateral crus was preserved, and the procedure was designed basically to create a better anatomy from an aesthetic point of view. The results were evaluated aesthetically and by cephalometry, and patients showed improvement; native crura preservation was maximized. This report suggests more prospective studies need to be conducted to demonstrate the efficacy of these surgical variations on the average patient.     

The reverse digital artery island flap: clinical experience in 120 fingers

Fingertip injuries represent the most common type of injuries seen in the upper extremity. Their management is functionally and aesthetically important but at the same time very controversial. The aim of this study is to report usefulness and postoperative results of reverse digital artery island flaps for fingertip reconstruction. From July of 1984 to December of 1995, 120 fingers in 110 patients with defects of the distal phalanx were reconstructed by reverse digital artery island flaps at Korea University Guro Hospital. We reviewed the medical records of our cases and analyzed them in several aspects. In 21 cases, neurorrhaphy was performed to improve sensibility. In the majority of the cases, the defect was covered primarily, whereas in 27 cases it was covered secondarily after composite graft, replantation, and so on. All the flaps survived except for one. Long-term follow-up for more than 6 months was possible in 44 fingers in 41 patients. Light touch and temperature sensation could be detected in all the evaluated flaps. The mean values of the static two-point discrimination test in sensate and insensate flaps were 6.2 and 10.2 mm, respectively. The reverse digital artery island flap is a safe and reliable procedure with a high survival rate and therefore is an excellent choice for coverage of fingertip defects.     

Congenital anomalies of the diaphragm. Personal experience with thirty-five consecutive cases

A personal experience of thirty-five consecutive patients with congenital anomalies of the diaphragm is reported. The anomalies included twenty-five Bochdalek hernias, seven diaphragmatic eventrations, and three esophageal hiatal hernias. Except for the patients with esophageal hiatal hernias, virtually all patients presented with respiratory embarrassment, twenty-seven of the thirty-five within 24 hours of birth. An especially high mortality is associated with this early onset of symptoms. The treatment was surgical with a thoracic approach used for right Bochdalek defects and eventrations, and an abdominal approach used for left Bochdalek hernias. The importance of proper preoperative and postoperative management in a well equipped neonatal intensive care unit is emphasized.     

Posterior interosseous nerve paralysis caused by fibrous band compression at the supinator muscle. A report of four cases

Four cases are reported of paralysis of the posterior interosseous nerve, caused by compression of the nerve between the Arcade of Frohse and the two heads of the supinator muscle. All four cases were treated by decompression with excellent results.     

Bilateral skeletonized mammary artery grafting: experience with 560 consecutive patients

OBJECTIVE: To test the hypothesis that the skeletonized technique of harvesting the internal thoracic artery improves the surgical results of bilateral internal thoracic artery grafting, we reviewed our 7-year experience with this technique. METHODS: Between July 1987 and December 1994, 560 patients received bilateral internal thoracic artery grafts and 236 additional grafts (average 2.6 +/- 0.6 anastomoses per patient). There were 515 men (92%) and the average age was 56.9 +/- 8.8 years. There were 63 diabetic patients (11.3%). During harvesting, the internal thoracic arteries were always totally skeletonized from the surrounding tissues without the use of electrocautery. RESULTS: Postoperative complications included reoperation for bleeding, 17 patients (3%), phrenic nerve paresis, 17 patients (3%), acute respiratory distress syndrome, 9 patients (1.6%), digestive complications, 8 patients (1.4%), neurologic complications, 6 patients (1.1%), and sternal complications, 6 patients (1.1%). No wound complications were observed in diabetic patients. The hospital mortality rate was 1.6% (9 patients, 2 cardiac causes). The early patency of internal thoracic artery grafts was 97.9%. Follow-up averages 29 +/- 20 months. There were 14 late deaths (4 cardiac causes). Angina recurred in 51 patients and the maximal stress test was abnormal in 47 patients. CONCLUSION: Bilateral internal thoracic artery grafting with skeletonized harvesting carried low post-operative mortality and morbidity and therefore it could be applied routinely without the fear of increased complication rate.     

Fatal poisoning with propoxyphene: report from 100 consecutive cases

The first 100 deaths caused by propoxyphene and recorded by the Chief Medical Examiner of North Carolina were studied. Victims ranged evenly in age from the second to the seventh decade. Over 65% were suicides with a female to male ratio of 2:1. Blood propoxyphene concentrations of 0.2 mg/dl were fatal, representing rapid ingestion of approximately ten capsules. In North Carolina, deaths due to propoxyphene have increased from five in 1969 to 49 in 1975. Raising physician-awareness of propoxyphene's toxicity and placing the drug in Schedule II are two of the author's recommendations for reducing the number of propoxyphene deaths.     

Sturge-Weber syndrome: experience with 14 cases

We report a first documented case in Senegal with simple transposition of the great arteries diagnosed in a 2 months old girl treated by Rashkind atrioseptostomy. Our patient benefited from clinical examination, ECG (15 derivations), chest X ray and standard laboratory tests. Pulsed-Doppler, two dimensional and TM echocardiography have been performed with an ATL MK 600 echocardiograph. Cardiac catheterism, angiocardiography and Rashkind procedure have been realized in our Department. These data are discussed and compared to the literature. At admission this patient presents with major cyanosis and polypnea. At examination, there is a 3/6 murmur at the left sternal border and a subclavicular continuous murmur. Laboratory tests showed metabolic acidosis and severe hypoxemia. Chest x-ray showed a cardio-thoracic ratio at 0.64 with increased pulmonary vascular markings. ECG showed right ventricular hypertrophy. Echocardiography-Doppler revealed ventriculo-arterial discordance with restrictive atrial septal defect and persistent ductus arteriosus. Rashkind procedure was followed by an increased aortic saturation. After 6 weeks there was an improvement of cyanosis and cardiac failure. Diagnosis of transposition of the great arteries is actually easier with development of ultrasonography which is useful when performed by experienced cardiologist. Spontaneous prognosis of this malformation is very poor. Rashkind atrioseptostomy is an important step for the initial treatment of transposition of the great arteries in terms of survival before open heart surgery.     

Clinical experience and indications of the free serratus fascia flap: a report of 21 cases

The free "serratus fascia" flap as a free flap was first described by Wintsch and named a free fascia flap of gliding tissue; however, it has not yet been given a distinct name. The particular advantages of this flap consist of an easy access and a low donor-site morbidity without functional deficit. Additionally, it may be designed very variably and molded even three-dimensionally as a tendon wraparound flap or folded to fill up cavities. In our clinic, we used this flap in 21 patients for distinct indications and in 7 patients as a vascular graft in fingers or great toe with a minimal adjacent layer of gliding tissue around the vessels for the treatment of cold intolerance after finger replantation or severe finger or toe trauma. In the other cases, this versatile flap served for the coverage of traumatically exposed tendons or bones at the extremities, covered with a skin graft. Eighteen flaps survived completely, whereas 3 flaps developed partial or superficial necrosis. Only once did a major complication by unintentional sacrification of the long thoracic nerve during flap harvesting occur, resulting in a wing scapula. We recommend this flap for defect cover at sites where a thin vascularized gliding layer for defect cover is needed, especially in distal extremities with exposed tendons or nerves, and present the current indications in discussing our experiences.     

Topical psoralen-ultraviolet A therapy for palmoplantar dermatoses: experience with 35 consecutive patients

We performed transesophageal echocardiography (TEE) and transcranial-color flow imaging (TC-CFI) in 38 patients (25 men, 13 women, mean age 51.5 years old) with cerebrovascular or cardiac disease in order to evaluate an accuracy in diagnosing right-to-left shunts (RLS) in the heart by TC-CFI as compared to TEE findings. We rapidly injected a mixture of 9 ml of cold saline and 1.0 ml of air into the antecubital vein during Valsalva maneuver. In TEE study, we took RLS positive when interatrial shunting of contrast microcavitations into the left atrium was visualized after complete opacification of the right atrium. In TC-CFI study, we considered RLS positive when we detected the high intensity transient signals (HITS) on the middle cerebral artery. The both studies were positive in 15 patients and negative in 19. Two patients were positive in TC-CFI and negative in TEE while the other two patients were negative in TC-CFI and positive in TEE. Therefore, the sensitivity of TC-CFI in diagnosing RLS was 88%, the specificity 90%, and the accuracy 89%. It seems that TC-CFI is a useful tool to estimate the RLS.     

A patient's perspective on the management of peptic esophageal stricture: experience and results in 113 consecutive cases

A retrospective analysis of 113 consecutive cases of benign esophageal stricture, all secondary to gastroesophageal reflux, 100 treated conservatively, 13 treated surgically, has been carried out in conjunction with a postal questionnaire of patients. Patients were requested to grade both their swallowing ability and the acceptability of their treatment. Of those responding to questionnaire, 88% of patients treated conservatively found their treatment acceptable or better, and 72% were left with either no or minimal restriction of diet. There was no correlation between either the total number or frequency of dilatations and the result achieved. Similarly, patient satisfaction appears largely independent of these variables. Doctors should be wary of taking recurrence of a stricture after initial dilatation as indicating a poor eventual outcome or a dissatisfied patient. There was no difference in terms of either the result or patient satisfaction between conservatively treated and surgically treated patients.     

Acute opiate overdose: characteristics of 190 consecutive cases

AIMS: To characterize the population of drug users consulting the Emergency Room (ER) of a university hospital with acute opiate overdose (AOO) and to assess rate of referral to specialized treatment programme. DESIGN: Survey of a 12-month sample of AOO patients. MEASUREMENTS: Medical and psychosocial features of the drug users, details of emergency treatment and referral by a mobile resuscitation team (SMUR) and the ER of our hospital (CHUV-Lausanne, Switzerland). In addition fatal AOO cases were collected by the Institute of Forensic Medicine (IFM) during the same period. FINDINGS: One hundred and eighty-four cases of AOO (134 patients) were treated. The files of the IFM detailed six additional deceased cases. This population of drug users was characterized by an over-representation of men (73%), by young age (27.4 years), by a high rate of multi-drugs use (90%) and by a high rate of multiple previous overdoses (2.6). Average length of stay was 20.1 hours but 41% of cases stayed less than 8 hours. Only one patient was readmitted within an 8-hour period. When discharged, 78% returned home. Unexpectedly, 67% of patients were not referred to any therapeutic programme for drug addiction. CONCLUSION: This study shows the low mortality of AOO when treated but also demonstrates the need to improve psychosocial evaluation and referral of drug addicts admitted with AOO.     

Results after resection of intraoral cancer and reconstruction with the free radial forearm flap

OBJECTIVE: Prospectively evaluate the effect on the nutritional status of a glucose polymer as energy supplementation alone in chronic hemodialysis patients with moderate and severe malnutrition. MATERIAL AND METHODS: The nutritional status of 55 hemodialysis patients was assessed by using a score that included Iron binding capacity, albumin, cholesterol, body mass index, mid brachial circumference, arm muscle area, triceps skinfold, and clinical impression. Twenty-two of 27 patients (14 men and 8 women, mean age 43 +/- 15 years, time on dialysis 65 +/- 49 months) were classified as moderately or severely malnourished and were supplemented for 6 months with 100 g of glucose polymers per day (equivalent to 380 kcal or 1590 kJ) added to the usual food intake. The patients were reevaluated at 3 and 6 months. RESULTS: Only body weight, body mass index, triceps skinfold, and brachial circumference and clinical impression increased significantly at the end of the third month (P < .05) in the 22 patients. These results were confirmed at 6 months in 18 patients that completed the study. Mean body weight increase was 2.4 kg (range, .2 to 6.3 kg). The nutritional status, evaluated through the score, improved in only 4 patients at the end of the study. Few gastrointestinal side effects were observed. Triglycerides increased from 136 +/- 40 mg/dL to 235 +/- 120 mg/dL. Follow-up of the patients showed that fat mass (assessed by anthropometry) was maintained for 6 months after supplementation was discontinued. CONCLUSION: Energy supplementation alone in patients with moderate and severe malnutrition on chronic hemodialysis resulted in an increase in body weight, owing to an increase in body fat, but the nutritional status did not improve.     

Sudden incapacitation: USAF experience, 1970-80

During the period 1970-80, there were reported 146 cases of in-flight sudden incapacitation in the USAF. Of these, 62 involved pilots, 14 were navigators, and 70 were student pilots. The etiologies of sudden incapacitation included illness without loss of consciousness, loss of consciousness, spatial disorientation, and improper M-1 maneuver. Each of these categories is analyzed with emphasis upon prevention, for example, not flying with symptomatic preexisting disease, continued emphasis upon spatial disorientation training, and correct performance of the M-1 maneuver. Based upon the data, conclusions and recommendations are suggested to minimize the risk of episodes of in-flight sudden incapacitation.     

The fabricated radial forearm flap in pharyngolaryngeal surgery: saliva leakage and its prevention

Reconstruction of the circular pharyngo-oesophageal defect continues to represent a formidable challenge for the head and neck surgeon. The fabricated radial forearm flap can provide thin and pliable skin and has potential in this one-stage reconstructive surgery. However, major problems with this technique are saliva leakage, fistula formation and stricture of the oesophageal anastomosis. Our experience with this flap for 11 pharyngo-oesophageal reconstructions has given us a better understanding of how to prevent these complications. Fistula formation and stricture were problems in our first two cases. With the 9 following cases, prevention of these complications was achieved by positioning the T-shaped suture lines of the tubed flap posteriorly. Our results suggest that adequate protection of the T-shaped suture lines during fabrication and anastomosis of the forearm flap is important in the prevention of saliva leakage.     

Gastric cancer with obstructive uropathy: clinical experience with 17 cases

In Tunisia a growing extension of chronic diseases has resulted from the environmental and behavioral changes such as the adoption of new dietary habits, sedentarity habitat, stress of urbanization and work conditions. To illustrate this trend, we undertook a household epidemiologic survey of a representative sample of the adult urban population of Soussa (n = 957) to assess the main cardiovascular risk factors except the lipid profile distribution. This study showed a high prevalence of hypertension (> 160/95 mm Hg): 18.8% with an adjusted rate of 15.6%. History of diabetes 10.2%, obesity (BMI > 30) 27.7% significantly higher in women (34.4%), android obesity 36%, smoking habits 21.5% significantly higher in men (61.4%). With this risk factor profile, Tunisia has to implement a national strategy of primary prevention and heart health promotion in addition to the efforts recently made in secondary prevention of some chronic diseases such as hypertension and diabetes.