Validation of the heat treatment step used in the production of diaspirin crosslinked hemoglobin (DCLHb) for viral inactivation--effect of crosslinking

During the years 1979-81, three different surgical techniques were used in the treatment of 87 ears with extensive cholesteatoma. All procedures were performed in one stage by the same surgeon. Ten to 13 years after the operations about 70 per cent of ears operated on by the canal wall up technique had developed a new cholesteatoma, which in most cases was recurrent, or a deep retraction pocket. A modification of this technique with mastoid obliteration resulted in a similar failure rate. In contrast, ears operated on by the canal wall down technique (in most cases with mastoid obliteration) had acceptable stability with a long-term recurrence rate of about 15 per cent. Most patients in the canal wall down group had a dry ear without significant cavity problems. Hearing in these patients was as least as good as hearing in patients with a preserved canal wall. We conclude that a meticulous one-stage canal wall down technique in ears with extensive cholesteatoma results in a high percentage of unproblematic, stable ears with satisfactory function. In contrast, if the posterior canal wall is preserved, recurrent cholestealoma is the rule more than the exception.     

5-year series of constricted (lop and cup) ear corrections: development of the mastoid hitch as an adjunctive technique

Despite the multitude of corrective procedures described, adequate surgical correction of the congenital constricted ear remains a challenge. The maintenance of the shape and elevation of the reconstructed upper neohelix poses a particular problem. In the present series, experiences with lop ear correction utilizing standard techniques and the use of the mastoid hitch as a useful adjunct to these procedures are described. A total of 19 ears were reconstructed. There were three type 1, eight type 2a, seven type 2b, and one type 3 deformities (Tanzer classification). A graded sequence of procedures was adopted. Mild deformities were corrected by cartilage scoring techniques; a V-Y advancement of the helical root was added for moderate deformities. Cartilage expansion by a banner flap was required for more severe deformities. A mastoid hitch, whereby the refashioned upper neohelix is sutured to the mastoid fascia, should be used as an adjunct to these procedures to maintain helical elevation and prevent recurrence. Severe type 3 deformities may require autologous auricular reconstruction. Mean follow-up time was 1 year. There were six excellent, seven good, four fair, and two poor results. Two patients who had not had mastoid hitch procedures developed a recurrence of the lop deformity. Adequate surgical correction of constricted ear deformities requires a variety of surgical techniques. The mastoid hitch being used for constricted ear correction has not been described elsewhere. The mastoid hitch is a useful adjunctive procedure that may be used effectively in combination with other procedures.     

Results of three different stapedectomy techniques: a comparative study]

We perform a comparative study on the results obtained through three stapedectomy techniques. The hearing gain was evaluated in 107 ears with total footplate removal, Shea prosthesis and connective tissue graft, in 81 ears with particular footplate removal, the same prosthesis, and no tissue graft, and in 66 ears with stapedectomy. The differences between the three groups in the air-bone gap closure or postoperative complications were not statistically significant. We conclude that results depend more on the surgeon than on the technique.     

Cholesteatoma surgery today

Four present-day surgical techniques are reviewed to assess their respective merits in surgery for cholesteatoma. The oldest method with an open cavity in ears with mastoid extension of cholesteatoma if combined with partial obliteration is still suitable for less experienced surgeons. Transcanal atticotympanotomy is suitable for limited epitympanic and tympanic cholesteatomas as long as it provides a direct view of the operative field. In similar ears, canal wall up surgery is employed if, additionally, mastoidectomy is needed because of chronic inflammation. Canal wall down surgery with full cavity obliteration with a musculoperiosteal flap, bone chips and bone pate should be the method of choice for all cholesteatomas extending beyond the facial nerve canal. The canal skin is kept as an intact tube and provides quick healing. Open cavities should be revised using similar obliteration techniques but, because of the lack of an intact canal skin tube, making use of a large modified K?rner skin flap.     

Combined tibio-talar and subtalar arthrodesis by retrograde nail in hindfoot rheumatoid arthritis

PURPOSE OF THE STUDY: Many techniques for ankle arthrodesis have been described. Some are not applicable to patients with severe rheumatoid arthritis (RA) because of osteopenia and deformities. This study describes a new surgical technique for arthrodesis in painful valgus deformity of the hind-foot in advanced rheumatoid arthritis (RA) with severe osteopenia. MATERIALS: The present series included 9 patients. Eleven talocrural and talocalcaneal arthrodeses were performed for degenerative changes secondary to RA involving hind-foot joints. All patients were reviewed after an average follow-up of 6 years. Mean duration of RA was 34 years. All patients had severe osteopenia, including major deformations of the hind-foot in 5 cases. METHODS: After removal of talocrural and talocalcaneal articular surfaces using an anterolateral approach, deformities were corrected by removal of an appropriate bone wedge. A Küntscher nail was then positioned in the calcaneal plantar cortical through the plantar surface of the foot and driven proximally into the medullary canal of the tibia through the talus. This nail allowed both deformity correction and fixation. Aftercare required immobilization in a short leg cast. Weight bearing was allowed with the cast approximately 5 weeks after surgery. The ankle was immobilized for 7.5 weeks. DISCUSSION: Results showed a 80 per cent fusion rate. Two non-unions occurred (one recurrence of valgus deformity after early nail migration requiring removal of the nail; and the other asymptomatic). A complication occurred in one foot (delayed healing). At follow-up, all patients but one were satisfied with respect to pain relief and residual deformities. Our results are comparable with those of other series and should be considered in the context of severe RA. CONCLUSION: This technique of vertical retrograde transarticular nailing allows an easy control of hind-foot deformities correction. Other techniques are preferable in case of solid bone. This technique is an acceptable alternative in advanced RA.     

Analysis of in vitro reaction layers formed on Bioglass using thin-film X-ray diffraction and ATR-FTIR microspectroscopy

We describe a technique for earlobe construction using the V-shaped flap with rotation and transposition techniques. This technique produces a natural appearing lobule without unpleasant secondary deformity. This method has been used on two patients, with very good results.     

Surgical correction of spastic thumb-in-palm deformity

A series of 31 operations on 27 patients for correction of the spastic thumb-in-palm deformity is reported. 19 patients were followed four years or longer post-operatively; the remainder have been followed for at least one year. In approximately 70 per cent of the operations, supplementary procedures were performed on the hand or forearm, as the deformity is usually only one facet of a complex spastic disability of the upper extremity. The surgical technique and illustrative cases are presented. Augmentation of a markedly weak extensor-abductor motor function is necessary, otherwise the spastic thumb-in-palm deformity will recur, as in two cases in the present series which required a second operation. The remainder of the patients were classified as improved, indicating that the thumb was no longer clenched in the palm, could be used in gross grasping activities, and the hand had become more useful. In no instance did the spastic hand become the primary functioning hand post-operatively.     

External cantilever sling in septorhinoplasty: a new technique

Development of mucoperichondrial and mucoperiosteal flaps bilaterally, total removal of the deviated septum, straightening it outside, followed by replacement as a free graft constitute an option in treatment of the severely deviated nose. Positioning and stabilization of the septum in this technique may prove insufficient in the majority of septorhinoplasty patients in whom both nasal bones are also immobilized. Positioning and stabilization can be achieved adequately by the use of the presented technique that involves passing a 3-0 nylon suture to suspend the cartilage replant to a plastic splint applied to the dorsum of the nose, one-third of which is taped over the realigned nasal bones. In the past 5 years, 45 patients have undergone septorhinoplasty using this technique. The minimum follow-up period was 6 months. No patient developed any major complications. Secondary correction was necessary to improve the aesthetic result in only one patient. The results in patients who underwent this surgical procedure suggest that the presented technique provides excellent results in severely deviated noses associated with major deviations of the septum but must be limited only to those whose deformity is so severe that other techniques will be insufficient to obtain the desired result.     

Deformity correction and arthrodesis of the midfoot with a medial plate

Nine feet in eight patients undergoing tarsometatarsal (Lisfranc) or other midfoot arthrodeses for posttraumatic or degenerative arthritis were reviewed retrospectively. All patients were treated using a medial one-third tubular plate spanning the midfoot joints to be fused. Three feet underwent fusion in situ while six feet underwent correction of residual planus, planovalgus, or cavovarus deformity at the time of fusion. All patients achieved fusion within 12 weeks. A good or excellent result was achieved in seven of nine feet. There was no radiographic or clinical evidence of pseudarthrosis or medial hardware failure in any patient. No patient to date has required hardware removal for a painful or prominent implant. The talus first metatarsal angle was improved an average of 15.5 degrees in the lateral plane and 10 degrees in the AP plane in patients undergoing deformity correction. The technique of using a medial plate for midfoot arthrodesis allows for reliable fusion in patients who require salvage for midfoot arthritis. This technique also allows for correction of deformity in patients with residual midfoot deformity.     

Removal and reinsertion of cemented femoral components during acetabular revision

The Mayo block is an extremely efficacious regional anesthetic technique used to provide anesthesia of the forefoot. Patients requiring surgical correction of hallux deformity, bunionectomy, and first metatarsal surgery may benefit from this technique. The Mayo block is a field block that anesthetizes the specific nerves of the forefoot that innervate the surgical field. This technique requires less local anesthesia than that required by direct local anesthetic infiltration and does not distort the surgical tissue planes. The Mayo block is effective. This technique has been used at one military hospital on more than 275 patients. The failure rate of the block is less than 1%. Learning this technique adds to the anesthetist's armamentarium of regional anesthesia, aids in rapid case turnover, and avoids the risks associated with major conduction and general anesthesia.     

Facial growth and the need for orthognathic surgery after cleft palate repair: literature review and report of 28 cases

PURPOSE: Controversy still exists regarding the optimal timing and surgical technique for primary cleft lip and palate (CLP) repair, and treatment protocols vary considerably. This study reviews the literature on timing and technique for primary repair and reports on the outcome for a consecutive group of patients treated by a single surgical protocol at the Sunnyview Cleft Palate Clinic. PATIENTS AND METHODS: Twenty-eight patients treated by a standardized clinical protocol from infancy through adolescence were evaluated with respect to the need for orthognathic surgery to correct jaw size discrepancy. For each patient, data was collected regarding type of cleft deformity, total number of surgical procedures from infancy, surgeon performing the primary repair, and the need or indication for orthognathic surgery. RESULTS: Twenty-five percent of patients treated by this protocol required orthognathic surgery because of anteroposterior jaw size discrepancy. The number of prior operations was not a significant factor. The need for orthognathic surgery was seen in all types of CLP deformity. Different primary surgeons varied considerably in the percentage of their patients who ultimately required orthognathic surgery. CONCLUSION: The results of this study parallel other larger cohort studies with respect to the percentage of patients requiring orthognathic surgery. The number of prior operations does not significantly affect the later need for orthognathic surgery.     

Frontofacial osteotomies, advancement, and remodeling by distraction: an extended application of the technique

The purpose of this clinical report is to present the distraction technique for advancement of the frontofacial skeleton as a unit. Our 14-year-old patient was diagnosed with Carpenter's syndrome and kleblattsch?del deformity at birth. At other centers the patient underwent corrective surgeries, including repeated fronto-orbital advancement in an attempt to correct the residual deformity. This has resulted in bony malunion and recurrent deformity, and it has left the patient with no available donor sites for harvesting of bone graft. The patient had class III malocclusion, severe midfacial and frontal deficiency, and relative turricephaly. We performed frontofacial osteotomies and placement of the distraction devices. Distraction of 20 mm was accomplished, correcting the exophthalmos and midface retrusion and producing class I dental occlusion. We conclude that distraction is an optional surgical method that can be applied in selected cases for advancement of the entire frontofacial skeleton.     

Effect of flavin coenzymes on the pyridoxine treatment of avitaminosis B6

In the treatment of Sprengel's deformity, extraperiosteal greenstick fracture of the clavicle in conjunction with surgical release of all attachments between the scapula and the spine provides an easy, safe method of relocating the scapula to its normal level. The improved position is maintained by temporary fixation of the inferior border of the scapula to the eighth rib with slowly resorbable sutures. Section of the coracoclavicular ligaments, excision of the superior pole of the scapula, and suture fixation of the medial angle of the scapula to the spinous process of the fourth vertebra enables the procedure to be performed on patients until the age of puberty. This surgical technique has been performed in 28 consecutive patients with Sprengel's deformity, aged 4 to 19 years, without any neurovascular complications. A normal scapular position was achieved in 67% of cases, 1 to 2 cm elevation in 29%, and 5 cm in 4%.     

The expression of regenerative growth factors in chronic liver injury and repair

The outcomes of surgical reconstruction for patients who have undergone extensive tumor resection of the mandible and associated soft tissue have been less than desirable for many reasons: lack of cancer cure, radiation problems, as well as inadequate functional reconstructive results. These patients traditionally have undergone multiple surgical procedures for restoration of the surgical deformity. With the advent of new donor sites and successful transfer of microvascular hard and soft tissue, one can restore the largest defects created during cancer excision. Combining these techniques with biocompatible dental implants and reconstructive bone plates, technology has advanced to the point of predictable outcomes. The restoration of appearance, mandibular function, and mastication is mandated by patients. Dental implants are now placed in vascularized bone reconstruction of the mandible immediately at the time of ablative surgery. This obviates the need for additional surgical reconstructive procedures, adjunctive hyperbaric oxygen therapy, and problems associated with the placement of dental implants in irradiated tissue.     

Application of endoscopic techniques in aesthetic plastic surgery

Although plastic surgeons had been slow to incorporate endoscopic techniques into their surgical armamentarium, there has been considerable interest in this field during the last 2 years. The aim of endoscopic brow lifting has been to achieve elevation of the brow through small scalp incisions without the associated nerve damage of the open approach and to accurately address excision of the muscles responsible for frowning. Endoscopic neck lift is a more recently pioneered technique which, although still in developmental stages, appears to provide good results. The technique involves undermining the skin of the neck extending from the chain to the jawline around the ear. Endoscopic facelifting is still very much in the experimental stages. Endoscopic techniques reduce the need for an incision in front of the ears. Using the endoscope, it has become a simple matter to perform a transaxillary breast augmentation using very small axillary incisions and precise placement of the implants. This results in excellent symmetry postoperatively and easy scar concealment. Abdominoplasty is another example of a procedure usually associated with a long incision and some degree of postoperative pain and immobility. Endoscopic abdominoplasty has been devised to provide not only contouring of abdominal fat through liposuction, but correction of the weakened abdominal muscle through a small incision placed just above the suprapubic hairline.     

Peritoneal dialysis. An adjunct to pediatric postcardiotomy fluid management

The need for structural grafting in rhinoplasty arises when the nasal skeletal framework is weakened, malpositioned, or both. This review will be limited to structural grafting of the cartilaginous nasal skeleton. Current techniques will be reviewed and a technique introduced that addresses the common deformity of a superiorly rotated and deprojected nasal tip complex while simultaneously correcting nasal valve collapse. This technique is referred to as the Dynamic Adjustable Rotational Tip (DART) technique. The operative technique of the DART, as well as the basic philosophy regarding the tensile nature of the cartilaginous nasal skeleton will be described.     

Intertrochanteric femoral osteotomy with concentric reduction of the femoral head in treatment of residual congenital acetabular dysplasia

A method of classification based upon increase of the anteversion and valgus deformity of the upper femur associated with a dysplastic acetabulum and subluxation of the femoral head demonstrates 4 main groups: I or II in patients 1 to 3 years of age; III, patients approximately 2 years of age; IV, patients with absolute contraindication for surgical intervention. The Monticelli technique employs a Kirschner wire for the internal fixation and incorporates it in a hip spica. The results of the surgical treatment are very gratifying when classification and specified indications are correct. In follow-up observations ranging from 3 to 11 years, with an average of 7 years, there were practically no complications other than a few superficial skin infections.     

Metopic synostosis: in favour of a "simplified" surgical treatment

Metopic synostosis is a relatively simple form of craniosynostosis, resulting from premature fusion of the metopic suture. In this pathology different degrees of dysmorphia of the anterior cranial fossa and the presence of associated anomalies of the skull might enable specific subgroups to be identified. Since most functional and cosmetic anomalies benefit from early surgical treatment, over the last few years neurosurgeons have been forced to elaborate less drastic, but nonetheless effective, surgical techniques. In the present report we analyze the surgical results obtained in a series of 62 infants with trigonocephaly operated on within their 1st year of life. Patients were subdivided into two groups (group I: 8 patients; group II: 54 patients) according to the specific dysmorphic characteristics of the frontal bone and anterior cranial fossa, and the presence of compensatory deformities affecting the anterior cranial base and temporo-parietal region. All the patients were treated using one of two relatively simple surgical techniques (procedure A: inversion of two hemifrontal bone flaps--48 cases; procedure B: the "shell" operation--14 cases). Both surgical procedures appeared to be effective, allowing adequate functional and cosmetic correction of the cranial deformity. In patients operated on following procedure B surgical time and blood loss were dramatically reduced. Long-term outcomes were satisfactory in all cases, irrespective of the surgical technique used. In the group II patients, however, progressive normalization of the interorbital distance was constantly observed, suggesting a different degree of stenotic involvement at the level of the anterior cranial base in these patients.     

Video-assisted thoracoscopic surgery (VATS). Endoscopic thoracoplasty technique

STUDY DESIGN: The study of two patients whose rib deformity was treated using a new endoscopic thoracoplasty technique is reported. OBJECTIVES: To report a new endoscopic thoracoplasty technique for the treatment of rib deformities associated with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Thoracoplasty has traditionally been performed as an open procedure, often necessitating additional incisions and/or tissue dissection. METHODS: Two children with significant rib humps associated with idiopathic scoliosis were treated with a new endoscopic thoracoplasty technique. RESULTS: Both children showed dramatic cosmetic improvement of their rib deformity. CONCLUSIONS: The indications for the use of video-assisted thoracoscopic surgery in the treatment of pediatric spinal deformity are expanding. We have extended our video-assisted thoracoscopic surgery repertoire to include endoscopic thoracoplasty for treatment of rib deformities associated with idiopathic scoliosis. The technique for endoscopic thoracoplasty is discussed, and illustrative cases are presented.     

Perichondritis of the ear

A total of five ears with perichondritis secondary to burns was treated using a method of excising cartilage. This treatment resulted in the need for general anesthesia, frequent repeat debridement and frequent loss of structure of the ear with subsequent deformity. The presentation, etiology, pathology and present modes of therapy are presented. Our experience stresses the importance of early recognition and treatment and further consideration for the use of drains with continuous antibiotic and proteolytic enzyme administration.