The role of the fibula head flap for joint reconstruction after osteoarticular resections.

INTRODUCTION AND AIM: Endoprosthetic reconstruction is considered the mainstay of limb salvage in periarticular bone tumours. However, this procedure has limited durability especially when performed in young patients. The free fibula head flap including the proximal articular surface represents one option for hemiarthroplasty reconstruction. The aim of this study was to investigate the role of the fibula head flap for joint reconstruction after osteoarticular resections. PATIENTS AND METHODS: All patients who underwent hemiarthroplasty procedures between 2000 and 2006 using the free fibula head flap were included in the study. Functional assessments were performed using the American Musculoskeletal Tumor Society (AMTS) classification. RESULTS: There were five males and two females (mean age: 22.6 ± 15.9 years). Five patients underwent reconstruction following resection of malignant bone tumours and two for chronic osteomyelitis of the distal humerus. In three patients, the fibula was used for distal radius and wrist joint reconstruction, and the remaining four patients for reconstruction of the distal humerus and elbow joint. A vascularised growth plate transfer based on the lateral geniculate vessels was performed in two patients. Atechnetium-bone scan confirmed viability of all flaps 10 days after surgery, and radiographic bony union was confirmed on average 5 months following surgery. There were no complications with the recipient or donor site after a median follow-up of 71 months (range: 12 months to 10 years). All patients achieved reasonable return of function and were able to perform all activities of daily living. CONCLUSIONS: We demonstrate that the hemiarthroplasty procedure using the free fibula flap with its proximal head is a safe procedure with good functional results. Performing autologous arthroplasty using a free fibula head flap may be a promising alternative to an endoprosthesis or alloplastic reconstruction with a low risk of complications and morbidity.

Ceftobiprole medocaril is an effective treatment against methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis in a rat model.

Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after median sternotomy is a major complication of cardiac surgery with significant morbidity and mortality rates. We evaluated the efficacy of ceftobiprole medocaril in a new rat model of mediastinitis and compared it to vancomycin. The model was induced in 92 rats. Infection was induced immediately after median sternotomy by the injection of MRSA (strain 3020, 1 × 10(7) cfu/rat) into the sternal bone. After 24 h, rats (groups of 6-8) were treated intraperitoneally for 5 days or 14 days by either: (i) saline (control, q8h), (ii) ceftobiprole medocaril (70 or 100 mg/kg, q8h), or (iii) vancomycin (50 mg/kg, q12h). Efficacy was determined by a reduction in bacterial cfu in the sternum and spleen tissues. Comparisons were performed using the Mann-Whitney test. A 5-day treatment course of ceftobiprole at both doses tested lead to a significant reduction in MRSA load in the sternum (p < 0.01) as compared to the control group and compared to 5-day vancomycin treatment, which lead to a non-significant reduction (p = 0.07). Longer treatment (14 days) with ceftobiprole lead to a complete clearance of MRSA from the sternum, similarly to vancomycin. Ceftobiprole also showed a significant effect on eliminating MRSA dissemination to the spleen compared to saline-treated rats. Ceftobiprole was effective in treating MRSA mediastinitis in the rat model. In the 5-day course, ceftobiprole showed a significant reduction in sternal MRSA counts and was superior to vancomycin. After 14 days, both ceftobiprole and vancomycin showed clearance of MRSA from the sternum in more than 50 % of rats and almost complete clearance in the remainder.

Wound 'dechronification' with negatively-charged polystyrene microspheres: a double-blind RCT.

OBJECTIVE: To compare the efficacy and safety of negatively-charged polystyrene microspheres (NCM)with controls (saline soaks) in the treatment of hard-to-heal wounds of various aetiologies. METHOD: Patients with one or more hard-to-heal wounds, defined as refractory to healing for at least 4 weeks, or those with exposed bone, tendon or ligament, were eligible for inclusion and were randomised to either NCM (PolyHeal; MediWound Ltd.) or controls, both applied twice daily for 4 weeks. Patients were monitored bi-weekly for an additional 8 weeks, while treated by standard wound care, at the investigators' discretion, and were re-evaluated 2 years after inclusion. The primary endpoint was defined as coverage of> 75% of the wound area by light-red granulation tissue after 4 weeks of treatment. RESULTS: Fifty-eight patients completed the study, 32 in the NCM group and 26 in the control group. The two most common wound types were those with primary etiologies of venous insufficiency and postoperative/post trauma. In the NCM group 47% of patients achieved > 75% light red granulation tissue after 4 weeks compared with 15% of patients in the control group (p=O.O I). The mean wound surface area in the NCM group was reduced by 39.0% after 4 weeks compared with 14.9% in the control group (p=0.02).The achievement of> 75% light red granulation tissue and reduction of mean wound surface area was also observed in the two main sub-groups (venous insufficiency and postoperative/post trauma), although it was not statistically significant, possibly due to the small sample size in each sub-group. CONCLUSION: This study demonstrates that compared to control treatment, NCM treatment of hard to-heal and chronic wounds improves formation of healthy granulation tissue and reduces wound size thus in fact 'kick-starting' the healing process and 'dechronifying' chronic wounds.

Detection of cancer cells in the axillary drainage using RT-PCR after operations for breast cancer.

The object of this study was to examine whether MUC-1 can be detected in the axillary lymphatic drainage of patients who have undergone conservative surgery for breast cancer and to assess the correlations between the presence of MUC-1 and prognostic factors in breast cancer. Sixty-eight women with invasive ductal carcinoma of the breast underwent wide local excision and axillary lymph node dissection. Axillary drains were inserted in all these cases, and the presence of MUC-1 and beta-actin was evaluated by RT-PCR in the lymphatic fluid collected after the operation. Prognostic factors included tumour size and grade, vascular and lymphatic invasion, clearance margins of the resected specimens and status of the axillary lymph nodes. RT-PCR assays for MUC-1 in the axillary fluid were positive in 17 patients (25%). The presence of MUC-1 was associated with increased tumour size and showed a positive correlation with axillary lymph node metastases and incomplete resection of the tumour. RT-PCR can disclose cancer cells in the axillary fluid after conservative surgery for breast cancer. The presence of MUC-1 in the axillary drainage may be associated with poor prognostic features, and its detection may have implications for therapy as it suggests that re-excision should be considered.

Walk-through injuries: glass door facial injuries.

During 1998, 13 patients were treated in the Tel-Aviv Sourasky Medical Center for complex facial soft-tissue injuries caused by passing through large, clear glass doors. All epidemiological details were gathered and analyzed. Of 1,100 soft-tissue facial injury admissions in 1 year, 13 patients had a substantial soft-tissue facial injury after passing through a glass barrier. Nine were injured during leisure time activity, five in a shopping mall, and four in their residence. Interestingly, the authors found a common pattern of facial injuries in all patients. It consisted of large, irregular, composite skin and soft-tissue flaps as well as large, tom, irregular skin lacerations. The nose was injured predominantly, and the injury was particularly complex. Their recommended management of these injuries is a thorough and careful evaluation of flap viability. Surgical management of avulsed, viable flaps includes margin debridement and repositioning. If the flap is narrow enough, it can be debrided and the margins adapted primarily. If viability of part of the flap is in doubt, that part should be debrided and used as a composite graft. When this graft dies, a full-thickness graft is taken from another facial site. The cosmesis of such a graft is better than using the debrided, thin segment as a skin graft that is too thin. The authors emphasize that there is a need to encourage authorities to reinforce regulations relating to injury prevention from architectural glass. The first is to use special glazing, either tempered glass, laminated glass, or both. The other method of improving safety is by indicating glass using decorations or warning stickers, or by making it partly translucent. Unless these regulations are obeyed, fatal or complex trauma may occur.

Abdominal recovery after laparotomy and omental transposition into a grossly contaminated median sternotomy wound.

Grossly contaminated median sternotomy wounds are frequently treated with transposed omental flaps. A laparotomy adjacent to such an infected wound carries the risk of peritonitis. It has been suggested that this risk may increase when the omentum, which has anti-infective properties, is removed from the abdominal cavity and is transposed to the chest. The authors evaluated abdominal recovery after laparotomy and omental transposition into an adjacent, grossly contaminated median sternotomy wound. The study group included 15 patients who had sternal wound reconstruction with an omental flap between 1990 and 1998. All patients underwent median sternotomy reconstruction according to a "two-compartment" operative sequence protocol, which included division of the surgical field into an upper (thoracic) contaminated zone and a lower (abdominal) clean zone. The control group was comprised of 15 patients who underwent elective laparotomy for splenectomy during the same time period. The effect of the surgical procedure on the abdomen was compared between the two groups. The timing of the reappearance of peristalsis and regular bowel function, and the incidence of bowel obstruction and postoperative peritonitis were similar in the two groups. The findings indicate that laparotomy and omental transposition in the presence of a grossly contaminated median sternotomy wound is a safe procedure, and is associated with a low rate of abdominal complications.

Retinal lesions in septicemia.

We explored the association between septicemia and specific retinal lesions in a prospective controlled study. Hemorrhages, cotton-wool spots, or Roth's spots were found in 24 of 101 septicemic patients (24%), compared to four of 99 age- and gender-matched control patients (4%) (P = .0002). There was no significant association between types of organisms or focus of infection and the presence of specific lesions. Histologic examination of affected eyes disclosed cytoid bodies in the nerve fiber layer without inflammation. A definite association between septicemia and retinal lesions was found and indicates the need for routine ophthalmoscopy in septicemic patients.