Vascular impairment and free tissue transfer in the lower extremity.

Fourteen patients with arteriosclerotic peripheral vascular disease and extensive tissue defects of the lower extremity, underwent microsurgical reconstruction using free tissue ("free flap") transfer. It was possible to provide coverage in ten of these patients. Analysis of this small series showed that only six of these ten patients were able to resume unassisted ambulation. The authors discuss technical aspects of microsurgical reconstruction in this unfavorable group of patients. Analysis of this small series suggest that: (1) inadequate patient motivation, and (2) inability to form granulation tissue in the soft tissue defect, either before or after a vascular reconstructive procedure, are both strong contraindications to microvascular free flap reconstruction in patients with arteriosclerotic peripheral vascular insufficiency of the lower extremity.

Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation.

The long-term outcomes and the quality of life were studied in patients who had had an open fracture of the tibial shaft with severe soft-tissue loss. Limb salvage with a free flap was attempted in twenty-seven patients (sixteen of whom had a successful procedure and were examined personally by us), while eighteen patients were managed concurrently with an early below-the-knee amputation. Soft-tissue coverage was successful in all but one patient in whom limb salvage had been attempted. Ultimately, however, five extremities were amputated, with an infection at the site of a non-union being the most common reason for amputation. The patients who had had limb salvage had more complications (p < 0.001), more operative procedures (p < 0.001), and a longer stay in the hospital (p < 0.05) than the patients who had had an early below-the-knee amputation. The long-term functional results for sixteen patients who had had a successful limb-salvage procedure (average duration of follow-up, thirty-five months) were compared with those for eighteen patients who had had a below-the-knee amputation (average duration of follow-up, forty-four months). The patients who had had a successful limb-salvage procedure took significantly more time to achieve full weight-bearing (p < 0.05), were less willing or able to work (p < 0.01), and had higher hospital charges (p < 0.006) than the patients who had been managed with an early below-the-knee amputation. They also had a significant decrease in motion at the ankle and subtalar joint in the injured leg compared with the contralateral leg (p < 0.001). A quality-of-life evaluation was possible for only thirteen of the patients who had had a successful limb-salvage procedure and for sixteen of the patients who had had a below-the-knee amputation. The two groups were similar in terms of their responses, but significantly more patients who had had limb salvage considered themselves severely disabled (p < 0.05). They also had more problems with the performance of occupational and recreational activities (p < 0.05). This study confirmed the reliability of modern microvascular free tissue techniques for the coverage of large soft-tissue defects associated with tibial fractures. It also showed that complications and difficulties in the restoration of osseous union are common and may be directly related to the less satisfactory functional, occupational, recreational, and quality-of-life outcomes that are seen in many patients who have had limb salvage.(ABSTRACT TRUNCATED AT 400 WORDS)

Concurrent radiation therapy, 5-fluorouracil, and cisplatin for stage II, III, and IV, node-negative, squamous cell head and neck cancer. Results and surgical implications.

METHODS: Between 1983 and 1989, 42 patients with Stage II, III, and IV, node-negative, squamous cell head and neck cancer were treated with concurrent 5-fluorouracil, cisplatin, and radiation therapy. Two courses of chemotherapy with 30 Gy of concurrent radiation therapy were to be followed in all patients by definitive surgery and then an additional 30 Gy of radiation therapy and one to two courses of chemotherapy. The patients who achieved a complete response to the initial induction treatment, however, did not undergo surgery. RESULTS: After the completion of all therapy, 41 of the 42 patients (98%) were considered disease-free. Only 4 of these 41 had relapses, for a projected Kaplan-Meier disease-free survival rate of 86%. Treatment failure occurred in no patients with Stage II, 1 of 17 patients with Stage III, and 4 of 14 patients with Stage IV disease. Of the 42 patients, 23 (55%) did not require surgery after achieving a complete response to induction therapy, and only 1 of these 23 patients subsequently had a relapse. CONCLUSIONS: Although the value of adding chemotherapy to conventional treatment remains unproven in squamous cell head and neck cancer, this treatment schedule appears promising in node-negative disease. Randomized trials will be necessary, however, to validate the efficacy of this approach and confirm the suggestion by the authors that surgery can be avoided in most patients with N0 disease.

Vein grafts in reconstructive microsurgery of the lower extremity.

This paper describes surgical techniques and results of lower extremity microsurgical reconstruction using vein grafts. During a 5 year period, free tissue transfers were used to reconstruct 118 lower extremity defects in 109 patients. In 28 of these cases (24%), saphenous vein grafts were used when reconstruction would otherwise have been difficult or impossible. A preliminary arteriovenous fistula was established between the proximal arterial source and the final venous drainage in the majority (26) of cases. Venous drainage was left intact at the point of entry into the deep venous system in 23 cases. Three complications included anastomotic clotting in 2 patients and postoperative blow-out of the vein graft in another; all were treated without flap loss. Flap survival was 86% in vein grafted patients and 94% in those cases in which vein grafts were not used. Flap loss was related in each case to the nature of the pre-existing condition, rather than to vein grafting per se.

Long-term results after chemoradiotherapy for locally confined squamous-cell head and neck cancer.

The long-term results after simultaneous chemoradiotherapy in 54 patients with previously untreated or minimally treated, locally confined (M0) squamous-cell carcinoma of the head and neck are presented. Multiple concurrent courses of radiation therapy and chemotherapy with cisplatin and a four-day 5-fluorouracil infusion were given. Twenty-eight patients underwent definitive surgery and 26 were treated without surgical resection. Treatment-associated toxicity was significant, including mucositis, myelosuppression, and a mean 12% loss of initial body weight. Of the 54 patients, 51 were ultimately rendered disease free by this combined modality protocol. With a follow-up ranging from 42-68 months, the projected Kaplan-Meier relapse-free survival for the entire patient cohort is 70%, with all relapses occurring within 17 months of patient entry. The projected Kaplan-Meier relapse-free survival for patients with Stage IV disease is 62%. The durability of these remissions suggests that there is a significant likelihood of cure in all patients with locally confined disease, and justifies comparative trials with standard treatment.

Long saphenous vein grafts as an aid to microsurgical reconstruction of the trunk.

The authors describe a method of closing truncal defects using free-tissue transfer when neither local tissue or vascular access are available. The long saphenous vein is dissected free as far distally as necessary and turned up, leaving its upper drainage intact. The distal end is then anastomosed to the femoral artery to create a temporary arteriovenous loop. After placing an appropriate free flap in the defect, the A-V loop is divided and used to provide both arterial supply and venous drainage for the flap. Anatomy, technique, and representative cases in which this method has been used for closing traumatic tissue defects of the trunk are presented and discussed.

Treatment of oral squamous cell carcinoma with simultaneous chemotherapy and radiation: results and surgical implications.

Thirty-seven patients with oral squamous cell carcinoma, many with advanced disease, were treated initially with a protocol using simultaneous intravenous 5-fluorouracil (5-FU) cis-platinum, and radiation. Twenty-two patients (62%) experienced complete remission after one cycle of therapy. Fifteen patients (38%) demonstrated an incomplete response; surgical resection was possible in 14 of these 15 patients. A second cycle of chemoradiotherapy was administered to all 37 patients. After this treatment resection is possible for some patients who are initially inoperable, and surgery is necessary only for those patients (38%) who show an incomplete remission after the first cycle of therapy and for those who present initially with bony invasion. Furthermore, the treatment of cervical nodes and intraoral disease may be divorced and the extent of surgery may be reduced for many patients. A 5-year survival of 76% is predicted for this group of patients. The described protocol shows promise for treatment of oral squamous cell carcinoma.

Simultaneous versus sequential combined technique therapy for squamous cell head and neck cancer.

Forty-eight patients with locally confined (M0) squamous cell head and neck cancer were prospectively randomized to receive either simultaneous (SIM) or sequential (SEQ) combined technique therapy with a 5-fluorouracil infusion, a cisplatin bolus injection, and radiation therapy. Patients with residual resectable disease underwent surgery after induction therapy, whereas those achieving a complete response to induction did not require surgery. Patients on the two treatment arms were equivalent in all measured variables, including disease extent. Toxicities of the SIM and SEQ arms also were equivalent except for mucositis and the resultant weight loss, which were more severe on the SIM arm (P = 0.002). With a follow-up time ranging from 9 to 41 months, seven of the 24 SIM patients and 14 of the 24 SEQ patients are considered treatment failures. The relapse-free survival is significantly better on the SIM arm (P = 0.03), although an overall survival advantage has not yet been demonstrated (P = 0.13). The achievement of a complete response after induction therapy correlates with both the relapse-free (P = 0.0005) and overall (P = 0.05) survival, and the likelihood of an induction complete response also is significantly better for those treated with the SIM schedule (P = 0.02). Eighteen patients did not require surgery after achieving an induction complete response. Relapse-free survival does not appear to be compromised in this patient subset.

Oral squamous cell carcinoma in children.

Squamous cell carcinoma of the oral cavity occurs very rarely in children and is particularly rare during the first decade of life. This article describes a case of squamous cell carcinoma of the maxillary alveolar ridge in a 7-year-old child. Subtotal maxillectomy was carried out with an apparent cure (33-month follow-up). A brief review of this disease as it occurs in children is included. Although this is an aggressive neoplasm, early and adequate surgical intervention may be curative.

Short saphenous vein grafts as an aid to microsurgical reconstruction of the lower extremity.

The authors present a method of free flap reconstruction using the short saphenous vein, when local vessels are not available in the lower extremity. Initially, a temporary arteriovenous fistula is created. This is subsequently divided to provide both arterial access and venous drainage for the flap. The use of the short saphenous vein has a number of advantages: 1) forty to 50 cm of length are available; 2) the vein is relatively thin-walled and has a nearly constant diameter throughout its length; 3) the vein may be left in situ at its upper end in some patients; 4) the vein drains into both the long saphenous and the popliteal veins. Thus, double drainage is provided. This may be of importance in patients with impaired outflow secondary to deep venous thrombosis or obstruction. 5) The separated vein graft components allow accurate ultrasonic monitoring of both arterial and venous circulation. Seven cases are presented of type IIIb and IIIc tibial fractures in which regional vessels were not accessible. Free flap reconstruction using in situ short saphenous vein grafts was successful in all seven patients. The anatomy of the short saphenous vein and surgical technique are considered.

Simultaneous radiotherapy and chemotherapy with 5-fluorouracil and cisplatin for locally confined squamous cell head and neck cancer.

Fifty-four patients with previously untreated or minimally treated locally confined (MO) squamous cell carcinoma of the head and neck were treated with chemoradiotherapy employing multiple courses of simultaneous radiation, cisplatin, and a 4-day 5-fluorouracil infusion. Twenty-eight patients subsequently underwent definitive surgery, and 26 were treated without surgical resection. Of the 54 patients, 51 were ultimately rendered disease free by this combined modality protocol. The projected relapse-free survival rate for the entire cohort is 71%, with a median relapse-free survival time greater than 17 months. Thirteen patients who had tumors that were technically operable did not undergo surgery after achieving a complete response to induction chemoradiotherapy. Only 1 of these patients experienced subsequent local failure. Although the treatment-associated mucositis and local failure. Although the treatment-associated mucositis and myelosuppression were significant, this chemoradiotherapeutic protocol offers a significant chance of relapse-free survival for all patients with locally confined disease and merits comparison with more standard treatment approaches.

Beyond replantation: microsurgical salvage of complex hand injuries.

The authors believe that certain complex hand injuries so severe as to be considered for amputation or simple proximal revision, may under some circumstances be salvaged with the use of appropriate microsurgical techniques. They present three examples of severely injured hands to illustrate the reconstructive potential of microsurgery. Salvage techniques are considered in some detail including debridement, evaluation and planning, fixation, restoration of circulation, reconstruction of tendons, joints and nerves, and provision of coverage. The importance of vein grafts for successful salvage of complex hand injuries is emphasized.

Chemoradiotherapy as initial management in patients with squamous cell carcinoma of the head and neck.

Thirty-nine previously untreated or minimally treated patients with squamous cell carcinoma of the head and neck were entered onto a chemoradiotherapy protocol employing multiple courses of simultaneous radiation therapy, cisplatin, and a 4-day 5-FU infusion. Thirty-eight patients were evaluable for response and toxicity. Twenty-three patients underwent surgical resection midway through this therapy and 11 (48%) were pathologically free of disease. Thirty-five of the 38 patients (92%) were ultimately rendered disease-free by this combined modality protocol. Thirty-one patients remain disease-free, with a projected 2-year disease-free survival of 74%. Although the treatment-associated mucositis and myelo-suppression were significant, this chemoradiotherapeutic approach is promising and merits further study.

Avulsion injuries of the thumb.

Similar findings in a series of seven avulsions of the thumb suggest that this injury is a well-defined entity. In all cases avulsion was the result of catching the digit in a rotating machine. In most cases a glove was worn. The usual clinical findings included extrinsic tendon avulsion from the forearm, nerve avulsion from the median nerve within the carpal tunnel, extensive arterial damage in the amputated thumb, and partial degloving of soft tissues. Successful replantation was possible in every case. We believe that vein grafts should be used routinely, anastomosed to normal distal vessels. The site of nerve injury should be identified by dissection of the median nerve within the carpal tunnel. Retrograde flaps should not be sutured for wound closure. We believe that replantation should be attempted in all cases of thumb amputation in which the part is available.

A palmar cross-finger flap for coverage of thumb defects.

We have devised a method of covering tissue defects of the distal thumb using a flap elevated between the two flexion creases on the palmar skin over the proximal phalanx of the long finger. The advantages of this method over the usual dorsally based, distal, cross-finger flap include improved appearance of the donor finger, comfortable positioning, and avoidance of joint contractures. Although sensitivity of the palmar scar, contractures, or other disadvantages of this approach were sought during follow-up, none were found.

Regional anesthesia in the upper extremity.

We have attempted to formulate a guide for surgeons who operate frequently on the hand and upper extremity and who wish to learn how to provide their own local anesthesia. The methods that we have presented are those that work well in our hands and are in frequent use in our practices. We recognize very clearly that there are other methods and that these work well for other surgeons. The method itself is not of great importance (given that it is safe and effective), but the philosophy of learning is. By observation and by practice, the surgeon will gain further mastery of his specialty; we feel strongly that local anesthesia is as much or more a part of surgery than it is of any other specialty. Reading and observation are important. Dissection, whether in the operating room as part of a surgical procedure or in the anatomy laboratory or morgue, is of great benefit in learning the whereabouts and relationships of the nerves that are to be blocked. In the end, however, the surgeon simply must try the various blocks himself on his own patients. Failure is not a calamity; we have tried to emphasize that there are ways to recover with a reasonable degree of grace. The worst calamity is not to learn, not become facile with techniques that are so ideally suited to surgery in the upper extremity.

Combination chemotherapy prior to definitive local therapy in squamous cell carcinoma of the head and neck.

30 patients with locally advanced squamous cell carcinoma of the head and neck were given chemotherapy with methotrexate, bleomycin and cis-Platinum prior to planned definitive surgery and/or radiation therapy. Chemotherapy was well tolerated and 90% of patients responded. Of 14 initially unresectable patients, 6 became operable after chemotherapy. After definitive therapy 70% of patients were considered complete responders, and 43% of the entire cohort remain disease-free. All partial responders have died. Patients receiving chemotherapy, surgery and radiation had a significantly greater likelihood of achieving a complete response than those receiving chemotherapy and radiation alone. Although this initial chemotherapy is highly active in this disease its contribution to ultimate survival is unclear. Overall treatment success is determined by the results of definitive therapy.

A simple method of controlling rotation in replanted digits.

A method of fixation for replanted digits is described. It consists of axial fixation with a wire passed longitudinally through the replanted digit, supplemented with a transverse wire passed across all the digits. In this way, splinting is provided and rotation is controlled. The method is simple, rapidly applied, and very effective.

Intraoperative heparin in replantation surgery--an experimental study.

An experimental study to define the usefulness of heparin in microvascular surgery was undertaken. Fifty-four rabbits underwent replantation of an amputated ear. The animals were randomly divided into two groups--"heparin" and "no heparin," with 27 animals in each group. Arterial patency was recorded based on direct microscopic observation of the anastomosed vessels prior to wound closure and on subsequent viability or necrosis of the ear during the surgical procedure was markedly enhanced by the use of intraoperative heparinization. The overall patency rate for the heparin group was 74%, whereas that of the no-heparin group was 44%--a statistically significant difference. This study confirms the value of intraoperative heparin in experimental replantation surgery using a rabbit ear model.

Crossed fingers and other tests of ulnar nerve motor function.

All tests for ulnar nerve motor function require demonstration and explanation if they are to be carried out reliably. The tests used most commonly may be difficult to elicit, particularly in children or in the presence of an acute injury. The authors have found that the ability to cross the middle over the index finger is a reliable test of ulnar nerve function. This maneuver of "crossing the fingers" is in common usage from childhood on as a good luck sign and is elicited easily in the presence of an intact ulnar nerve. An annotated table is included of other tests that may be useful in evaluating ulnar nerve integrity.