[Further experiences with transplantation of the head of the fibula]. / Weitere Erfahrungen mit der Transplantation des Fibulakopfes.

We are presenting our experience with vascularized epiphyseal transplantation of the upper end of the fibula, based distally on the anterior tibial artery in two patients, one suffering from septic epiphysitis of the hip with complete loss of the head and neck of the femur, the other suffering from radial club hand following septic loss of the radius, excluding its proximal and distal articular segments. In the first patient, the fibular epiphysis bridged the bone defect and provided growth at the neck of the femur. This restored hip stability, reduced limb-length discrepancy, initiated some degree of acetabular development, and maintained a functional range of hip motion. In the second patient, transplantation of the upper end of the fibula was used to bridge a gap resulting from complete resorption of the right radius and provide for growth of the radius. At follow-up, complete union of the graft was noted. The club-hand appearance improved markedly. Pronation and supination were regained. However, donor-site morbidity was a problem. It included sloughing of part of the peroneal muscles and the skin edge of the incision. This was due to loss of the anterior tibial artery as well as injury to the peroneal vessel collaterals supplying the skin and peroneal muscles. The latter occurred due to opening of the posterior compartment of the leg in an attempt to locate the anterior tibial artery at its origin from the popliteal artery. It is therefore concluded, that transplantation of the upper end of the fibula is a valuable reconstructive alternative for septic epiphysitis with complete loss of the head and neck of the femur as well as for septic loss of the radius. However, whenever an extended part of the upper end of the fibula needs being harvested, this should be performed through an anterior approach, in order to avoid sloughing of the skin and muscles of the anterior and lateral compartments of the leg.

Reconstruction after resection of tumors around the knee: role of the free vascularized fibular graft.

We present our experience with reconstruction after resection of tumors around the knee, using free vascularized fibular grafting. The study included 23 patients. The lower femur was involved in 17 cases, the upper tibia in 6. The cases included giant cell tumor of the lower femur (2 patients), giant cell tumor of the upper tibia (1 patient), malignant fibrous histiocytoma of the lower femur (1 patient), parosteal osteosarcoma (1 patient), and periosteal osteosarcoma (1 patient). The remaining patients suffered from conventional osteogenic sarcomas. The size of the defect ranged from 12 to 16 cm in length. Skin flap necrosis after tumor resection was the most common complication encountered. Other complications included peroneal nerve involvement in one case and rupture of the arterial anastomosis in another. All transferred fibulas progressed to union within 7-9 months. Union time of both upper and lower ends of the fibula and time of appearance of periosteal reaction were identical. In evaluating periosteal hypertrophy of the fibula, the hypertrophy (de Boer) index (de Boer HD, Wood MB, J Bone Joint Surg 1989;71B:374-378) proved unreliable. False positive results are obtained, when callus formation around the lower end of the femur is far more abundant than at the upper end of the fibula. For this reason, we introduced the graft index. The latter is the ratio between the diameter of the graft at its thinnest portion at latest follow-up to its diameter on the day of operation, as calculated on plain radiographs. Two of the viable fibulas developed stress fractures after plate removal. Functional and quality-of -life results were satisfactory. It is concluded that the free vascularized fibular graft remains a valuable reconstruction option after the resection of tumors around the knee, provided certain precautions are followed. First, before closure of the wound, the skin flaps should be assessed for their viability. Necrotic parts should be excised. Stable fixation is a necessary prerequisite at the time of operation. Removal of the fixation device should not be guided by union or periosteal hypertrophy, but by true widening of the medullary canal.

Clinical study of a new preparation of 8-methoxypsoralen in photochemotherapy.

BACKGROUND: Oral 8-methoxypsoralen is the drug of choice in photochemotherapy of several dermatoses, e.g., vitiligo and psoriasis. The aim of this trial is to produce a new preparation of the drug, which is able to overcome the difficulties met with the oral use of the older preparations. METHODS: A new preparation containing ultramicronized methoxypsoralen (8-MOP) in 10 mg capsules was tried in an open trial. The trial included 53 patients (15 psoriasis, 26 vitiligo, and 12 tinea versicolor). Light testing showed that the strongest erythema appeared 30 minutes after ingesting the capsules. Patients were exposed to UVA after that period. Laboratory studies were also performed using high performance liquid chromatography to assay the serum concentrations of the drug on normal individuals. RESULTS: Thirteen of the 15 psoriasis patients (87%) showed an excellent response (a remission) after 30 sittings. Twenty-two of the 26 vitiligo patients (85%) showed an excellent response (acceptable repigmentation) after 70 sittings. The 12 patients with tinea versicolor (100%) showed complete repigmentation after 12 sittings. The laboratory studies showed the optimum time to be between 35 to 55 minutes, verifying the clinical observation. CONCLUSIONS: The therapeutic effective dose was found to be 0.25 mg/kg. This new preparation of 8-MOP proved to be well tolerated by the patients, causing no epigastric discomfort, nausea, or vomiting, overcoming the biggest obstacle of oral 8-MOP therapy. It was also well tolerated by patients known to be sensitive to oral and/or topical 8-MOP therapy.

Argon laser trabeculoplasty as initial therapy for glaucoma.

Argon laser trabeculoplasty (ALT) was used as the initial treatment in 30 eyes of 20 patients with uncontrolled open-angle glaucoma in Egypt. None of the patients had received previous medical or surgical therapy. The average reduction of intraocular pressure with ALT alone was 10.1 mm Hg. Medical and surgical glaucoma therapy was avoided in 83% (25 eyes) of the treated eyes during an average follow-up period of 7 1/2 months. The data indicate that ALT can be used as a safe and effective initial treatment for glaucoma in developing countries where socioeconomic factors make the medical treatment of glaucoma impractical.

An insulated diathermy electrode.

A thin, conical diathermy electrode with a smooth-surfaced bent, insulated tip was designed for use in narrow incisions, corners, and angles of dissected scleral flaps. It permits precise delivery of focal diathermy and avoids undesirable parafocal tissue damage. This electrode is especially valuable for preventing uveal bleeding from a sclerochoroidal incision over the pars plana ciliaris and for treating small posterior retinal breaks.

Ultrasonically accelerated resorption of vitreous membranes.

A noninvasive procedure was used to treat membranes within the vitreous with controlled exposure to focused high-intensity ultrasound in rabbit eyes. Membranes were created by injecting small quantities of platelet-rich plasma into the vitreous of the intact globe of anesthetized rabbits. The average time for untreated membranes (controls and shams) to be resorbed was 34 days, whereas the average time to total resorption of membranes treated with ultrasound was 21 days. This comparison showed that high-intensity ultrasound was effective in accelerating the resorption of this type of vitreous membrane. This ultrasound technique is totally noninvasive and can be used without damage to other ocular tissues. Although this animal model departs in some respects from human vitreous membranes, eventual clinical applications are indicated in selected cases where vitrectomy must be delayed or is contraindicated. Noninvasive disruption of vitreous membranes by therapeutic ultrasound offers great promise for reducing the visual limitations produced by such membranes, and eliminating the sequence of disease leading to permanent visual loss.

Retrospective ocular study of patients receiving oral 8-methoxypsoralen and solar irradiation for the treatment of vitiligo.

A retrospective ocular study of patients receiving oral 8-MOP and exposure to solar irradiation for the treatment of vitiligo is presented. Fifteen patients between the ages of 20 and 40 years of age were selected who had been under therapy for 5 to 23 years. No ocular abnormalities were found.

Clinical and laboratory evaluation of 8-methoxypsoralen toxicity.

Twenty-seven patients with vitiligo took (Meladinine 8-methoxypsoralen) for 2 to 12 years. They were selected from those patients who, in an attempt to get a more rapid repigmentary response, exceeded the advised doses by ingesting from 7-16 tablets (equivalent to 70-160 mg) per day. These regimens were well tolerated. Hepatic and renal function were not affected.