Tissue expansion for repair of severely complicated Achilles tendon ruptures.

We report on two patients with severely complicated Achilles tendon ruptures (ATR), including re-rupture, postoperative deep infection and subsequent tissue loss. Tissue expansion was used to facilitate tendon reconstruction and to ensure good healing potential with skin closure without tension. Tissue expansion is a valid option in patients with complicated ATR. The outcome for the two patients described here was good, with improved function and no major complications.

Salvaged limbs after tibial shaft fractures with extensive soft-tissue injury: a biopsychosocial function analysis.

BACKGROUND: The purpose of this study was to perform a biopsychosocial function analysis of the outcome in patients with a salvaged leg after tibial shaft fractures associated with extensive soft-tissue injury. METHODS: A retrospective review of 18 consecutive patients with tibial shaft fractures and extensive soft-tissue damage with a mean Injury Severity Score of 31 was undertaken. All patients were assessed for their physical function, psychological status, and general function. RESULTS: The range of motion and torque of the ankle joint were severely affected. The knee joint was affected, but only with regard to the torque during concentric muscular activities. Nottingham Health Profile scores showed that the general and social function for these patients were significantly affected. Five of 18 patients suffered from depression. CONCLUSION: Salvage procedures should be advocated if possible, but careful selection of patients on the basis of mental and social factors is crucial for the outcome.

Percutaneous sclerotherapy of venous malformations of the head and neck using sodium tetradecyl sulphate (sotradecol).

Thirty-eight patients with venous malformations of the face, neck, and tongue underwent percutaneous sclerotherapy with direct puncture and instillation of sodium tetradecyl sulphate (Sotradecol) (33-67% solution, mixed with contrast material) into the lesions. Each patient underwent from one to seven treatment sessions (mean 2.2), followed by reconstructive surgery in three cases. Of the 34 patients who responded to the follow-up questionnaire, the late results were excellent or good in 23 patients (68%), moderate in eight, unchanged in three, and were worse in one. Compared with our previous experience of embolisation of such malformations with ethanol, the results with Sotradecol were slightly worse. There was one serious complication, unilateral loss of vision in a patient with a large malformation that extended to the orbit. In conclusion, percutaneous sclerotherapy with Sotradecol is effective treatment for venous malformations of the head and neck. Careful planning is essential to reduce the risks of the treatment.

Extended free lateral arm flap with preservation of the posterior cutaneous nerve of the forearm.

The free lateral arm flap has become a well-defined and reliable flap for various reconstructive purposes. Little attention has been paid, however, to the possibility of preservation of the posterior cutaneous nerve of the forearm (nervus cutaneus antebrachii posterior) sacrifice of which results in numbness of the dorsal part of the forearm. In this study, an anatomical dissection showed that in many cases it would be possible to preserve the nerve. We did 23 free lateral arm flaps in 22 patients during the period 1989-1994. The maximum flap length was 40 cm. Standard maximum width in most cases was 6 cm, and by using a new expansion technique it reached 10 cm in one case. Furthermore, with meticulous dissection the posterior cutaneous nerve of the forearm was either preserved or cut and rejoined in 21 patients, so minimising sensory loss at the donor site.

Purine metabolism during microsurgical transfer of human skeletal muscle.

The effect of ischaemia followed by reperfusion on energy metabolism was studied in human skeletal muscle after microsurgical free transfer. Muscle biopsy specimens from 11 patients treated by free muscle transfer for facial palsy, injury to an extremity, or scalp defect were studied. The biopsy specimens were taken during ischaemia and after one hour of reperfusion, respectively. They were analysed for ATP to uric acid and creatine phosphate by high pressure liquid chromatography. Ischaemia lasting one or two hours affected the energy metabolism of the muscle cell as evidenced by a 50% reduction in creatine phosphate; a 20% reduction in ATP and in the energy charge; a 100% increase in inosine monophosphate, and a 700% increase in hypoxanthine and xanthine. Reperfusion for one hour improved these figures somewhat, and induced the production of uric acid. Skeletal muscle can therefore tolerate ischaemia for up to two hours in the clinical situation without permanent damage to the tissues.

Instillation of alcohol into venous malformations of the head and neck.

Vascular malformations are errors of vascular morphogenesis, and must be differentiated from vascular tumours such as haemangiomas, because the natural history and treatment are different. Vascular malformations may be arteriovenous with high blood flow, or venous with low blood flow. Venous vascular malformations grow among soft tissues and are difficult to delineate at operation. Direct puncture under fluoroscopy with injection of contrast medium is one method of visualising the cavities of a venous malformation. Instillation of concentrated alcohol directly into such cavities is a possible treatment. Forty-four patients with venous malformations of the head or neck have been treated since 1984, of whom 31 responded to a follow up questionnaire. Twenty-three responded to injection of ethanol alone, and eight also required reconstructive surgery; 26 of the 31 described the result as "good" or "excellent" (84%).

Direct puncture of large arteriovenous malformations in head and neck for embolisation and subsequent reconstructive surgery.

Five patients with large arteriovenous malformations (AVM) of the head and neck, which were too large or inconveniently placed for operation alone, were treated by embolisation after direct puncture; two of them were subsequently operated upon. They all recovered without complications. Embolisation of the nidus and subsequent operation is a good alternative for the treatment of large AVM. Ligating the supplying arteries is not a treatment. If the arterial routes to the nidus have previously been closed by ligatures selective catheterisation is impossible, though direct puncture of the nidus is a possibility. The nidus of the AVM can then be obliterated by embolisation either as a treatment, or as a preoperative procedure.

The combined tensor fasciae latae/rectus femoris musculocutaneous flap: a possibility for major soft tissue reconstruction in the groin, hip, gluteal, perineal, and lower abdominal regions.

A 57-year-old man, with a long-lasting multiple hereditary cartilaginous exostoses, presented with a progressive tumor growth in the left iliac wing and in the gluteus maximus muscle. An open biopsy revealed a secondary chondrosarcoma, which had developed from an osteochondroma. A wide surgical resection, sparing the inferior limb, was the option for treatment. The fairly constant and reliable vascular anatomy of the lateral circumflex femoral artery, as confirmed by 27 previous anatomical dissections, gave us the opportunity to repair the wide postoperative defect by means of a single, very large flap, combining the vascular territories of the tensor fasciae latae and rectus femoris musculocutaneous flaps. The postoperative period was uneventful, and 1 year after surgery the man had no sign of local recurrence or metastases, and the flap was fully viable without sign of local complication. A functional evaluation was performed on a Kin-Com II dynamometer, showing major impairment of the limb that had undergone surgery. Despite the severe functional disturbance, the man prefers the impaired status to an amputation after a hemipelvectomy.

Prepared neurovascular forehead island flap for reconstruction of minor full thickness nasal defects. Case report.

A forehead neurovascular island flap has twice been used for reconstruction of minor full thickness nasal defects caused by surgical removal of malignant tumours. The flap was raised one month before transposition, and a split thickness skin graft was applied to the inner surface of the galea of the flap. The periosteum of the forehead was also grafted, thus repairing the donor site before the flap was removed. The flap is based on the supraorbital artery, which was dissected to its origin at the incisura or supraorbital foramen. The advantages are those of a small flap with external as well as internal lining and with preserved sensibility.

Use of a vertical island flap for correction of epispadias.

An 18-year-old man presented with epispadias. His main complaints were dorsal curvature of the penis and difficulties during erection and micturition. Primary urethroplasty at another hospital had been only minimally successful. The public bones were normal and he was continent. He was treated by complete excision of the chordee and urethroplasty. Local flaps were used to reconstruct the glandular urethra, and a vertical penile island flap was used to replace the missing portion of the penile urethra. Good straightening of the penis and a new urethra with a well-closed meatus at the tip of the glans were achieved in a single-stage operation. No complication occurred, and the result was satisfactory from both the aesthetic and functional points of view.

The morphological sequences in man of de- and reinnervation in free muscle transfer with microneurovascular anastomoses.

Muscle biopsies from two patients treated by free gracilis muscle transfer and micro-neurovascular anastomoses for long standing facial palsy due to previous damage to the facial nerve during removal of tumours were examined by histochemistry and electron microscopy. Sequential muscle biopsies of one case taken at various intervals after transferring the muscle permitted the study of events of de- and reinnervation of human skeletal muscle. The changes in the early stages of denervation included atrophy of type 2B fibres. This was followed by progressive atrophy of all fibre types, distortion of the internal structure of the muscle fibres with the incidence of various cytoplasmic inclusions. Massive necrosis of the muscle did not occur. A prominent increase in satellite cells and their maturation to myotubes and new muscle fibres were evident. Reinnervation occurred with the formation of neuromuscular junctions some of them being at preformed sole plates. Fibre type grouping was apparent in addition to other changes such as the occurrence of targetoid hypertrophied muscle fibres. These changes are similar to those described previously during de- and reinnervation studies in experimental animals.

Hand function after replantation or revascularization of upper extremity injuries. A follow-up study of 21 cases operated on 1979-1985 in Göteborg.

Twenty-one patients with revascularized/replanted amputated parts of the upper limb were studied for an evaluation of hand function. Two patients had been injured at the lower arm to wrist level, four between the wrist and MCP joint, three distal to the MCP joints in thumbs and/or fingers, and twelve in the thumb only. Hand function was measured as grip and pinch strength, range of movement (ROM), sensibility (two point discrimination), and Sollerman test score. Cold sensitivity as related to circulatory changes in the replanted limb was evaluated in six patients using the critical opening test (COP). Twelve of 17 initiated replantations (71%), and 11 of 12 revascularizations (92%), were successful. Hand function was restricted in patients with amputations at the lower arm to wrist level, fair in replanted midhands, good, but with wide variations after replantations at the MCP or distal II-V fingers, and best of all in replanted thumbs. Sensibility was poor in a majority of the patients. Three out of six of the patients who were COP-tested had significantly reduced blood pressure in the replanted part. The test results (grip, ROM, Sollerman score) in three patients with amputated thumbs were not found to differ greatly from those with replanted thumbs. These results raise the question of whether the Sollerman test underestimates the importance of the thumb or whether the thumb is overestimated in hand function.

Microsurgical epididymovasostomy in the treatment of occlusive azoospermia.

In principle, azoospermia has two explanations: occlusion of the duct system and serious dysfunction of the testicular parenchyma. Some cases of duct occlusion are suitable for reconstructive surgery. The authors describe a reconstructive technique based on full mobilization of a single loop of the epididymal duct as caudally as possible with two-layer side-to-end anastomosis to the vas deferens. To ensure follow-up evaluation of each anastomosis, unilateral anastomosis was done primarily. In a few cases, cross-over anastomosis was necessary. In cases of reoperation, if possible, this was performed on the same side. When the epididymal duct system was found empty, the contralateral epididymis was explored. Patients with postoperative oligozoospermia were offered a supplementary contralateral operation. From 1980 to 1984, 41 patients underwent epididymovasostomy. At follow-up evaluation, 35 (85%) presented sperms in repeated tests. Fifteen of these patients (37%) have fathered children. Patients with postoperative normospermia and no antisperm antibodies had an excellent fertility prognosis. The single-loop dissection technique provides anatomic specificity and a high percentage of patent anastomoses and does not interfere with the possibilities of reoperation.

Venous malformations in the face and neck. Radiologic diagnosis and treatment with absolute ethanol.

Venous malformations in the face and neck have a characteristic clinical picture. They consist of a cluster of venous cavities with a very slow blood flow and are normally not demonstrated at conventional external carotid angiography. Previous methods of treatment have been of limited value but recently good results have been reported with instillation of fibrosing agents as Ethibloc and ethanol. Five patients with facial venous malformations were referred for therapy. External carotid angiography was performed and was almost normal in all patients. Superselective catheterization demonstrated the malformation clearly in 2 patients only. Direct puncture phlebography confirmed the diagnosis by demonstrating the venous cavities in all the patients. This procedure was concluded by instillation of absolute ethanol into the cavities. There was a marked reduction in size of the malformation but it was not permanently completely occluded. The treatment was repeated in 4 patients with further reduction of the size, but small remnants are still left. Serious complications with extensive soft tissue necrosis occurred in one patient probably as a result of extravasation of ethanol. The necrosis later healed well after surgical treatment. Instillation of ethanol under radiologic control seems to be a promising way of treatment of venous malformations.

Microsurgical replantation of a total scalp avulsion. Case report.

In June 1982, a 9-year-old girl sustained a total scalp avulsion including the entire right eyebrow, the upper third of the skin of the dorsum of the nose and the medial half of the left eyebrow. On both sides the temporal skin was included and in the neck a border of just 1 cm of hairbearing area was left intact. The scalp was successfully replanted. The operative procedures, the pre-operative and post-operative treatment are described and discussed. The follow-up time is 3 years and the sequelae have been found to be minimal.

Distally based fasciocutaneous flap from the sural region. A preliminary report.

Based on the principle of skin vascularization through perforating branches along intermuscular septa, a new distally based fasciocutaneous flap from the sural region is presented. Its use in reconstruction of defects in the middle and lower third of the leg is demonstrated by the clinical application in our sample of 3 cases. The limits of the extent and the exact basis of its vascularity have to be determined by further investigations.