Results of treatment of tibial and femoral osteomyelitis in adults.

From January 1, 1971, to December 31, 1985, 425 patients with chronic osteomyelitis of the femur or tibia were seen at the authors' institution. The success rate in this recent experience was 84.4% compared with 50.9% in the authors' results published in 1970. A classification of chronic osteomyelitis is as follows: (1) hematogenous osteomyelitis; (2) osteomyelitis in united fractures (fracture with union); (3) osteomyelitis in nonunion (fracture with nonunion); and (4) postoperative or posttraumatic osteomyelitis in which bone was not fractured. For management of the scarring of surrounding soft tissue, there has been a change to excision of the scarred tissue and reliance on muscle flap, free-tissue transfer, or closure of soft tissues without irrigation with antibiotic solution. In recent years, free microvascular osseous grafts have permitted more aggressive resection of the involved osseous tissue. The predominance of gram-negative organisms and penicillin-resistant Staphylococcus aureus and the occurrence of methicillin-resistant S. aureus continue.

The management of intraosseous arteriovenous malformations in the head and neck area.

It is necessary that the treatment of arteriovenous malformations in general be undertaken by a team that consists of a radiologist who is experienced in angiography and embolization and a plastic surgeon. The latter should be well versed in angiographic techniques and should be able to comprehend the dynamics of these malformations. In this report, three patients with high-flow, high-shunt arteriovenous intraosseous malformations of the head are presented. Two of these presented as emergencies with almost uncontrollable bleeding and were initially treated with embolization and then mandibular resection and reconstruction within the first 48 hours. In one patient, a further reconstructive procedure using free vascularized tissue was carried out. A third patient with involvement of the maxilla, again presenting with bleeding, was treated with embolization and, because of the deformity that would be created by resection, was simply observed. However, this patient is to be reassessed in the future and may well come to maxillectomy. It is emphasized that the treatment of these patients requires careful assessment, embolization, and resection as indicated after discussion between radiologist and surgeon.

Free tissue transfer for reconstruction of the weight-bearing portion of the foot.

Twenty-eight patients treated with free tissue transfer for soft-tissue coverage of the weight-bearing portion of the foot were investigated over a minimum follow-up period of 12 months. Seven were treated with a sensory innervated flap transfer, and 21 had a noninnervated skin or muscle flap transfer. Secondary procedures to debulk or sculpture the flap were necessary in seven patients. Complications occurred in six patients and were either related to lack of protective sensibility (in three) or excessive flap mobility (in three). Impaired flap sensibility was more common in noninnervated flaps, but excessive flap mobility was more typical of cutaneous flaps. The merits of an innervated cutaneous flap, which may be excessively bulky, must be weighed against those of a well-contoured muscle flap without sensory innervation.

Experience with 80 rectus abdominis free-tissue transfers.

Eighty patients receiving rectus abdominis free-tissue transfers are discussed. The operations were performed between July of 1983 and December of 1986. Specifically, the patients were followed in the clinic to determine the extent and degree of donor-site morbidity. Sixty-two flaps were transferred to the lower extremities, 15 to the head and neck, 2 to the arm, and 1 was placed intrathoracically. Osteomyelitis was the most common indication for free-muscle transfer in 33 patients, soft-tissue defects in 26, and facial soft-tissue augmentation in 14 patients. In the 80 rectus abdominis free-muscle transfers, there were 9 local complications. A seroma occurred in 4 patients, wound infection in 3, and an abdominal wall hernia occurred in 1 patient. The success rate for muscle transfer was 93 percent with six flap losses. Because there is a low incidence of donor-site complications, the surgical dissection is relatively easy, and the relative consistency and size of the deep inferior epigastric pedicle are good, the rectus abdominis muscular unit is now one of the most frequently used free-tissue transfers at our institution.

Physical and psychological outcome after burns.

The relationship between compliance of moderately or severely burned patients with suggested plans of treatment and outcome was examined retrospectively by reviewing medical records. This review was limited to patients admitted to our facilities between 1977 and 1982 with burns in the moderate or major burn category and admitted within seven days of their injuries. The outcome measures included the following: limitation in range of motion (ROM), hypertrophic scar formation, total days of care required, quality of life, and impact of event. Noncompliance was related to the outcome as measured by limitation in ROM (P less than 0.01) and total days of care required (P less than 0.0001). A trend for diminished quality of life was related to noncompliance (P less than 0.08). Extent of injury (measured by total body surface area involved) was not related to ROM, quality of life, or impact of event but was related to total days of care required (P less than 0.01); there was also a trend toward scarring (P less than 0.06).

Membranous basal cell adenoma of the parotid gland. Malignant transformation in a patient with multiple dermal cylindromas.

The rare association of dermal cylindroma (turban tumor), trichoepithelioma, eccrine spiradenoma, and membranous basal cell adenoma of the parotid gland has been previously reported. It is believed that this combination represents a peculiar inherited tumor diathesis involving neoplasms of presumed ductal origin, eccrine in the skin and intercalated in the parotid gland. We describe a patient in whom the basal cell adenoma of the parotid gland underwent malignant transformation.

Squamous cell carcinoma occurring in a skin-grafted ileostomy stoma. Report of a case.

A squamous cell carcinoma arose in a skin-grafted ileostomy stoma 26 years after proctocolectomy for Crohn's colitis. The patient presented with peristomal ulceration and pain of several months' duration. Attention is drawn to this late complication of ileostomy which requires wide local excision and relocation of the stoma.

Experience with one hundred consecutive free flaps.

Our first 100 free flap operations are reviewed. The location and cause of the defects requiring free flaps, the flaps used, and the outcome are tabulated. The lower leg was the most common site of defect. Osteomyelitis and trauma were the most common causes. The latissimus dorsi and tensor fascia lata were the most useful flaps. Of the 15 patients with failed flaps, wound closure was accomplished by other methods in 13 and 2 underwent amputation. One of the patients with a successful free flap ultimately underwent amputation because of recurrent osteomyelitis.

Soft-tissue coverage for the treatment of osteomyelitis of the lower part of the leg.

For treatment of chronic osteomyelitic wounds of the lower part of the leg, a three-stage approach is necessary: (1) adequate debridement of bone and soft tissue, (2) control of infection by open packing with frequent dressing changes and use of intravenously administered antibiotics, and (3) healthy soft-tissue coverage and obliteration of dead space. If the bone is unstable, it can be immobilized temporarily by means of external fixation. Bone grafting can be accomplished by use of conventional bone grafting after healing of the soft tissues, a vascularized bone graft, or open bone grafting. Soft-tissue coverage is provided by a local muscle flap or a free muscle flap. We prefer to cover the muscle with a skin graft. The muscle flaps described in this article obliterate dead space, provide soft-tissue coverage, act as a bed for skin grafts, and improve the vascularity of the wound.

Lower extremity salvage and reconstruction by free-tissue transfer. Analysis of results.

The application of soft tissue or bone free-tissue transfers to lower extremity salvage or reconstruction was assessed in a review of 86 consecutive procedures done during a 36-month period. This group included 65 cases of free skin or muscle flap transfer and 21 cases of free vascularized bone transfer. In terms of tissue viability, the success rate was 80.2% (78.5% for the soft tissue group and 85.7% for the bone group). With due consideration of indications, the incidence of secondary sepsis in patients with chronic osteomyelitis, and other potential complications, free-tissue transfers are valuable for salvage and reconstructive surgery of the lower extremity.

Skeletal reconstruction by vascularized bone transfer: indications and results.

The indications for and the results of 60 consecutive microvascular bone transfers performed at our institution during a 50-month period are reviewed. All 60 patients were followed up for at least 1 year. The overall primary union rate was 67%, and the eventual union rate was 77%. The most frequent indication for the procedure was long-bone reconstruction after limb-salvage wide local resection of a malignant tumor. We achieved the best results with limb reconstruction after resection of a malignant tumor and with recipient sites that involved the forearm or mandible. In contrast, our results were least favorable with reconstruction after resection for chronic osteomyelitis and with reconstruction of defects of the shoulder girdle. Overall, vascularized bone transfer seems to be a valuable reconstructive technique for management of clinical problems that involve massive skeletal defects.

Local muscle flaps in the treatment of chronic osteomyelitis.

When large soft-tissue and osseous defects remain after débridement of a chronic osteomyelitic lesion, application of a local muscle flap can be an effective way to achieve wound closure. Utilizing this surgical technique and specific antimicrobial therapy for the causal microorganisms, the infectious process was eradicated in thirty-nine of forty-two patients with osteomyelitis who were followed for at least two years after treatment. The osteomyelitic process was post-traumatic in origin--that is, a complication of a fracture or its treatment--in twenty-eight patients, the result of soft-tissue trauma without a fracture in eight, a complication of elective surgery in three, and the result of hematogenous seeding in three patients. Nine of the forty-two patients had an infected non-union. The infectious process involved the tibia in 62 per cent of the patients. Pseudomonas aeruginosa was the most frequently isolated causal organism. A soleus or gastrocnemius muscle flap was most frequently utilized to achieve closure. In five patients, a combination of two muscle flaps was utilized. Although this technique successfully eradicated the infectious process in 93 per cent of the patients, twenty-two patients required additional surgical treatment. Six required such treatment for a persistent non-union and two, for weakened diaphyseal bone after eradication of the septic process. A cancellous bone-grafting procedure was performed in all eight patients after the muscle flap had healed, and union was achieved in six of them. One patient eventually requested an amputation for a persistent non-union, and the remaining patient had a fibular synostosis performed for a persistent tibial non-union. A local muscle flap can be used in patients with a large defect of soft tissue and bone after débridement of an osteomyelitic lesion if the flap can be elevated and transposed into the defect without compromising its vascular supply. Although they are not applicable to the treatment of all patients with osteomyelitis, local muscle flaps can be extremely useful in the treatment of this lesion. When combined with thorough débridement and specific antimicrobial therapy, it has become a successful technique in the management of chronic osteomyelitis.

Vascularized muscular and musculocutaneous flaps for management of osteomyelitis.

Thirty-three cases of recalcitrant osteomyelitis treated by free tissue transfer are reviewed. The immediate success rate was 76 per cent; however, on follow-up for at least 1 year, there was a 12 per cent rate of recurrent drainage. The authors conclude that this is a good operation for this problem but that it is not a panacea because if followed long enough, a significant number of patients will develop recurrent drainage.

Lower-extremity muscle flaps.

An outline of the muscle flaps for use in coverage of the lower extremity is presented. The more reliable muscle flaps are specifically discussed and illustrated in clinical cases.

Chronic osteomyelitis treated with a muscle flap.

The use of local muscle flaps in the treatment of chronic osteomyelitis is outlined. The defect treated must be in an anatomic location that permits rotation of the muscle flap. A recent review of 42 patients treated with this technique showed the local muscle flap to be efficacious in 39 of the 42 patients treated.

Gracilis myocutaneous vaginal reconstruction.

Pelvic exenteration or extensive abdominoperineal resections, in combination with radiation therapy, may result in difficulties with healing of the wound in the perineum. In addition, the reconstruction of a functional vagina is rendered difficult. At the Mayo Clinic between February 1980 and October 1981, eight patients underwent vaginal reconstruction with use of bilateral gracilis myocutaneous flaps. Although complications were experienced, the procedure resulted in healed wounds in all patients. Patient satisfaction with respect to sexual function was variable. Reconstruction of the vagina and closure of the extensive defect after pelvic exenteration by using gracilis myocutaneous flaps seems to be a worthwhile and appropriate procedure.

Posttraumatic lower extremity reconstruction by vascularized bone graft transfer.

Fourteen cases of vascularized bone transfer in the lower extremity for reconstruction of extensive bony defects are reviewed. Followup ranges from nine to 62 months. Donor sites include iliac crest in ten cases, fibula in two cases, rib in one case, and radius-ulna in one case. The indication for the procedure was reconstruction of an extensive bony defect after osteomyelitis in seven cases, acute trauma in five cases, chronic nonunion in one case, and a composite physis reconstruction in one case. In 13 (93%) of the 14 cases, success was ultimately achieved; however, six cases required a second operation. We conclude that this procedure is very valuable in the management of extensive bony defects of the limbs, but in approximately half the cases further surgery or complication can be anticipated.

Rectus abdominis muscle flaps for closure of osteomyelitis hip defects.

In chronic defects of osteomyelitis good results can be achieved using radical debridement, long-term systemic antibiotics, and soft-tissue coverage with muscle flaps. In three patients, the rectus abdominis muscle was a reliable means of filling dead space and providing soft-tissue coverage, at the same time bringing in a new blood supply for these chronic hip joint wounds. There were no complications, and all wounds have remained closed at follow-up periods ranging from two months to one year.

Use of the omental free flap for soft-tissue reconstruction.

Omentum can be useful as a free flap for soft-tissue reconstruction in a variety of difficult wounds. Omentum was successfully used as a free flap in 11 of 15 patients. Of the 15 defects, 2 were located on the scalp, 2 on the face, 2 on the thigh, and 9 on the lower leg. The failure rate of 27% (4 out of 15) was higher than the 10 to 15% failure rate that we have experienced with skin and muscle flaps. The most frequent cause of failure was the use of diseased recipient vessels for the microvascular anastomoses, that is, vessels with scar tissue, inflammation, or arteriosclerotic changes. Poor blood flow in the recipient vessel also was a harbinger of trouble. This low-flow phenomenon was more prevalent when the anterior tibial vessels of the lower leg were used. In spite of these problems, omentum is useful as a free flap for selected difficult soft-tissue defects.