CURRENT TREATMENT OPTIONS OF DUPUYTREN´S DISEASE.

Dupuytren's disease (fibromatosis of the palmar fascia, benign neoplastic fibromatosis, Dupuytren's contracture) is a disease characterized by growth and successive contracture of single parts of the palmar aponeurosis. This condition is known and has been treated for several centuries. In the advanced stages of the disease, it leads to significant limitation of hand function, resulting in reduced quality of life of the patient. Dupuytren's disease (DD) is a life-long disease with a variable course and a heterogeneous clinical presentation. Therapy focuses on the clinical manifestations of the disease as well as on reduction of the functional limitation of the hand caused by the disease. In addition to conservative and surgical procedures, there are also some mini-invasive methods available. Treatment should be reserved for centres and experienced surgeons specialized in hand surgery.

Management of infected tibial fractures and chronic tibial osteomyelitis by muscle flap transfer: a comparison of two series of patients.

OBJECTIVE: The goal of this work is to compare therapeutic results of two groups of patients with an infected fracture or chronic osteomyelitis of the lower leg and ankle joint treated by the method of radical debridement followed by free flap transfer or muscle transposition. PATIENTS: In the period between 1 January 2002 and 30 September 2007 the authors used this method in the treatment of 52 patients (10 females and 42 males) with the average age of 44 years (ages ranged from 10 to 67). The observed group of patients was divided into retrospective and prospective subgroups. METHODS: The difference between the retrospective and prospective parts of the study was how radical the debridement and necrectomy of the soft tissues was. A comparison of therapeutic results in both subgroups was made by evaluation of the amounts of postoperative complications, number of follow-up surgeries and the actual weight-bearing ability of the treated extremity. RESULTS: The difference in the number of postsurgical complications (7 versus 2) was not significant (p=0.123), and neither was the difference in the number of follow-up surgeries (20 versus 17, p=0.706). The difference in the number of patients with fully weightbearing extremities (21 versus 22) was also not significant (p=0.670). CONCLUSION: The authors feel that analysis of complications showed somewhat better results in the prospective part of the study, despite the lack of statistical proof. Therefore the authors regard the method of extensive debridement with the following coverage of the soft tissue defect by muscle flap as suitable for the treatment of infected fractures in the area of the lower leg and ankle joint and the treatment of osteomyelitis of the tibia.

[Reccurent tibial osteomyelitis after the segmental bone transport: a radical interdisciplinary treatment]. / Rekurentní osteomyelitida tibie po transportu kosti a její radikální interdisciplinární lécba.

Long-term or recurrent osteomyelitis results in the deterioration of soft tissue quality at the site of an infectious process. An insufficient perfusion of the scar tissue contributes to difficult treatment of osteomyelitis. A local transpositional or free muscle flap used to replace the vulnerable scar tissue will enhance perfusion of the affected bone and will help to control osteomyelitis. The authors present the case of a patient who had been treated by bone transport for a 14-cm-long segmental defect of the tibia after post-traumatic osteomyelitis. Recurrent osteomyelitis was found nine years after the primary surgery. The whole tibial cavity was opened leaving a 12-mm-wide trepanation opening, and debridement of all necrotic and inflammatory tissue including dystrophic skin was performed. The Orr technique was used for further treatment. There was no relapse and granulation tissue samples repeatedly gave negative culture results. Therefore, at the second stage, the soft tissue defect was covered with a free latissimus dorsi muscle flap. Anastomoses to the recipient vessels were technically difficult to carry out in the tissue greatly affected by previous chronic inflammation. Ten days after the surgery the patient was allowed to stand and walk, full weight-bearing was allowed at 2 months post-operatively when the flap was completely integrated. At 6-year follow-up the extremity was fully weight-bearing, with no recurrence of infection, and the patient was satisfied with the outcome. The authors regard this interdisciplinary management (extensive bone and soft tissue debridement, free muscle flap transfer) as a method indicated for the treatment of recurrent tibial osteomyelitis.

[Plastic and reconstructive surgery and orthopaedics interdisciplinary cooperation in the management of extremity injuries. Review]. / Mezioborová spolupráce plastické a rekonstrukcní chirurgie a ortopedie pri osetrování koncetinových traumat. Souborný referát.

Gradual particularization of medicine, as witnessed during the second half of the 20th century, resulted in a detailed development of individual subspecializations. Association of therapeutic options resulting from enormous development of these subspecialization brought a new dimension to the treatment of formerly unmanageable conditions. The closest cooperation between a plastic surgeon and a traumatologist is required in the management of patients with serious extremitiy injuries. The conditions include, in particular, amputations of extremities without skeletal and soft tissue devastation, where replantation may be considered, and extensive soft tissue and skeletal injuries, requiring replacement of the missing soft tissue cover following the treatment of the skeletal parts. A new aspect of the cooperation includes common care for infected long bone fractures and osteomyelitides, where primary and extensive skeletal and soft tissue debridement is followed by covering the defect with a muscular or a musculocutaneous flap, facilitating reperfusion and infection management.

[Muscle flap transfer of the treatment of infected tibial and malleolar fractures and chronic osteomyelitis of the tibia]. / Vyuzití muskulárního laloku pri lécení infikovaných zlomenin a chronické osteomyelitidy v oblasti bérce a hlezna.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the results of treatment in patients with infected fractures or chronic osteomyelitis in the tibial and ankle regions by radical debridement of skeletal and soft tissues and coverage of the defect, using free flap transfer or muscle flap transposition. MATERIAL: Between January 1, 2002 and December 31, 2004, 26 patients were treated by this method; 13 had infected tibial or ankle fractures and 13 showed osteomyelitis of the tibia. All patients, in the case of failure, would have been indicated for below-knee amputation. The group comprised six women and 20 men at an average age of 46 years (range, 10 to 67 years). METHODS: In this retrospective study, the following data were recorded: type of injury (multiple trauma, combined trauma, single trauma), fracture type according to the AO classification, grade of injury in open fractures by the Gustillo and Anderson classification, number of previous operations in patients with infected fractures, microbiological findings in all patients before defect coverage with a flap, interval between the injury and flap coverage, number of post-operative complications, number of subsequent operations, period of relief for the treated limb, actual weight-bearing of the limb, patient's satisfaction with the therapy. RESULTS: Since one patient died of heart attack during follow-up, 25 patients (5 women and 20 men) were included in the final evaluation. The average follow-up was 27 months (range, 15 to 49 months). The healing of infection and union of bone were recorded in 21 patients (84 %). Healing with pseudoarthrosis development occurred in three patients (12 %). One patient (4 %) had to undergo leg amputation due to persistent secretion. The duration of treatment before coverage of the defect was on average 10 weeks (range, 4 weeks to 6 months) in the patients with infected fractures, and 9 years (range, 2 to 20 years) in the patients with osteomyelitis. Post-operative complications were recorded in seven patients (27 %). Impaired vascularization of the flap in the early post-operative period was found in two patients (8 %). In two patients (8 %) residual infected tissue under the flap resulted in purulent secretion. In three patients (12 %), at the time of evaluation, the lower extremity could not bear weight due to non-union of fractured bone. DISCUSSION: The use of free or transposition muscle is regarded as the optimal method for the treatment of extensive defects of soft tissues in limb traumatology. The advantages include: good quality coverage of the defect; ability of vascularized flap tissue to transport antibiotic to the defect area; long-term improved perfusion in the fracture region is important for fracture healing. CONCLUSIONS: The treatment of infected tibial and malleolar fractures by debridement and subsequent coverage of soft tissue defects, using muscle flap transfer, permits elimination of infection in most of the patients, but often requires subsequent surgery in order to provide biological stimulation for healing of defective fractures. Treatment of osteomyelitis of the tibia by this method is demanding, but has a good prospect of healing in a period shorter than is necessary for treatment without muscle flap transfer.

Breast reconstruction using free tram flap transfer--ten years experience.

Over the course of ten years, 119 breast reconstruction procedures using a free TRAM flap transfer were performed in our department. In the present review, the authors explain the indication pattern for breast reconstruction. The age of patients undergoing breast reconstruction is given, as well as a description of the time interval between mastectomy and breast reconstruction, which recipient vessels were used, the general and local complications and the complications relating to the anastomosis. The review of the group of patients is supplemented by information on the time interval between breast reconstruction and reconstruction of the nipple areolar complex as well as summarized data on the results of breast reconstruction that were achieved using a free TRAM flap transfer.

Evaluation of results of replantations at the Department of Plastic Surgery, University Hospital Královské Vinohrady, during the period 1994-1999.

During the period from 1994-1999, 226 patients were treated, incl. 91 replantations and 135 revascularizations. The group included 199 men and 27 women. The success rate of microsurgical reconstruction operations in replantations was 78%, in revascularizations 93%. As compared with the period 1984-1993, the success rate in replantations improved by 4%, while the indication pattern was preserved.

Treatment of chronic osteomyelitis of the lower extremity using free flap transfer.

Between 1987 and 1995, 25 patients with chronic osteomyelitis of the lower extremity were treated by transfer of muscle or musculocutaneous flap. The subsequent follow-up extended over more than three years. Five patients developed a recurrence. Two were reoperated on and healed completely; in two an amputation had to be performed; and in one the infection persists. Recurrence occurred mainly in patients in whom the bone cavity could not be filled completely with muscle.

Effect of primary repositioning of the nasal septum on facial growth in unilateral cleft lip and palate.

OBJECTIVE: The objective of this study is to evaluate whether manipulation of the nasal septum, its release, and changing of its abnormal position in infancy has an impact on maxillary growth and facial development in patients with unilateral cleft lip and palate. DESIGN: Roentgencephalometric investigation. SETTING: Cleft Centre at the Clinic of Plastic Surgery, Prague. PATIENTS: Two consecutive groups of male patients (n = 32 and 30) with complete unilateral cleft lip and palate without associated malformations at 15 years of age. INTERVENTIONS: The patients were operated on by the same team of surgeons and by the same method (lip: Tennison and primary periosteoplasty; palate: pushback with pharyngeal flap surgery), with the exception of complete primary repositioning of the nasal septum performed only in one group. MAIN OUTCOME MEASURES: Roentgencephalometric data of both series of patients were compared with a t-test. All measurements were performed by one investigator. RESULTS: Patients with primary repositioning of the nasal septum had a more favorable nasal prominence and better vertical growth of the upper and whole face in posterior height. Better growth in anterior height was only suggested; maxillary retrusion was equal in both groups. CONCLUSIONS: Primary repositioning of the nasal septum has a favorable effect on nasal development, and it neither deteriorates nor markedly improves maxillary growth in patients with unilateral cleft lip and palate.

Penile replantation--a case report.

The authors submit a successful case of penile replantation. They discuss the course of the procedure and document the immediate and long-term result of this procedure.

Changes in craniofacial development due to modifications of the treatment of unilateral cleft lip and palate.

OBJECTIVE: The objective of this study was to evaluate the craniofacial morphology of children with unilateral cleft lip and palate (UCLP) resulting from differing management protocols practiced in Prague from 1945 to 1976. DESIGN: The craniofacial morphologies of four groups of patients were compared. Two groups were assessed retrospectively (individuals born from 1945 to 1963), and two groups were followed on a longitudinal basis (individuals born from 1966 to 1976). SETTING: The study was conducted at the Cleft Lip and Palate Center at the Department of Plastic Surgery, Prague, which has a catchment area population of 6 million. PATIENTS: The subjects were a consecutive series of adult males (n = 84) who had complete UCLP without associated malformations. INTERVENTIONS: Patients born from 1945 to 1955 did not receive centralized orthodontic therapy. From 1945 to 1965, the alveolar process in the area of the cleft was not surgically repaired. Primary bone grafting was used for the group born from 1965 to 1972, and primary periosteoplasty was used in the subsequent period. Throughout the period covered by the study, the palate was operated on by pushback and pharyngeal flap surgery. From 1945 to 1965, the lip was repaired initially according to Veau, and later according to Tennison and Randall, and during this time, fixed appliances were used for orthodontic treatment. RESULTS: The results for the period from 1945 to 1955 are characterized by mandibular overclosure with anterior crossbite. Centralized orthodontic treatment in the later period improved sagittal jaw relations due to the posterior displacement of the mandible and an edge-to-edge bite was attained, but maxillary retrusion was unchanged. Primary bone grafting increased retrusion of the maxilla, which was compensated by further posterior displacement of the mandible. An edge-to-edge bite was also obtained. Primary periosteoplasty reduced maxillary retrusion, and the marked proclination of the upper dentoalveolar component with fixed appliances resulted in a positive overjet. It was no longer necessary to push the mandible back to the extent required in bone grafting. CONCLUSION: Effective orthodontic treatment made the greatest contribution to improved facial development. It allowed compensation of maxillary retrusion by changes in the position of the mandible or by proclination of the upper dentoalveolar component with fixed appliances. The applied surgical methods using primary bone grafting caused deterioration of the anterior growth of the maxilla.

[Melorheostosis (case history).]. / Meloreostóza.

The authors present the case of a patient with a diagnosis at the age of 10 of melorheostosis affecting the left lower extermity with the reduction of flexion in the knee joint as a dominant finding. Despite the releasing operation on the soft tissue complicated by infection in the wound and dihescence there is a continuous progress in the reduction of the range of motion in the knee causing ever greater difficulties for the patient. Authors point out some specific features of this disease the incidence of which is 1 :1 000 000 and describe the plan of further treatment.

Exposure to stress alters the effects of dynorphins in the hot plate test.

The analgesic effects of intracerebroventricularly (i.c.v.) administered dynorphin A(1-13) and its analog dynorphin A(1-10)amide using the hot plate test were studied in mice. Both dynorphins applied i.c.v. by the freehand method had an analgesic effect but no effect was seen when applied i.c.v. through an implanted cannula. Moreover, freehand i.c.v. injection of saline increased the time of immobility in the forced swimming test and glycaemia levels compared with intact mice. In contrast to the freehand injection, saline administration through an implanted cannula did not influence the immobility of animals in forced swimming test when compared with the intact controls. These results suggest that 1) the freehand method is very stressful procedure of administration which could influence the effects of dynorphins in the hot plate test and 2) dynorphins exert an analgesic effect in the hot plate test only when combined with a stressor (freehand i.c.v. injection).

Chronic traumatic wounds of the leg.

The authors report the results of a retrospective study of the treatment of chronic defects of soft tissues and bones of the leg and foot with free muscle and musclecutaneous flaps. The study deals with the results of the use of the microsurgical techniques during the period of 11 years at the Department of Plastic Surgery of the 3rd Medical School in Prague. Discussed are the advantages and disadvantages of this technique as one the of possible therapeutic methods inclusive of the results obtained at the above mentioned department.

Treatment of defects and instable skin scars on heavily exposed parts of the leg.

The authors report a series of 41 patients subjected to a transfer of the sensitive fasciocutaneous flap to a defect or to instable skin scars on the leg. Described are immediate as well as longterm surgical results in relation to the sensitivity of the transferred flap and the condition of the donnor site of the flap.

Free cross leg flap as a method of reconstruction of soft tissues defects.

Authors demonstrate on clinical cases the possibility of reconstruction of soft leg tissues by the use of the so called free cross flap. This method appears to be convenient in cases where there are no suitable recipient vessels within reach on the injured extremity and where the defect is of such an extent that the conventional cross flap does not provide sufficient amount of tissue.

Internal mammary vessels as recipient vessels to the free TRAM flap.

For the reconstruction of the breast after mastectomy, it is possible to use the internal mammary artery and vein as recipient vessels. The authors consider their experience and some new knowledge gained on the basis of 53 cases. They try to promote the indisputable advantages of the use of the mentioned recipient vessels.

[Reduction surgery of the breasts at the Plastic Surgery Clinic in Prague]. / Redukcní operace prsu na klinice plastické chirurgie v Praze.

The authors present an account of the history of surgical treatment of hypertrophic breasts at the Clinic of Plastic Surgery in Prague. They divided the period from 1928 to the present time into stages with regard to the predominating technique. The authors emphasize also the necessity of careful selection of the surgical procedure with regard to the type and extent of the defect.

Importance of an early tissue transfer in the treatment of complicated injuries of lower extremities.

3rd degree fractures with extensive defects of soft tissues represent a major therapeutical problem. The technique of free tissue transfer makes it possible to adopt an active access to primary treatment to this injuries. Radical necrectomies may be performed without respect to the extent of the defect that will arise. The authors present their experience regarding an early coverage of the defect of the lower extremity by means of a free flap. The time period between the accident and tissue transfer as well as a suitable flap type are taken in consideration.

Ten years of replantation surgery at the Department of Plastic Surgery, Charles University Hospital, Prague.

The authors present results of the ten years replantation surgery centre at the department of plastic surgery in Prague. The presented series of patients includes 393 persons operated on because of amputation or ischaemic injury to the region of the upper extremity. The number of replantations and revascularisations in the individual years is analysed, as well as the age of the patients, type of injury, mechanism of injury and operation results.