Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy.

OBJECTIVE: Besides other factors, the choice of reconstructive method for full thickness thoracic wall defects depends on the morbidity of preceding surgical procedures. The pedicled latissimus dorsi flap is a reliable and safe option for reconstruction of the thorax. A posterolateral thoracotomy, however, results in division of the muscle. Both parts of the muscle can be employed to close full thickness defects of the chest wall. The proximal part can be pedicled on the thoracodorsal vessels or the serratus branch; the distal part can be pedicled on paravertebral or intercostal perforators. This retrospective study was undertaken to evaluate the reconstructive potential of both parts of the latissimus dorsi in thoracic wall reconstruction after posterolateral thoracotomy. METHODS: Between 1987 and 1999, 36 consecutive patients underwent reconstruction of full-thickness thoracic wall defects with latissimus dorsi-flaps after posterolateral thoracotomies. The defects resulted from infection and open window thoracostomy (n=31), trauma (n=3) and resection of tumours (n=2). The patients' average age was 57 years (range 22-76 years). Twenty-five patients were male, 11 were female. In 31 cases the split latissimus dorsi alone was employed; in five cases additional flaps had to be used due to the size of the defects, additional intrathoracic problems or neighbouring defects. RESULTS: In 34 cases defect closure could be achieved without major complications. Empyema recurred in the pleural cavity in one case and one patient died of septicaemia. The 15 patients who had required a respirator in the preoperative phase could be extubated 4.8 days (average) after thoracic wall reconstruction. Postoperative hospital stay averaged 16 days. CONCLUSIONS: Different methods are available for reconstruction of full thickness defects of the thoracic wall. After posterolateral thoracotomy in the surgical treatment of empyema, oncologic surgery and traumatology, the latissimus dorsi muscle still retains some reconstructive potential. Advantages are low additional donor site morbidity and anatomical reliability. As it is located near the site of the defect, there is no need for additional surgical sites or intraoperative repositioning. In our service, the split latissimus dorsi muscle flap has proven to be a valuable and reliable option in thoracic wall reconstruction.

Hand surgery and the internet: results of a worldwide survey.

The opportunities offered by the Internet are employed increasingly in medicine. To obtain data on the extent to which the Internet is used by hand surgeons, survey forms were sent to 1043 participants of the Congress of the IFSSH in Vancouver in 1998. Ninety-four per cent of the respondents use the Internet. Most of the participants use the World Wide Web for literature searches, information on events and to read scientific articles. E-mail is used for general and scientific communication with colleagues and also for transmission of patient-related data. Perceived apprehensions include secure transmission of sensitive data, slow data transmission, and the lack of structure and of an authority to control the contents of the Internet. Virtual congresses and a newsgroup on hand surgery seem to be worthwhile future goals. Some problems pointed out in this survey have already been solved, at least partially, and possible solutions for the rest are discussed.

[Water jet dissection in fatty tissue]. / Wasser-Jet Dissektion im Fettgewebe.

BACKGROUND: The first report about the use of water-jet dissection in surgery dates 1982. The advantage compared to conventional cutting is the preservation of vessels and nerves, thus facilitating the precise coagulation thereafter. Devices of the new generation with coherent jet are used in liver surgery in order to reduce blood loss. The use of water-jet dissectors in other fields of surgery is currently under investigation. The preparation of vessels in fatty tissue is of special interest for plastic surgeons. The technical parameters of the hydro- or water-jet device have to be optimised. METHOD: Abdominal fat tissue of fresh cadavers was cut under standardised conditions with different parameters of the dissector. The depth of the cuts and the morphology of the blood vessels were analysed. RESULTS: Between 20 and 60 Bar cutting pressure of the water-jet and one single pass the cuts are 8 mm deep. Deeper cuts can be achieved by repeated application on the same cut. When using 40 Bar and 5 passes the cutting depth is 1.7 cm. Higher pressure as 50 or 60 Bar do not lead to deeper cuts. The water-jet dissection leads to a water uptake of the cut tissue. Morphologically all the vessels, lying in the cut are undamaged if the pressure doesn't exceed 40 Bar pressure range. CONCLUSION: The optimal pressure for water-jet dissection of fatty tissue lies between 30 and 40 Bar. Higher pressure does not lead to deeper cuts, but increases the risk of vessel damage. The vessels in the remain morphologically intact if he cutting pressure lies below 50 Bar. The effect of the mechanical irritation of the vessels has to be investigated in vivo, before using the water-jet dissector for preparation of blood vessels in humans e.g. for flap dissection.

[Iatrogenic necrosis of the large toe after tourniquet placement--clinical course and reconstruction]. / Iatrogene Grosszehnekrose nach belassener Blutsperre--klinischer Verlauf und Rekonstruktion.

We present a necrosis of the big toe in a 20-year-old woman with an ingrowing toenail after wedge-shaped excision in the big toe. The reason for the necrosis was a tourniquet that was left in place after the operation. The ischemia, which lasted for 2 days, resulted in subtotal necrosis of the big toe. Six weeks after the operation the patient underwent microsurgical reconstruction. This is a report on the treatment of this complication from the beginning. Early surgical intervention is advocated.

[The lower trapezius muscle island flap. Anatomic principles and clinical relevance]. / Der untere M. trapezius-Insellappen. Anatomische Grundlagen und klinische Relevanz.

Up to now, there is no uniform anatomic description neither of the branches of the subclavian artery nor of the pedicle of the lower myocutaneous trapezius flap. A dissection study was carried out on 140 necks in 70 cadavers. Variations of the subclavian artery and its branches, vessel diameter at different levels, the course of the pedicle under the levator scapulae muscle, the arc of rotation of the island flap, and the variations of the segmental intercostal branches to the lower part of the trapezius muscle were examined. Results of this study enable us to suggest a new nomenclature for the branches of the subclavian artery, a proper pedicle definition, and a technique for safe flap elevation. The lower trapezius island flap is a thin and pliable myocutaneous flap with a constant pedicle which ensures safe flap elevation. This flap has the potential for a wider acceptance due to minor donor site morbidity, large arc of rotation, and an ample range of clinical applications in the head and neck area as an island flap as well as a free flap.

[The posterior interosseous flap--review and personal experience]. / Der Interossea posterior-Lappen--Ubersichtsarbeit und eigene Erfahrungen.

The posterior interosseous flap was first introduced by Zancolli and Angrigiani (1985) and short time later by Penteado and Masquelet (1986). The flap is used for soft tissue reconstruction in the hand but has not gained wide acceptance due to tedious pedicle dissection and venous problems. In 1993, Angrigiani et al. published a simplified modification in the elevation of the flap. They included a constant fasciocutaneous perforating vessel in the flap to enhance the viability. We applied the modified elevation technique in twelve patients. Our experience, indications, and complications will be discussed. In contrast to Angrigiani's statement, our flaps still show a temporary mild to moderate venous congestion similar to the flaps raised in the original technique.

Venous thrombosis in a replanted finger with underlying factor V Leiden mutation.

Resistance to activated protein C (APC resistance) was described recently as a cause for thrombophilia. APC inactivates coagulation co-factors Va and VIIIa. A single base-pair mutation changing Arg506 to Gln at the APC cleavage site of the factor V gene leads to a factor V Leiden variant, which is the most frequent cause of APC resistance. Recently, its role in peripheral venous thrombosis during pregnancy was described. We here report a case with thrombosis of the venous anastomoses after finger replantation with resistance to activated protein C associated with factor V Leiden mutation.

Transsection of the peroneal nerve complicating knee arthroscopy: case report and cadaver study.

We report the case of a 36-year-old male patient who sustained a hyperextension trauma of the left knee. After performing diagnostic arthroscopy (partial tear of the anterior cruciate ligament) and partial resection of the anterior cruciate ligament, the patient experienced a complete paralysis of the peroneal nerve. One year after the first surgical procedure, a reconstructive repair of the peroneal nerve and a transfer of the anterior tibial muscle was performed. This complication is reported for the first time in literature.

Life-saving muscle flaps in tracheobronchial dehiscence following resection or trauma.

OBJECTIVE: In the presence of acute inflammation and necrosis of the wall, tracheo-bronchial defects are difficult to manage. The absence of adequate vascularization and the contaminated area prevent successful direct re-suturing. METHODS: In order to restore a sufficient blood supply we used a pedicled latissimus dorsi or a pectoralis major flap that was entered into the thorax after a 10-cm resection of the second rib. A portion of the muscle was fitted into the tracheo/bronchial defect by reinforced sutures. The remaining muscle was sutured to the tissue surrounding the defect. This method was applied in various septic conditions: Bronchial defects; complete dehiscence of the right (n = 6) or left (n = 1) main bronchus at the carinal level following resection for lung cancer (n = 4) or for tuberculous (n = 2) on nontuberculous pleuropneumonia (n = 1). Tracheal defects; (1) destruction of one third of the tracheal circumference involving the cricoid down to the fourth ring following tracheotomy in presence of a septic sternum after intrathoracic goiter and Bechterew's disease; (2) 30% dehiscence of the anastomosis and septic sternum following tracheal resection; (3) Mediastinitis involving tracheal and esophageal wall following a 7 cm long iatrogenous laceration of the intrathoracic trachea. RESULTS: In one case the latissimus dorsi developed venous stasis on day 2 and was replaced by the pectoralis major muscle which showed uneventful healing. In all other patients the muscle flap resulted in an uneventful closure of the defect and recovery. CONCLUSIONS: Large, well vascularized, pedicled muscle flaps ensure a safe closure of tracheo-bronchial defects or dehiscences even in presence of gross necrosis and sepsis.

Reconstruction of a complex defect on the foot with an osteotendofasciocutaneous lateral arm free flap. Case report.

A one-stage reconstruction of a complex defect of the dorsum of the foot was undertaken with an osteotendofasciocutaneous lateral arm free flap in a 21 year old man. A vascularised strip of the triceps tendon with the adjacent part of the olecranon was used to reconstruct a missing tibialis anterior tendon with the insertion into the medial cuneiform bone. Recovery was uneventful and he was discharged from hospital after two weeks.

[Abdominal fibromatosis in a 58-year-old male patient]. / Abdominelle Fibromatose bei einem 58jährigen männlichen Patienten.

We report on a 58 year-old male patient, in whom abdominal fibromatosis occurred 3 years after laparotomy and irradiation on account of rectal cancer. Abdominal fibromatosis are very rare tumour-like fibrous lesions of the anterior muscular abdominal wall, mainly affecting fertile females. Men, however, are only rarely affected and without age preponderance. A hereditary or mutant generalized defect of growth regulation of fibrous tissue is considered to be the cause of this disease; moreover, trauma, hormonal effects and pregnancies often play a role as cofactors. Interestingly, there is a high correlation between abdominal fibromatoses and osseous lesions of the femur, mandible and thoracic, as well as lumbar spine. In our case thoraco-lumbar Scheuermann's disease was detected.