Calcium sulphate delivery system with tobramycin for the treatment of chronic calcaneal osteomyelitis.

The case of a 24-year-old woman with Pseudomonas aeruginosa and Proteus mirabilis chronic calcaneal osteomyelitis is presented. Extensive debridement of the necrotic bone and application of tobramycin-loaded polymethylmethacrylate beads was performed and ciprofloxacin was given post-operatively. Three months later, laboratory tests, including complete blood cell count, erythrocyte sedimentation rate and C-reactive protein, were normal. At this time, extensive surgical debridement and filling of the osseous defect with autologous iliac cancellous bone graft and tobramycin-impregnated calcium sulphate pellets and paste were performed. Oral ciprofloxacin was administered for 3 months after surgery. At the latest follow-up, 2 years later, the patient had full weight-bearing function; there was no recurrence of the infection, and complete incorporation of the autologous bone and calcium sulphate graft with the host bone was observed. This case demonstrates that two-stage surgical treatment with extensive debridement and tobramycin-impregnated calcium sulphate was effective in treating chronic calcaneal osteomyelitis.

Munchausen's syndrome presenting as severe panniculitis.

Factitious disorders may trouble any physician during his/her career. A considerable number of cases of Munchausen's syndrome (self-induced disorder) are misdiagnosed in clinical practice. A 36-year-old woman was admitted to our hospital because of fever and abdominal pain. Physical examination showed signs of inflammation of the abdominal wall, and histological examination revealed severe panniculitis. We investigated various aetiologic factors that could probably be related to fat necrosis, but we found no explanation of the phenomenon until we verified the diagnosis of Munchausen's syndrome. 2 years later, the patient underwent surgery for removal of needles, which she herself had deliberately located under her skin. High index of suspicion and physician's persistence are necessary to make the correct diagnosis in the various protean manifestations of Munchausen's syndrome.

Alternatives in soft tissue reconstruction of the ankle and foot.

Reconstruction of soft tissue defects of the ankle and foot still presents a challenge. This is related to both the lack of large soft tissue flaps in this part of the body suitable for transfer to adjacent injured areas and to of the unique characteristics of the soft tissues of the sole of the foot. Microsurgery has solved some of these problems with the transfer of soft tissue from more distal areas. Several small arterialized and sometimes innervated flaps from the intrinsic tissues of the foot are also available for reconstruction of defects of limited size. The present report assesses 49 flaps, 15 local and 34 microsurgical transfers which were performed in 46 patients. The results suggest that there are several effective alternatives for coverage of soft tissue defects of the ankle and foot.

Vascular impairment and free tissue transfer in the lower extremity.

Fourteen patients with arteriosclerotic peripheral vascular disease and extensive tissue defects of the lower extremity, underwent microsurgical reconstruction using free tissue ("free flap") transfer. It was possible to provide coverage in ten of these patients. Analysis of this small series showed that only six of these ten patients were able to resume unassisted ambulation. The authors discuss technical aspects of microsurgical reconstruction in this unfavorable group of patients. Analysis of this small series suggest that: (1) inadequate patient motivation, and (2) inability to form granulation tissue in the soft tissue defect, either before or after a vascular reconstructive procedure, are both strong contraindications to microvascular free flap reconstruction in patients with arteriosclerotic peripheral vascular insufficiency of the lower extremity.

Transpositional microsurgery in multiple digital amputations.

In 34 of the 62 patients treated for complete multiple digital amputations, the severed part was not replanted in its anatomical position, but in the place of the most useful stump. This procedure is defined as transpositional digital microsurgery and refers to the transposition and replantation of any digit to another stump which plays a more significant role in the function of the hand. Twenty-eight patients had transposition of a digit, while six patients underwent thumb transposition. All except six of the transposed digits survived, while all of the thumbs survived the surgical procedure. The cosmetic appearance of the hand with a transposed digit or thumb was acceptable to the patients. Two-point discrimination was assessed to be 10-14 mm for the transposed digits, and the functional ability of the transplanted digit was comparable to digits which were replanted in their anatomical position. In conclusion, transpositional digital microsurgery remains a useful alternative for the treatment of multiple digit amputations, particularly in patients with severely damaged non-replantable amputated parts.

Vein grafts in reconstructive microsurgery of the lower extremity.

This paper describes surgical techniques and results of lower extremity microsurgical reconstruction using vein grafts. During a 5 year period, free tissue transfers were used to reconstruct 118 lower extremity defects in 109 patients. In 28 of these cases (24%), saphenous vein grafts were used when reconstruction would otherwise have been difficult or impossible. A preliminary arteriovenous fistula was established between the proximal arterial source and the final venous drainage in the majority (26) of cases. Venous drainage was left intact at the point of entry into the deep venous system in 23 cases. Three complications included anastomotic clotting in 2 patients and postoperative blow-out of the vein graft in another; all were treated without flap loss. Flap survival was 86% in vein grafted patients and 94% in those cases in which vein grafts were not used. Flap loss was related in each case to the nature of the pre-existing condition, rather than to vein grafting per se.

Long-term results after chemoradiotherapy for locally confined squamous-cell head and neck cancer.

The long-term results after simultaneous chemoradiotherapy in 54 patients with previously untreated or minimally treated, locally confined (M0) squamous-cell carcinoma of the head and neck are presented. Multiple concurrent courses of radiation therapy and chemotherapy with cisplatin and a four-day 5-fluorouracil infusion were given. Twenty-eight patients underwent definitive surgery and 26 were treated without surgical resection. Treatment-associated toxicity was significant, including mucositis, myelosuppression, and a mean 12% loss of initial body weight. Of the 54 patients, 51 were ultimately rendered disease free by this combined modality protocol. With a follow-up ranging from 42-68 months, the projected Kaplan-Meier relapse-free survival for the entire patient cohort is 70%, with all relapses occurring within 17 months of patient entry. The projected Kaplan-Meier relapse-free survival for patients with Stage IV disease is 62%. The durability of these remissions suggests that there is a significant likelihood of cure in all patients with locally confined disease, and justifies comparative trials with standard treatment.

Treatment of oral squamous cell carcinoma with simultaneous chemotherapy and radiation: results and surgical implications.

Thirty-seven patients with oral squamous cell carcinoma, many with advanced disease, were treated initially with a protocol using simultaneous intravenous 5-fluorouracil (5-FU) cis-platinum, and radiation. Twenty-two patients (62%) experienced complete remission after one cycle of therapy. Fifteen patients (38%) demonstrated an incomplete response; surgical resection was possible in 14 of these 15 patients. A second cycle of chemoradiotherapy was administered to all 37 patients. After this treatment resection is possible for some patients who are initially inoperable, and surgery is necessary only for those patients (38%) who show an incomplete remission after the first cycle of therapy and for those who present initially with bony invasion. Furthermore, the treatment of cervical nodes and intraoral disease may be divorced and the extent of surgery may be reduced for many patients. A 5-year survival of 76% is predicted for this group of patients. The described protocol shows promise for treatment of oral squamous cell carcinoma.

Simultaneous versus sequential combined technique therapy for squamous cell head and neck cancer.

Forty-eight patients with locally confined (M0) squamous cell head and neck cancer were prospectively randomized to receive either simultaneous (SIM) or sequential (SEQ) combined technique therapy with a 5-fluorouracil infusion, a cisplatin bolus injection, and radiation therapy. Patients with residual resectable disease underwent surgery after induction therapy, whereas those achieving a complete response to induction did not require surgery. Patients on the two treatment arms were equivalent in all measured variables, including disease extent. Toxicities of the SIM and SEQ arms also were equivalent except for mucositis and the resultant weight loss, which were more severe on the SIM arm (P = 0.002). With a follow-up time ranging from 9 to 41 months, seven of the 24 SIM patients and 14 of the 24 SEQ patients are considered treatment failures. The relapse-free survival is significantly better on the SIM arm (P = 0.03), although an overall survival advantage has not yet been demonstrated (P = 0.13). The achievement of a complete response after induction therapy correlates with both the relapse-free (P = 0.0005) and overall (P = 0.05) survival, and the likelihood of an induction complete response also is significantly better for those treated with the SIM schedule (P = 0.02). Eighteen patients did not require surgery after achieving an induction complete response. Relapse-free survival does not appear to be compromised in this patient subset.

Oral squamous cell carcinoma in children.

Squamous cell carcinoma of the oral cavity occurs very rarely in children and is particularly rare during the first decade of life. This article describes a case of squamous cell carcinoma of the maxillary alveolar ridge in a 7-year-old child. Subtotal maxillectomy was carried out with an apparent cure (33-month follow-up). A brief review of this disease as it occurs in children is included. Although this is an aggressive neoplasm, early and adequate surgical intervention may be curative.

Simultaneous radiotherapy and chemotherapy with 5-fluorouracil and cisplatin for locally confined squamous cell head and neck cancer.

Fifty-four patients with previously untreated or minimally treated locally confined (MO) squamous cell carcinoma of the head and neck were treated with chemoradiotherapy employing multiple courses of simultaneous radiation, cisplatin, and a 4-day 5-fluorouracil infusion. Twenty-eight patients subsequently underwent definitive surgery, and 26 were treated without surgical resection. Of the 54 patients, 51 were ultimately rendered disease free by this combined modality protocol. The projected relapse-free survival rate for the entire cohort is 71%, with a median relapse-free survival time greater than 17 months. Thirteen patients who had tumors that were technically operable did not undergo surgery after achieving a complete response to induction chemoradiotherapy. Only 1 of these patients experienced subsequent local failure. Although the treatment-associated mucositis and local failure. Although the treatment-associated mucositis and myelosuppression were significant, this chemoradiotherapeutic protocol offers a significant chance of relapse-free survival for all patients with locally confined disease and merits comparison with more standard treatment approaches.

Short saphenous vein grafts as an aid to microsurgical reconstruction of the lower extremity.

The authors present a method of free flap reconstruction using the short saphenous vein, when local vessels are not available in the lower extremity. Initially, a temporary arteriovenous fistula is created. This is subsequently divided to provide both arterial access and venous drainage for the flap. The use of the short saphenous vein has a number of advantages: 1) forty to 50 cm of length are available; 2) the vein is relatively thin-walled and has a nearly constant diameter throughout its length; 3) the vein may be left in situ at its upper end in some patients; 4) the vein drains into both the long saphenous and the popliteal veins. Thus, double drainage is provided. This may be of importance in patients with impaired outflow secondary to deep venous thrombosis or obstruction. 5) The separated vein graft components allow accurate ultrasonic monitoring of both arterial and venous circulation. Seven cases are presented of type IIIb and IIIc tibial fractures in which regional vessels were not accessible. Free flap reconstruction using in situ short saphenous vein grafts was successful in all seven patients. The anatomy of the short saphenous vein and surgical technique are considered.

Beyond replantation: microsurgical salvage of complex hand injuries.

The authors believe that certain complex hand injuries so severe as to be considered for amputation or simple proximal revision, may under some circumstances be salvaged with the use of appropriate microsurgical techniques. They present three examples of severely injured hands to illustrate the reconstructive potential of microsurgery. Salvage techniques are considered in some detail including debridement, evaluation and planning, fixation, restoration of circulation, reconstruction of tendons, joints and nerves, and provision of coverage. The importance of vein grafts for successful salvage of complex hand injuries is emphasized.

Chemoradiotherapy as initial management in patients with squamous cell carcinoma of the head and neck.

Thirty-nine previously untreated or minimally treated patients with squamous cell carcinoma of the head and neck were entered onto a chemoradiotherapy protocol employing multiple courses of simultaneous radiation therapy, cisplatin, and a 4-day 5-FU infusion. Thirty-eight patients were evaluable for response and toxicity. Twenty-three patients underwent surgical resection midway through this therapy and 11 (48%) were pathologically free of disease. Thirty-five of the 38 patients (92%) were ultimately rendered disease-free by this combined modality protocol. Thirty-one patients remain disease-free, with a projected 2-year disease-free survival of 74%. Although the treatment-associated mucositis and myelo-suppression were significant, this chemoradiotherapeutic approach is promising and merits further study.

Avulsion injuries of the thumb.

Similar findings in a series of seven avulsions of the thumb suggest that this injury is a well-defined entity. In all cases avulsion was the result of catching the digit in a rotating machine. In most cases a glove was worn. The usual clinical findings included extrinsic tendon avulsion from the forearm, nerve avulsion from the median nerve within the carpal tunnel, extensive arterial damage in the amputated thumb, and partial degloving of soft tissues. Successful replantation was possible in every case. We believe that vein grafts should be used routinely, anastomosed to normal distal vessels. The site of nerve injury should be identified by dissection of the median nerve within the carpal tunnel. Retrograde flaps should not be sutured for wound closure. We believe that replantation should be attempted in all cases of thumb amputation in which the part is available.

A palmar cross-finger flap for coverage of thumb defects.

We have devised a method of covering tissue defects of the distal thumb using a flap elevated between the two flexion creases on the palmar skin over the proximal phalanx of the long finger. The advantages of this method over the usual dorsally based, distal, cross-finger flap include improved appearance of the donor finger, comfortable positioning, and avoidance of joint contractures. Although sensitivity of the palmar scar, contractures, or other disadvantages of this approach were sought during follow-up, none were found.

Combination chemotherapy prior to definitive local therapy in squamous cell carcinoma of the head and neck.

30 patients with locally advanced squamous cell carcinoma of the head and neck were given chemotherapy with methotrexate, bleomycin and cis-Platinum prior to planned definitive surgery and/or radiation therapy. Chemotherapy was well tolerated and 90% of patients responded. Of 14 initially unresectable patients, 6 became operable after chemotherapy. After definitive therapy 70% of patients were considered complete responders, and 43% of the entire cohort remain disease-free. All partial responders have died. Patients receiving chemotherapy, surgery and radiation had a significantly greater likelihood of achieving a complete response than those receiving chemotherapy and radiation alone. Although this initial chemotherapy is highly active in this disease its contribution to ultimate survival is unclear. Overall treatment success is determined by the results of definitive therapy.

A simple method of controlling rotation in replanted digits.

A method of fixation for replanted digits is described. It consists of axial fixation with a wire passed longitudinally through the replanted digit, supplemented with a transverse wire passed across all the digits. In this way, splinting is provided and rotation is controlled. The method is simple, rapidly applied, and very effective.

Intraoperative heparin in replantation surgery--an experimental study.

An experimental study to define the usefulness of heparin in microvascular surgery was undertaken. Fifty-four rabbits underwent replantation of an amputated ear. The animals were randomly divided into two groups--"heparin" and "no heparin," with 27 animals in each group. Arterial patency was recorded based on direct microscopic observation of the anastomosed vessels prior to wound closure and on subsequent viability or necrosis of the ear during the surgical procedure was markedly enhanced by the use of intraoperative heparinization. The overall patency rate for the heparin group was 74%, whereas that of the no-heparin group was 44%--a statistically significant difference. This study confirms the value of intraoperative heparin in experimental replantation surgery using a rabbit ear model.