The expanded forehead scalping flap: a new method of total nasal reconstruction.

The challenge of total nasal reconstruction is particularly formidable in the pediatric patient. Forehead skin is taut, and conventional methods of reconstruction, such as the midline forehead flap, provide a paucity of tissue in this age group. Tissue expansion is well-suited modification to overcome this limitation, but as applied to the midline forehead flap, it does not address the resulting vertical forehead scar. We present a new technique for total nasal reconstruction using an expanded, transversely oriented forehead scalping flap in a pediatric patient. This approach not only provides a generous amount of forehead skin but also limits donor-site morbidity and scarring by orienting incisions transversely at the hairline and within the scalp.

Perineal wound closure with the rectus abdominis musculocutaneous flap after tumor ablation.

BACKGROUND: We describe the transpelvic rectus abdominis musculocutaneous flap for closing large, often irradiated, perineal defects in patients with cancer. METHODS: We studied 9 men and 17 women who underwent wide excision of advanced T3 and T4 tumors and who had preoperative chemotherapy, radiotherapy, or both. After tumor ablation, we used a transpelvic rectus abdominis musculocutaneous flap to fill pelvic dead space and primarily close the perineal wounds. Twelve simultaneous vaginal reconstructions were performed. RESULTS: Wounds healed promptly in 14 patients. Healing was delayed in the remaining 12 patients due to poor flap adherence to irradiated tissue beds (9), complete flap loss (2), or partial flap loss (1). Delayed healing was associated with the combination of obesity and prior irradiation. Other perioperative complications included localized abdominal wound infection (2), enterocutaneous fistula (1), and abdominal herniation (1). Local disease was controlled in 20 of 26 patients. Mean follow-up was 22 months. CONCLUSION: Transpelvic rotation of the rectus abdominis musculocutaneous flap facilitates healing large, difficult, perineal wounds, resulting from cancer ablation.

The first elective free flap in a cardiac transplant patient.

A case of free fibula transfer for mandibular reconstruction in a cardiac transplant patient is described. The reconstructive microsurgeon should be aware of the special requirements of these immunosuppressed patients and flap transfer should be performed in specialized centers with the interaction of different specialties to make the procedure safe and successful.

The Canadian experience with pulsed magnetic fields in the treatment of ununited tibial fractures.

A clinical survey of 56 patients was conducted at four different centers in Canada to evaluate the effect of extremely low frequency pulsed magnetic fields (PMF) on ununited fractures of the tibia. All ten patients with delayed union and 84% of the 44 patients with nonunion healed. One case with a traumatic pseudarthrosis and one with a congenital pseudarthrosis failed to respond to treatment. These results compare favorably to those reported by others using a system with different pulse characteristics. Prolonged immobilization is necessary and poses problems of rehabilitation. Nonunions with a gap between the tibial fragments and pseudarthroses are better treated with bone grafting and internal fixation prior to electrical stimulation.

Non-invasive treatment of ununited fractures of the tibia using electrical stimulation.

A non-invasive method of electrical stimulation of healing in ununited fractures of the tibia by pulsed magnetic fileds has been evaluated. In a series of 17 patients all but two of the fractures united within 4 to 10 months, with an average time of just under six months. The method is sufficiently promising to merit further clinical investigation.

The effect of low frequency magnetic fields on the healing of the osteotomized rabbit radius.

The object of this experimental work was to evaluate the effect of a noninvasive method of electrical stimulation on the healing of freshly-created osteotomies of the rabbit radius. The apparatus consisted of a solid core electromagnet energized by a square wave unidirectional current. The magnetic field was pulsed transversely across the osteotomy site of the radius while the animal was confined to a restraining device 6 hours daily for 5 days per week. In one group of animals the influence of different pulse frequencies, using 0.1 Hz, 1 Hz, and 4 Hz, was evaluated, while the period of stimulation was kept constant at 2 weeks. In another group of animals, exposure was continued for 3 and 4 weeks while the pulse frequency was kept constant at 1 Hz. Histologic and radiologic comparison with control animals revealed that the initiation of the healing process can be accelerated in magnetic fields pulsed at 1 Hz, but that this effect is not maintained, and that the total period of time required for union is not significantly shortened. In view of these findings, this form of treatment is not recommended for clinical use in the treatment of recent fractures of long bones.

Synovial nature of pathologic periarticular structures, including subcutaneous nodules. descent from embryonic arthrogenic fibroblasts: a hypothesis.

In the embryo the periarticular fibroblasts were the producers of the greater part of the joint they surround in later life, as well as of the tendon sheaths and bursae. It is postulated that adult fibroblasts have retained atavistic arthrogenic properties, and may react to traumatizing, inflammatory and oncogenic stimuli by forming periarticular joint-like structures: "arthromas" such as ganglia, meniscal cysts, synovial cysts, synovial sarcoma and subcutaneous nodules. The arthroid nature of these growths manifests itself by the presence of a central cavity, which can be identified as a synovial cavity by histologic, histochemical and electron-microscopic methods. In case of affection of the joint all of these adnexa may be involved. A resemblance of these structures to embryonic joint tissues has been noted for years. The nature of the subcutaneous nodule is discussed at some length. It may contain one or more synovial clefts; synovial elements may be found in its centre by histochemistry and electron-microscopy. Recent and personal findings shed a new light on palisading cells, which may be fibroblasts, having taken up again their embryonic task as synovioblasts. From periarticular fibroblasts thus three kinds of tumors may arise; benign (ganglia, cysts, subcutaneous nodules), malignant (synovial sarcoma) and "semi-malignant" (pannus in rheumatoid arthritis).

Ankylosing spondylitis and inflammatory bowel disease. II. Prevalence of peripheral arthritis, sacroiliitis, and ankylosing spondylitis in patients suffering from inflammatory bowel disease.

To establish the prevalence of peripheral arthritis, radiographic sacroiliitis, and ankylosing spondylitis in patients with inflammatory bowel disease, 58 consecutive patients suffering from ulcerative colitis (UC) and 51 with Crohn's disease (CD) underwent a detailed rheumatological examination. In addition, all patients were screened for the presence of the antigen HLA B27. Peripheral arthritis was found in 14 (8 UC, 6 CD) patients (12.8%); radiographic sacroiliitis was diagnosed in 11 (5 UC, 6 CD) (10.1%), of whom 10 were asymptomatic; and ankylosing spondylitis was diagnosed in 2 UC and 2 CD patients (3.7%). 18.9% of the UC and 3.9% of the CD patients were HLA B27 positive. One of the 11 patients with radiographic sacroiliitis and 2 of the 4 with ankylosing spondylitis had the HLA B27 antigen. Peripheral arthritis, radiographic sacroiliitis, and ankylosing spondylitis are apparently frequent manifestations in patients suffering from inflammatory bowel disease. Asymptomatic radiographic sacroiliitis in these patients appears to differ from idiopathic ankylosing spondylitis, both clinically and genetically. Evaluation of subjective rheumatological complaints, necessary for a confident diagnosis of ankylosing spondylitis, according to the New York criteria is difficult during a flare-up of the inflammatory bowel process, as was shown in 4 CD cases with marked limitation of lumbovertebral function and chest expansion, but no radiological abnormalities of the SI joints.

Ankylosing spondylitis and inflammatory bowel disease. III. Clinical characteristics and results of histocompatibility typing (HLA B27) in 50 patients with both ankylosing spondylitis and inflammatory bowel disease.

A study was made, in co-operation with several gastroenterology and rheumatology centres, of the clinical and genetic characteristics (HLA B27) of 50 patients suffering from both inflammatory bowel disease (38 Crohn's disease (CD), 12 ulcerated colitis (UC)) and ankylosing spondylitis (AS), the latter diagnosis being established according to the New York criteria. 20 CD (52.6%) and 8 UC (66.7%) patients were HLA B27 positive. The presence of HLA B27 was studied in relation to clinical parameters, such as first occurrence of symptoms of AS or inflammatory bowel disease (IBD), a history of peripheral arthritis, iridocyclitis, and a positive history of AS or IBD. Our patients were found to have heterogeneous clinical features: on one side of the spectrum a group of cases was distingiushed with the typical characteristics of idiopathic AS, often being HLA B27 positive. On the other side a smaller group of HLA B27 negative patients was observed, with severe intestinal inflammatory pathology, lacking most of the typical clinical features of idiopathic AS ('secondary' form of AS). Finally, between these two extremes a group of patients was found with less pronounced clinical or genetic characteristics. These different clinical and histocompatibility patterns suggest a mixed aetiopathogenesis of AS in IBD patients. Such a 'syndrome' of AS might harbour both idiopathic AS and forms of AS 'secondary' to the intestinal inflammatory pathology.