Internal fixation of phalangeal fractures using titanium miniplates.

Although widely utilized in the treatment of metacarpal fractures, plate fixation in phalangeal fractures remains controversial. Increased potential for infection, breakage, and added soft-tissue trauma leading to increased joint stiffness have been cited as important negative factors. A retrospective analysis of titanium plate fixation of phalangeal fractures over a 7-year period is presented. From 1991 to 1998, 16 fractures (13 men, 3 women; age range, 19-70 years) were managed with plate fixation using the Profyle titanium plating system as the primary modality of treatment. All plates were seated dorsally using an extensor tendon-splitting approach. The average follow-up period after surgery was 5 months (range, 3-28 months). Fracture patterns varied: 31% (5 of 16) were open fractures and 69% (11 of 16) were closed. Complications occurred in 25% of patients (4 of 16) and consisted of pain or other trigger that required removal of hardware, flexion contracture at the proximal interphalangeal joint, and extensor lag. There were no instances of hardware failure, infection, or malunion. The quality of recovery of joint motion was assessed using the Total Active Flexion Scale: nine digits were graded excellent, another six were categorized as good, and only one digit was judged as poor. A review of the current literature is presented along with suggested guidelines for the application of miniplate fixation for fractures of the phalanges.

Ambulatory surgery for cleft lip repair.

Standard of care for cleft lip repair has included preadmission testing, surgical correction, and postoperative hospital care. Driven not by managed care economics but to speed the safe home care of infants by parents, the authors have gained experience in ambulatory cleft lip repair. In this retrospective study the authors evaluated the outcome of patients who underwent ambulatory cleft lip repair compared with those patients who were hospitalized after surgery. From 1989 to 1998, 24 cleft lip repairs in 24 patients performed by the senior author were evaluated. Two groups were treated. Group 1 (N = 11) consisted of ambulatory unilateral cleft lip repairs and group 2 (N = 13) consisted of inpatient unilateral cleft lip repairs. Important surgical factors considered were technique of cleft lip repair, performance of ancillary procedures, type of local anesthetic administered, and intravenous steroid administration. Time to first postoperative feeding and complications, including bleeding, spontaneous or traumatic wound dehiscence, and infection, were considered important outcome parameters. There were no differences in surgical technique or use of antibiotics and postoperative analgesics between the two groups. None of the patients in group 1 underwent ancillary procedures. Four patients underwent soft palate repair and 3 patients underwent insertion of myringotomy tubes among group 2 patients. The use of a 1:1 mixture of 1% lidocaine and 0.5% bupivacaine with epinephrine vs. 1% lidocaine with epinephrine as a local anesthetic and intravenous steroid administration was greater in group 1 (92%) than in group 2 (33%) patients. The average time to the first postoperative feeding was more than 1 hour sooner in the ambulatory group (p < 0.05) compared with the hospitalized group (excluding the 4 patients who underwent soft palate repair). There were no complications among patients with ambulatory cleft lip repair, and there were two cases of minor wound separation in patients who received postoperative hospital care. Although many variables factor into the outcome after cleft lip repair, these data support the safety and continued practice of ambulatory cleft lip repair.

Little finger-to-thumb microvascular transfer.

This case report documents a unique thumb reconstruction performed at the authors' institutions. The amputated dominant right thumb of a manual laborer was electively reconstructed with microvascular transfer of the previously partially amputated little finger from the same hand. At 1 year postoperatively, the patient returned to work with excellent grip and pinch strength, thumb opposition to all digits, and 8 mm of static two-point discrimination. The technical details of the operation are described and compared with other analogous reports in the literature.

The effect of ketorolac on microvascular thrombosis in an experimental rabbit model.

This study was undertaken to evaluate the effect of ketorolac (Toradol), a potent cyclooxygenase inhibitor used for postoperative pain, on microvascular thrombosis in an established thrombosis model. Bilateral 3-mm arterial inversion grafts (n = 66) were constructed in the femoral arteries of New Zealand White rabbits. ALZET (ALZA Corporation, Palo Alto, Calif.) osmotic pumps were implanted in the external jugular veins for drug delivery. The blinded protocol called for the experimental animals to receive intravenous doses of ketorolac of 1.72 mg/kg per day (group 1) or 3.44 mg/kg per day (group 2), while control animals received equivalent volumes of saline. Patency was assessed at 7 days. Whereas 52 percent (13 of 25) of control vessels remained patent, 70 percent (14 of 20) and 86 percent (18 of 21) of group 1 and group 2 vessels, respectively, were patent at 1 week. This decrease in microvascular thrombosis with delivery of ketorolac was statistically significant (p = 0.0094). Ketorolac, at experimental doses approximating 9 and 18 mg IV q6h in a 70-kg man, demonstrated a statistically significant reduction in microvascular thrombosis. This study supports its use in clinical microvascular surgery.

A comparison of iliac and cranial bone in secondary grafting of alveolar clefts.

This retrospective study compares the success of iliac versus cranial bone autografts in the secondary grafting of alveolar clefts. The study group was 116 patients with complete records and radiographs from a pool of 186 consecutively grafted patients at Children's Hospital of Philadelphia. The quality of graft "take" was graded radiologically. Variables potentially influencing outcome were evaluated and included graft type (iliac versus cranial bone), cleft type (unilateral versus bilateral), cleft severity (complete unilateral or bilateral cleft lip and palate versus cleft of the alveolus only), age at grafting, and complications. Although graft "take" versus "nontake" seemed comparable in iliac and cranial bone graft groups, iliac bone showed a statistical superiority over cranial bone, with more radiologically excellent grades (p = 0.04) in all cleft types. Likewise, when the two graft types were compared in more severe clefts (complete unilateral and bilateral cleft lip and palate), iliac bone showed statistical superiority (p = 0.02) over cranial bone. However, they seemed comparable in less severe clefts of the alveolus only (p = 0.22). Recipient-site complications and their sequelae were comparable in iliac versus cranial graft groups, and no age-related differences were noted in children grafted above or below age 10.

The anatomy of the lower serratus anterior muscle: a fresh cadaver study.

Forty fresh cadaver dissections were studied to determine variations in the anatomy of the lower portion of the serratus anterior muscle. In all cases, the lower three to five slips of the serratus anterior muscle were supplied by one to three branches from the thoracodorsal artery, the so-called serratus branches. Three vascular patterns were identified: type I with one branch (40 percent), type II with two branches (50 percent), and type III with three branches (10 percent). The mean dimensions of the lower serratus anterior flap were 18.0 x 9.0 cm (range 12.0 x 8.0 cm to 21.0 x 15.0 cm). The mean pedicle length was 11.3 +/- 2.8 cm (range 7.3 to 13.3 cm). A crow's foot landmark has been identified to facilitate flap dissection. This landmark marks the juncture of the long thoracic nerve and the dominant serratus branch. This juncture can be found at the superior border of the sixth or seventh rib. The lower serratus anterior flap is ideal for reconstruction of small to moderate-sized defects because of its flat, broad dimensions and its long vascular pedicle.

The versatile superficial inferior epigastric flap for breast reconstruction.

The superficial inferior epigastric flap is a versatile free flap that has added to the techniques available for autogenous breast reconstruction. It is especially advantageous when previous thoracic radiation and/or abdominal surgery preclude the use of conventional transverse rectus abdominis musculocutaneous flaps. Eight superficial inferior epigastric flaps were used to reconstruct 7 breasts in 6 patients. In 4 patients the superficial inferior epigastric flap was used as part of a composite free flap. In 1 patient, a lower abdominal wall flap was transferred on bilateral pedicles. In another, bilateral flaps were raised to reconstruct both breasts. The superficial inferior epigastric flap offers several advantages. It uses relatively abundant lower abdominal wall skin and subcutaneous tissue while preserving the underlying fascia and rectus muscles. A cadaver study illustrates the clinical territory of this flap. The superficial inferior epigastric flap provides an excellent option for autogenous free flap reconstruction of the breast, alone or in combination with other flaps.

The effect of dextran on microvascular thrombosis in an experimental rabbit model.

Although low molecular weight dextran is commonly utilized in clinical microsurgery, few experimental data are available documenting its efficacy. Bilateral 2-mm arterial inversion grafts were constructed in the femoral arteries of New Zealand White rabbits. The experimental group (n = 40 grafts) received a 5-day constant infusion of intravenous dextran 40 at 2.1 ml/hour, and the control group (n = 50 grafts) received no infusion. Whereas 85 percent (34/40) of the dextran grafts were patent at 1 week, only 48 percent (24/50) of the control grafts were patent (p = 0.0003). Scanning electron micrographs revealed a decrease in both platelet and fibrin deposition in the patent dextran arterial inversion grafts versus the patent control specimens. As a marked diminution in microvascular thrombosis was demonstrated at a clinically relevant dose, the continued use of intravenous dextran 40 in clinical microsurgery is supported by this study.

Radial and ulnar artery repairs: assessing patency rates with color Doppler ultrasonographic imaging.

This study was undertaken to evaluate the patency rate of radial and ulnar artery repairs performed with use of the magnification afforded by the operative microscope. Color Doppler ultrasonographic imaging was chosen as a reproducible, noninvasive technique to evaluate patency and graphically display vascular flow characteristics. Twenty-eight consecutive patients with 35 arterial injuries form the study group. Twenty-four patients with 31 arterial lacerations were available for enrollment in the protocol. Follow-up ranged from 1 to 40 months (average, 10 months). Eighteen male and six female patients sustained 13 radial and 18 ulnar artery lacerations, all sharp. Four patients required interposition vein grafting. Overall patency after repair was found to be 84%, with 82% of single vessels and 86% of double vessels patent. The patency of single vessels repaired without the use of vein grafts was 100%. These results indicate that microscope-assisted repairs of the radial and ulnar arteries remain patent at a higher rate than is commonly cited.

The effect of ibuprofen on microvascular thrombosis in an experimental rabbit model.

The efficacy of ibuprofen in reducing microvascular thrombosis in a well-established experimental model was studied. Bilateral 2-mm arterial inversion grafts were constructed in the femoral arteries of New Zealand White rabbits. The experimental group (n = 40 grafts) received subcutaneous injections of ibuprofen 15 mg/kg t.i.d. beginning 1 day preoperatively and continued for 7 days postoperatively. The control group (n = 42 grafts) received injections of an equivalent volume of saline three times per day. Patency was evaluated at 7 days by the distal milking test. Seventy-three percent of the ibuprofen grafts were patent at 7 days, whereas 57% of the control grafts remained open. This difference in microvascular patency was not statistically significant. Representative scanning electron micrographs revealed a moderate reduction in aggregated platelets and overall clot density in the patent ibuprofen arterial inversion grafts compared with the patent control specimens. Although the use of ibuprofen as a sole antithrombotic agent cannot be recommended as the result of this study, it may be efficacious when used in conjunction with other agents such as dextran 40.

Efficacy of epidural anesthesia in free flaps to the lower extremity.

Epidural anesthesia is an effective means of providing pain control and chemical sympathectomy at the spinal nerve root level. The purpose of this study is to compare the efficacy of the combination of epidural and general anesthesia to general anesthesia alone in patients undergoing free flaps to the lower extremity. A retrospective review of 35 consecutive patients (36 operations) from November of 1988 to November of 1990 undergoing free tissue transfer to the lower extremity was undertaken. Sixteen patients had epidural and general anesthesia, and 19 (20 operations) had general anesthesia alone. There were no significant differences in the age or sex of the patients, the distribution between acute and chronic wounds, or the number of cigarette smokers in the two groups. There were no flap losses in the epidural group (100 percent success) and one major, but nonmicrovascular complication (6 percent). In the nonepidural group, there were one flap loss (95 percent success) and five major complications (25 percent). These included three microvascular complications (15 percent). There were significantly fewer patients with postoperative atelectatic fevers in the epidural group versus the nonepidural group. In this consecutive series of patients, epidural supplementation of general anesthesia for free flaps to the lower extremity was associated with uniformly successful flap survival and a lower rate of microvascular complications compared to general anesthesia alone.

Treatment of hand injuries by external fixation.

Thirty-five consecutive applications of external fixation to the hand, including 27 acute cases and 8 reconstructive procedures, were studied. In both settings, external fixation was used not only for skeletal stabilization but also for management of the soft tissues. Twenty of the 22 acute fractures healed, and six arthrodeses with interposition bone grafts resulted in fusion. Three septic nonunions resolved, and two united successfully. There were no complications. We recommend external fixation systems in the hand, and several case reports are included in the study to illustrate the various applications.

Treatment of chronic traumatic bone wounds. Microvascular free tissue transfer: a 13-year experience in 96 patients.

During a 13-year period at the Massachusetts General Hospital, Boston, Massachusetts, 97 microvascular free tissue transfers have been performed for soft-tissue reconstruction in 96 patients following bone debridement for chronic traumatic bone wounds. These 96 patients comprise a continuation study of 18 original patients reported in 1982. During a 13-year follow-up period (mean, 77.1 months), 95.8% of these 96 patients have enjoyed complete wound closure with a lack of drainage after the debridement and free tissue transfer. Most of the patients (89.6%) encountered in this study are ambulatory without assist and 5.2% of patients have undergone amputation. Twenty-three per cent of patients required subsequent segmental bone defect reconstruction in the lower extremity after infection eradication. The pathophysiology of chronic traumatic bony wounds is different from that of chronic hematogenous osteomyelitis and thus a high incidence of long-term successful management can be seen through complete wound debridement and adequate soft-tissue coverage.

Judgment and approach for management of severe lower extremity injuries.

Severe lower extremity injuries are devastating in their impact on the patient, his or her family, and the future. A critical evaluation of the results of previous salvage efforts provides the basis for the formulation of a treatment strategy. Success can be measured only in terms of functional outcome. The type of therapy is perhaps less important than the effectiveness of establishing a coordinated multidisciplinary approach to these injuries.

An experimental model for the study of canine flexor tendon adhesions.

An experimental model for the study of canine flexor tendon adhesions was designed using a standardized crush-abrasion injury, meticulous sheath closure, and three-week limb immobilization. Ten animals in the experimental protocol were evaluated for visible adhesion formation. With use of a flexor tendon adhesion rating scale, consistent adhesion formation was documented with an average score of 10.4 +/- 2.1 (range, 0 to 12). Five additional animals had biomechanical testing. Applying an increasing load to the proximally divided profundus tendon (0 to 10 Newtons), it was found that the angle of distal interphalangeal joint motion and the displacement of the toe were significantly decreased, and the work generated significantly increased in the experimental versus control digits (p less than 0.05). The consistent production of visible adhesions thus correlates with biomechanical impairments in toe motion and work. The study of agents aimed at diminishing flexor tendon adhesions will thus be facilitated by this reliable model. Systemic or intrasheath administration of agents will be possible.

Surgical management of ulnar artery aneurysms.

In a ten-year review (1978 to 1988), ten ulnar artery aneurysms in nine male patients were studied. Blunt trauma led to 70%, penetrating trauma to 20%, and 10% had no history of trauma. Three cases were seen as asymptomatic palmar masses with brief antecedent histories of 4 weeks or less. Seven patients with aneurysms had persistent vascular hand symptoms for 6 weeks or longer. All seven symptomatic lesions proved to be sources of emboli. Diagnostic arteriography was done in all cases. Intraoperative digital plethysmography aided in operative decisions regarding the necessity for microvascular reconstruction. Five aneurysms were resected with end-to-end ulnar artery microvascular repairs, four resected without repair, and a single case treated with long-term anticoagulants. Follow-up, averaging 40 months, showed uniform improvement in vascular symptoms, with no loss of jeopardized tissues. Ulnar artery aneurysms, well studied preoperatively and intraoperatively, can be treated successfully with selective microvascular reconstruction.

Lactation as a complication of aesthetic breast surgery successfully treated with bromocriptine.

A case is presented of lactation occurring ten days after mastopexy with augmentation mammaplasty. Milk-draining sinuses involving the operative incisions necessitated prompt diagnosis and treatment to avoid breast implant loss. Bromocriptine, an ergot derivative, was used to suppress a pathologically elevated prolactin level and successfully effect a rapid resolution of lactation.

Salvage of a failing microvascular free muscle flap by direct continuous intravascular infusion of heparin: a case report.

A free gracilis muscle transfer with skin graft was performed for reconstruction of a type IIIB lower extremity traumatic wound with acute exposure of the distal tibia fracture site and an extensive soft-tissue wound. The free muscle flap failed from a venous thrombosis that was recognized 12 hours postoperatively, and reexploration revealed extensive venous thrombosis throughout the lower leg. The flap was salvaged by direct catheter administration of heparin into the vena comitans of the gracilis artery, which bathed the newly repaired venous anastomosis with an anticoagulating dose of heparin without systemic elevation of the patient's PTT. Ultimate full flap survival and wound healing ensued.