Complex injuries of the forearm. Coverage considerations.

Complex forearm injuries involve damage to the skin and underlying tissues. The best results are obtained when a multidisciplinary approach is taken to their management. Management of the acute injury should be done in a manner that takes into consideration late reconstructive procedures and best possible final function outcome. This article reviews initial management and options for soft-tissue coverage. Advantages and disadvantages of a wide variety of procedures are discussed and in addition the authors review some of the more controversial areas and give personal preferences.

Limb salvage surgery and adjuvant radiotherapy for soft tissue sarcomas of the forearm and hand.

Twenty-five consecutive patients with soft tissue sarcoma of the forearm and hand were assessed for limb-salvage surgery and were entered into a prospective study evaluating oncologic details and functional outcome. Seventeen patients had received incomplete primary excision elsewhere and presented with local recurrence or residual disease. Three had pulmonary metastases at the time of presentation. Twenty-three patients were candidates for limb-salvage surgery and 20 received adjuvant radiotherapy. The mean follow-up period was 37 months. There was local recurrence in three patients who had initially received marginal excision of the primary sarcoma, and three patients died of systemic disease. Limb function was assessed prospectively using both patient-based and clinician-based functional scoring systems and revealed good to excellent results in all but three patients. Eighty-eight percent of those who survived and did not require amputation were able to return to occupational and activities of daily living with no or minimal functional limitation. This study demonstrates that limb-salvage surgery, with adjuvant radiotherapy when necessary, is an effective alternative to amputation in the majority of patients with sarcoma of the forearm and hand. Radiation toxicity is rarely a problem.

Sternotomy infections: sternal salvage and the importance of sternal stability.

OBJECTIVE: To review the management of sternal wound infection after cardiovascular surgery. DESIGN: Retrospective case study. SETTING: All management took place in a single tertiary-care university hospital. PATIENTS: Twenty-one consecutive patients seen over a 3-year period who had infected median sternotomy incisions after cardiovascular surgery. INTERVENTIONS: Surgical eradication of infection, including sternal débridement and rewiring or placement of vascularized muscle flaps, or both. MAIN OUTCOME MEASURES: Resolution of infection and restoration of sternal stability. RESULTS: The development of sternal wound infection was found to be associated with sternal instability. In 12 of 17 patients treated initially with sternal débridement and rewiring the infection was cured. Vascularized muscle flap transfers were required to eradicate the infection in the remaining patients. CONCLUSIONS: Sternal débridement and rewiring is an effective initial treatment for sternal wound infections in selected patients. Some patients may require placement of muscle flaps for definitive treatment.

Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand.

High-resolution ultrasound is capable of detecting foreign bodies of practically any composition. The purpose of this study was to determine in a controlled manner the sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand. Each of 15 fresh-frozen cadaver hands was divided into 21 standardized sites for potential foreign body insertion. Foreign bodies consisted of two sizes of three different materials (wood, glass, and metal). Foreign bodies were randomly assigned to 50% of the available sites. The empty sites served as controls. All hands were scanned by a single radiologist using high-resolution ultrasound at a frequency of 10 MHz. The radiologist was unaware of which specimens contained foreign bodies. Of the 166 foreign bodies inserted in total, 156 were detected by ultrasound. Ten sites were falsely analyzed as negative, for a sensitivity of 94%. There was one false positive result and 148 true negatives. The specificity was therefore 99%. The high specificity of ultrasound allows foreign body presence to be confirmed given a positive result. A combination of ultrasound and x-ray films should allow for diagnosis and localization of virtually all foreign bodies in the hand.

Epiphyseal plate transplantation: an historical review.

Non-vascularized and vascularized transplantation of epiphyseal plate autografts have been performed both clinically and experimentally for over 100 years. However, the ultimate clinical goal of vascularized transplantation of epiphyseal plate allografts for paediatric extremity reconstruction remains elusive, due primarily to the lack of suitably nontoxic techniques to prevent graft rejection. We have summarized the published clinical and experimental investigations of vascularized epiphyseal plate transplantation, and organized the experiments and clinical operations into four main groups: (1) local vascular studies on unmanipulated epiphyseal plates, (2) studies of epiphyseal plate behaviour after orthotopic replantation, (3) studies of epiphyseal plate behaviour after heterotopic transplantation, and (4) studies of epiphyseal plate behaviour after allograft transplantation. Prior investigations into the non-vascularized transplantation of epiphyseal plate autografts and allografts are presented as background. These groups of studies serve as the building blocks for the more clinically applicable experimental investigations outlined in the final section of this review.

Short-term response of epiphyseal plate cell populations following selective devascularization and microsurgical revascularization.

The distal femoral epiphyseal plates of 21 8-week-old New Zealand white rabbits were totally or partially (nutrient artery only) devascularized, or devascularized and then microsurgically revascularized. Sacrifice was at 24, 48 or 72 hours postoperatively. The heights of the proliferative and hypertrophic zones of the epiphyseal plates operated upon were compared with the contralateral control epiphyseal plates for both the central and the peripheral regions of the epiphyseal plate. Neither extent of devascularization nor revascularization had a significant effect on the height of the proliferative zone of chondrocytes at any of the follow-up intervals. Selective devascularization of the nutrient artery led to a significant increase in height of the central region of the hypertrophic zone of chondrocytes at 48 and 72 hours. Microsurgical revascularization did not lead to a significant change in the height of either the central or the peripheral regions of the hypertrophic zone of chondrocytes at any of the follow-up intervals. This study is another 'building block' experiment toward vascularized epiphyseal plate transplantation in humans.