Calcaneogenesis.

We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.

A large necrotic defect secondary to a cutaneous sinus tract of odontogenic origin: a case report.

This article reviews the case of a patient with a periapical dental abscess that drained inferior and posterior to the angle of the jaw and created a large purulent cutaneous defect. Both the diagnosis and treatment issues are discussed.

Complex upper extremity vascular trauma in an urban population.

Eighty patients with upper extremity vascular trauma were treated during a 4-year period. Of 123 vascular injuries, 95 were arterial, 1 was primary venous, and 27 were associated venous injuries. Causes included penetrating (64%), blunt (27%), and iatrogenic injuries (9%). Arteries injured were ulnar (34), radial (28), brachial (22), subclavian (6), and axillary (5). Numbers of patients with associated injuries were nerve (53), vein (27), bone (23), and soft tissue injuries (60). The most common techniques of arterial repair were end-to-end anastomosis (50), followed by interposition saphenous vein grafting (40). Fasciotomy was used in 36 patients. Two arterial repairs failed during surgery and required revision (1) or thrombectomy (1). One radial artery repair thrombosed during late follow-up, with maintenance of normal extremity perfusion via the ulnar artery. No amputations were required, and 83% of all patients treated for nerve injuries resolved or improved their neurologic deficits. Two or more operations for surgical debridement and subsequent wound closure were required in 35 patients. This study supports an aggressive approach to diagnosis and treatment of complex upper extremity vascular trauma emphasizing meticulous surgical technique, liberal use of fasciotomy, and aggressive intraoperative debridement and repair of associated injuries.

Post-trauma reconstruction with free tissue transfer--analysis of 442 consecutive cases.

We reviewed 442 consecutive free flaps performed between July 1979 and December 1987 in 423 trauma patients. The ages ranged from 2 to 76 years. There were 339 males and 84 females. Soft-tissue coverage was the most frequent (56.3%) indication, followed by unstable wound, extensive bone loss, chronic osteomyelitis, insensate scar, loss of specialized tissue, and contour deformity. Most of the reconstructed defects (72.4%) were located in the lower extremity and the great majority (42.3%) involved the lower third of the leg. Motor vehicle accidents were the main (45.6%) cause of the defects followed by motorcycle injuries (28.6%), industrial accidents (15.1%), farming accidents (3.6%), and gunshot wounds (3.3%). Seventeen types of free vascularized cutaneous, myocutaneous, muscular, osseous, osteocutaneous, fascial, fasciocutaneous, sensate, and specialized tissue transfers were used. The latissimus dorsi free flap was the most frequently performed tissue transfer. Only 2.3% of the flaps were done within the first 48 hours post-trauma, although 76.5% of the transfers were completed within the first 2 weeks after injury. The overall success rate was 96.4% and the incidence of re-exploration was 14.7%. Free tissue transfers provide a very reliable method for dealing with difficult reconstructive problems in trauma patients.

Tissue pH monitoring in microsurgery: a preliminary evaluation of continuous tissue pH monitoring as an indicator of perfusion disturbances in microvascular free flaps.

In an experiment using a continuous tissue pH monitoring system, selective occlusion of the vessels supplying lower abdominal island flaps in Sprague-Dawley rats resulted in predictable tissue pH changes. Arterial occlusion resulted in a rapid fall in pH. In all three experimental groups, the steepest rate of pH drop occurred during the first 30 minutes postocclusion. In a series of 9 patients who underwent microvascular free flap surgery the continuous pH monitor was employed postoperatively. Tissue pH was (and remained) normal in well-perfused free flaps. Tissue pH fell almost immediately with anastomotic failures. These findings demonstrate that pH measurement offers the microvascular surgeon a new, simple, and reliable approach to perfusion assessment in free flaps. Perhaps improved survival rates will result from earlier anastomotic exploration in compromised free flaps that exhibit falling pH values.