Aharon Amir

Free fibula long bone reconstruction in orthopedic oncology: a surgical algorithm for reconstructive options.

The fibula free flap became popular in orthopedic oncology for limb-sparing long bone tumor resection. It is particularly suitable for intercalary or resection arthrodesis options. In the present series, a surgical reconstruction algorithm was used, enabling each patient to receive a personalized technique. During the years 1998 to 2002, 30 patients underwent limb-sparing surgery for long bone sarcoma. There were 18 males and 12 females. Their mean age was 23 years (range, 9 to 70 years). The diagnoses were Ewings sarcoma (11 patients), osteogenic sarcoma (eight patients), chondrosarcoma (five patients), giant cell tumor of bone (three patients), high-grade soft-tissue sarcoma (two patients), and leiomyosarcoma of bone (one patient). The majority of tumors where located in the lower extremity (23 patients), mostly in the femur (15 patients with four tumors in the proximal femoral shaft, five tumors in the distal femoral shaft, five tumors in the whole femoral shaft, and one tumor in the proximal femoral head). In seven patients, the upper extremity was involved; in six patients, the radius was involved; and in one patient, the humerus was involved. The free fibula flap was used in three types of approaches: vascularized fibula as an osseous flap only (18 patients), a combination of a vascularized fibula flap in conjunction with an allo-graft (Capannas technique; 10 patients), and a free double-barreled fibula (two patients). All flaps survived. Postoperatively, all patients were monitored clinically, radiologically, and by radioisotope bone scan studies. Callus formation and union were shown 2.6 to 8 months postoperatively. Patients who underwent lower extremity reconstruction were nonweightbearing for 3 to 9 months, with a transition period in which they used a brace and gradually increased weightbearing until full weightbearing was achieved. Eight patients had 11 recipient-site complications. Two patients (6.7 percent) had hematomas, and three patients (10 percent) had infection and dehiscence of the surgical wound with bone exposure in one patient; all complications resolved with conservative treatment only. Failure of the hardware fixation system occurred in two patients, mandating surgical correction. No fibula donor-site complications were recorded. In intercalary resections, the use of the vascularized fibula flap as an isolated osseous flap might be insufficient. Different body sites have different stress loads to carry, depending on the age of the patient and on his individual physical status. To achieve initial strength in the early period, the authors combined the free fibula flap with an allograft (Capannas method) or augmented it as a double-barreled fibula. They propose a surgical algorithm to assist the surgeon with the preferred method for reconstruction of various long bone defects in different body locations at childhood or adulthood. Long bone reconstruction using a vascularized fibula flap, alone or in combination with an allograft, autogenous bone graft, or double-barreled fibula for limb-sparing surgery, is a safe and reliable method with a predictable bony union, good functional outcome, and a low complication rate.

Clinical comparative study of Aquacel and paraffin gauze dressing for split-skin donor site treatment

The management of split-thickness skin graft donor sites is targeted towards promoting the healing process, while minimizing adverse effects and complications. The aim of this study was to compare donor site treatment outcome between Aquacel, a carboxymethylcellulose-based hydrofiber dressing, and the standard mesh paraffin gauze dressing. The study included 23 adult patients. Half of the skin graft donor site in the proximal thigh was dressed with paraffin gauze and the rest with Aquacel. The results indicated that patients treated with Aquacel experienced significantly less pain and a more rapid rate of epithelialization compared with patients treated with mesh paraffin gauze dressing. Final scarring (ie, after the 1-year follow-up) was significantly better with the Aquacel dressing. We conclude that Aquacel dressing is superior to the standard mesh paraffin gauze dressing for split-thickness donor site area in pain relief, ease of treatment, promotion of epithelialization, and the quality of scarring.

A simple, rapid, reproducible tie-over dressing

A simple and quickly performed technique for the construction of tie-over dressings is described. After adjustment of the graft to the skin defect, skin staples are used to tack simultaneously the graft and looped silk threads circumferentially. Securing the threads is achieved by using a shortened disposable syringe cylinder through which the threads are passed and held in place by the adjusted piston. A stable fixation is easily achieved in all cases using one or more of these devices depending on the size of the defect. This technique enables the subsequent application of the dressing if needed.

Treatment of earlobe keloids by extralesional excision combined with preoperative and postoperative "sandwich" radiotherapy.

Background: Earlobe keloids can form after cosmetic ear piercing, trauma, infection, or burns, or spontaneously. These keloids are highly resistant for treatment and are followed by severe cosmetic implications. There are various surgical and nonsurgical treatment modalities for earlobe keloids, with no universally accepted treatment policy and a wide range of reported recurrence rates. The authors present their experience of treating earlobe keloids using the “sandwich” technique protocol; extralesional excision and external-beam radiotherapy are given a day before and a day after the operation. Methods: The authors retrospectively reviewed all patients with earlobe keloids treated by the “sandwich” technique between the years 1996 and 2005. Patients were categorized into two groups: a high-risk group for previously treated patients and patients with a tendency for hypertrophic scars and keloids, and a low-risk group for the others. All patients underwent extralesional excision of the keloid and local radiotherapy before the excision and following it. Follow-up was a minimum of half a year and included a patient satisfaction questionnaire and documentation of keloid recurrence or cure. Results: A total of 23 patients were treated by this protocol; 57 percent were male. Patients had an average age of 24 years. The most common keloid etiology was earlobe piercing. Recurrence rates for the low-risk and high-risk groups were 25 and 27 percent [percent of the patients], respectively. Overall patient satisfaction was high. Conclusion: The combined excision and “sandwich” radiotherapy technique is a simple and effective method for treating earlobe keloids, with high patient satisfaction and low recurrence and complication rates.

Our experience with Wisebands: a new skin and soft-tissue stretch device.

Complex wounds that involve skin and soft-tissue defects that are unsuitable for primary closure by conventional suturing are common in the field of surgery. Among the many surgical options available to overcome these problems are various mechanical devices that have recently been proposed for delayed primary closure of such wounds. The authors present their experience with a new complex wound closure device, Wisebands, a device uniquely designed for skin and soft-tissue stretching. During the last 2 years, the authors have treated 20 patients with 22 skin and soft-tissue wounds for which primary closure was not feasible. The Wisebands devices were applied to the wounds, stretching the skin and underlying soft tissue, gradually closing the defects until the edges were sufficiently approximated for primary closure. Successful wound closure was achieved in 18 patients (90 percent). The Wisebands devices were removed in two patients (10 percent) because of major wound complications. In two other patients (10 percent), minor wound complications had occurred that did not necessitate removal of the device. At a mean follow-up of 1 year (range, 10 months to 2 years), stable scarring with no functional or significant aesthetic deficit was achieved. The authors conclude that the Wisebands device facilitates closure of complex skin and soft-tissue wounds, with low morbidity and complication rates, and can provide the surgeon with another important tool for closing complex wounds. Nevertheless, appropriate patient selection, intraoperative judgment, and close postoperative care are essential to ensure closure and avoid undue complications.

Combined thermal and crush injury to the hand and fingers

Combined thermal and crush injury is a relatively rare type of injury, although it may be more common in industrial settings. The combined insult of heat and pressure results in an injury that apparently is more severe than the simple additive effect, as the heat is transmitted deeper through the crushed tissues. The full extent of tissue destruction cannot always be fully recognized initially. Treatment in stages is the preferred approach, rather than attempted immediate reconstruction procedures. Failure of immediate skin grafting procedures in some of the cases presented herein was the result of underestimation of the severity of trauma. Early debridement should be done soon after admission. Definitive treatment as dictated by the magnitude of injury needs to be delayed until the extent of injury is delineated. Our conclusions from the presented experience with this type of injury were successfully applied in the treatment of the last presented patient.

Comprehensive approach in surgical reconstruction of facial nerve paralysis: a 10-year perspective.

Facial paralysis presents diverse functional and aesthetic abnormalities. Reconstruction may be achieved by several methods. We reviewed the management and outcome of facial paralysis patients to establish principles on which a comprehensive reconstructive approach may be based. Records were reviewed of all patients operated for facial paralysis at our institution between 1998 and 2007. Ninety-five patients were included, of which 15 patients had static reconstruction alone, and 80 patients had dynamic reconstruction. Presented is our experience in reconstruction of facial paralysis over the past decade, delineating a comprehensive approach to this condition. Various surgical techniques are described.