Burt M. Greenberg

Therapeutic value of intravenous heparin in microvascular surgery: an experimental vascular thrombosis study.

In an attempt to decrease a 10 to 15 percent vascular thrombosis rate leading to graft occlusion, low-dose human-grade heparin was studied to determine if carefully monitored intravenous therapy would increase 7-day patency in a known potent thrombosis model. In New Zealand white rabbits, the type of infusate administered intravenously, either saline (30 animals) or heparin (35 animals), was selected at random after completing a 2-mm arterial inversion graft in the femoral artery. A 72-hour infusion was used in all animals; the control group received sterile saline and the experimental group received a heparin infusion at 45 µl per hour after a 500-unit bolus. All grafts in both groups were patent at the time of groin closure. Patency in the heparin-perfused group was 67 percent (24 of 35) as compared to 19 percent (6 of 30) in the control group (p < 0.05) 1 week postoperatively. Scanning electron microscopy showed significantly less dense fibrin deposition and a decrease in the number of aggregated platelets in the heparin-perfused grafts. Partial tissue thromboplastin time values in the experimental group ranged between 55 and 75 seconds (control 20 to 25 seconds). We have shown that heparin, an inexpensive and readily available agent, maintains 1-week microarterial patency and results in few complications in a reliable, reproducible, and versatile thrombosis model. The clinical ramifications of using an antiplatelet agent that diminishes fibrin deposition in microsurgery are apparent.

Salvage of jeopardized total-knee prosthesis ; the role of the gastrocnemius muscle flap

Total-knee arthroplasty has provided many patients with excellent long-term functional results. However, exposure of a total-knee replacement usually eventuates in failure. The relatively superficial location of the prosthesis, the need for early active motion, previous surgical incisions, and a variety of systemic factors may militate against early wound healing. Restoration of well-vascularized soft-tissue cover can salvage an otherwise disastrous situation. The authors recommend early operative intervention upon observation of wound breakdown, devitalized skin edges, or significant subcutaneous infection leading to necrotic overlying skin. The operative procedure found to salvage the majority of prostheses consists of adequate debridement, antibiotic irrigation (of the joint, if exposed), and coverage with a well-vascularized muscle flap, preferably the medial gastrocnemius muscle. The operative technique and ultimate long-term outcome are reviewed based on experience with 10 consecutive patients presenting with a jeopardized knee prosthesis. Follow-up ranged from 1 to 6 years. Representative case histories are presented.

Trigonocephaly: surgical considerations and long term evaluation.

Trigonocephaly accounts for approximately 10% of all craniosynostosis. Severe trigonocephaly results in a triangular-shaped forehead, superior-lateral orbital depression, hypotelorism, and compensatory occipital-parietal calvarial changes. Radiographic findings include ovoid orbits with parallel medial borders, thickened keel-shaped frontal bone, small ethmoid sinuses, and a short anterior cranial fossa with pitched sphenoid wings. Our experience with 50 infantile cases of severe nonsyndromic trigonocephaly patients treated from 1987 to 2005 is clinically reviewed to assess long-term growth based on a standardized operative technique. The average age of the patients at surgery was 6 months and the mean follow-up was 12 years. Our complication rate was 2%; the reoperative rate was 12%. The use of resorbable rigid plate fixation combined with alloplastic augmentation has improved the cosmetic outcome in patients treated since 1996 and reduced the reoperative rate.

Congenital bifid sternum: repair in early infancy and literature review.

Sternal clefting is an unusual congenital anomaly that should be repaired in early infancy. Early surgery is facilitated by a highly compliant bony thorax. The surgical technique is described, including the (1) removal of a wedge at the confluence of the two lateral sternal bands to allow their apposition, (2) intraoperative assessment of pulmonary compliance and central venous pressure, (3) use of bilateral pectoral flaps, and (4) resulting avoidance of major costochondral stair-step osteotomies. The suggested age of repair is 1 to 4 weeks of age.

Alloplastic reconstruction of large cranio-orbital defects: a comparative evaluation.

Norian CRS, Bone Cement (Synthes CMF), and Mimix (Lorenz) have been used to reconstruct large cranio-orbital defects in 85 patients. Resorbable mesh (Macropore), used in combination in selected patients, obviates dura pulsations that have been postulated to cause fragmentation of alloplastic material. Norian is composed of monocalcium phosphate, monohydrate, α-tricalcium phosphate, and calcium carbonate. Admixture with NaPO4 creates dahllite, which has a higher carbonate content (4%–6%) than hydroxyapatite (0%). CRS is soluble at low pH, facilitating its resorption and replacement by bone. In contradistinction, Mimix is converted to aqueous solution at 37°C, supports fibrovascular ingrowth and bony interdigitation at the implant-material surface. Forty-five adults (mean age = 42 years) and 40 children (mean age = 8 years) were evaluated with respect to etiology of defect, size, location, gram usage of alloplast material, type of alloplast, postoperative clinical course, and complications. A minimum of 3-year follow-up is available; 22 adult patients additionally underwent resorbable mesh reconstruction. There were 7 (8%) complications, including infection, extrusion, a sterile loculated fluid collection and fragmentation. No difference in complication rate was noted between biomaterials. Two additional patients exhibited resorption (Norian), necessitating reaugmentation. Alloplastic replacement of cranio-orbital defects has recently advanced dramatically. Bivalved cranial bone grafting with its attached morbidity and sequelae can be avoided. Resorbable mesh allows for the placement of alloplast material in larger defects while avoiding dura pulsation causing alloplast fragmentation. In avoiding titanium type reconstruction, it obviates any interference with radiologic diagnosis and radiotherapeutic modalities. Long-term results are needed to assess bone growth within alloplast and to study bone growth in alloplastic reconstructed pediatric patients.

Great toe-to-hand transfer: Role of the preoperative lateral arteriogram of foot

This report correlates the results of the lateral angiogram of the foot with the operative dissection and eventual outcome in 29 patients in whom a great toe-to-hand transfer was performed to treat a traumatic loss of the thumb. Our angiographic findings were confirmed by surgical exploration and indicated that (1) in 20 (70%) of 29 patients the first dorsal metatarsal artery (FDMA) originated from the dorsalis pedis artery, dorsal to the midlongitudinal axis of the first metatarsal bone; (2) in 6 (20%) of 29 patients the FDMA originated from the dorsalis pedis artery, plantar to the midlongitudinal axis of the first metatarsal bone; (3) in the remaining 3 (10%) of 29 patients the arteriogram of the lateral foot indicated that the plantar metatarsal artery supplied the great toe in a dominant pattern, necessitating its use as the donor vessel; and (4) the measured lumenal diameters of the dorsal and plantar metatarsal arteries (mean diameter = 1.30 mm and 1.27 mm, respectively) did not significantly differ. The lateral views of the foot were helpful in permitting distinct identification of the location and size of the metatarsal arteries to the great toe.

Correlation of postoperative bone scintigraphy with healing of vascularized fibula transfer: a clinical study

This study examines the usefulness and reliability of bone scintigraphy in correlation with radiological and clinical evidence of bone healing in 15 patients who underwent microvascular transfer of the fibula. All patients were followed for a minimum of 18 months postoperatively. Technetium-99 methylene diphosphonate bone scans and the most recent radiographs were blindly rereviewed. Bone scintigraphic results were characterized as (1) clearly positive (i.e., excellent visualization of the fibula), (2) clearly negative (i.e., no evidence of tracer uptake in the fibula), or (3) indeterminate (i.e., artifact present as a result of metallic or soft tissue interference). Bone radiographs were classified into three typical patterns: (1) complete bony union and graft hypertrophy, (2) incomplete union (either distal or proximal) requiring a second procedure), and (3) nonunion, with increased proximal and distal lucency (with or without pathological fracture) and loss of graft definition. Eleven patients had positive scintigraphic scans postoperatively. In 8 no subsequent procedure was necessary; 2 patients required additional bone grafts to augment the osseous reconstruction; viable fibulas were seen at reoperation. One patient with a positive scan showed decreased graft definition at four months followed by autograft fracture. Three patients had indeterminate scans, 2 of whom evidenced uncomplicated clinical and radiological union. One patient had a clearly negative scan and ultimately tibia-fibula synostosis was required to attain stability. Bone scintigraphy appears to correlate with survival, but not necessarily union, of a vascularized fibula autograft. Additional monitoring techniques should be used in combination with a one-time bone scan to both monitor the patency of the microanastomoses and to prioritize the orthopedic management of the patient.

A socioeconomic analysis of digital replantations resulting from home use of power tools

Forty-seven digits in 21 patients who sustained partial or complete amputations from the home use of power tools were replanted or revascularized during a 1-year period. This represented 69% of the microvascular surgery performed for hand injuries during that year. The cost of repairing an average of 2.4 digits was

Comparative bacterial clearances of muscle and skin/subcutaneous tissues with and without dead bone: a laboratory study.

7000 (surgeons fee) plus

Efficacy of Intraarterial Heparin in Maintaining Microvascular Patency: An Experimental Model

697 per hour (operating room fee), as per fiscal year 1987. Postoperative hospitalization averaged 15 days at a cost of