Dean Ad-El

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.

Prophylactic antibiotics for burns patients: systematic review and meta-analysis

Objective To assess the evidence for prophylactic treatment with systemic antibiotics in burns patients. Design Systematic review and meta-analysis of randomised or quasi-randomised controlled trials recruiting burns inpatients that compared antibiotic prophylaxis (systemic, non-absorbable, or topical) with placebo or no treatment. Data sources PubMed, Cochrane Library, LILACS, Embase, conference proceedings, and bibliographies. No language, date, or publication status restrictions were imposed. Review methods Two reviewers independently extracted data. The primary outcome was all cause mortality. Risk or rate ratios with 95% confidence intervals were pooled with a fixed effect model if no heterogeneity was present. Results 17 trials were included. Trials that assessed systemic antibiotic prophylaxis given for 4-14 days after admission showed a significant reduction in all cause mortality (risk ratio 0.54, 95% confidence interval 0.34 to 0.87, five trials). The corresponding number needed to treat was 8 (5 to 33), with a control event rate of 26%. Perioperative non-absorbable or topical antibiotics alone did not significantly affect mortality. There was a reduction in pneumonia with systemic prophylaxis and a reduction in wound infections with perioperative prophylaxis. Staphylococcus aureus infection or colonisation was reduced with anti-staphylococcal antibiotics. In three trials, resistance to the antibiotic used for prophylaxis significantly increased (rate ratio 2.84, 1.38 to 5.83). The overall methodological quality of the trials was poor. Conclusions Prophylaxis with systemic antibiotics has a beneficial effect in burns patients, but the methodological quality of the data is weak. As such prophylaxis is currently not recommended for patients with severe burns other than perioperatively, there is a need for randomised controlled trials to assess its use.

Expression of liver-specific markers in naïve adipose-derived mesenchymal stem cells

Background: Increasing evidence suggests that adipose tissue contains mesenchymal stem cells (MSC) that possess the ability to transdifferentiate into other cell types including hepatocytes, similar to bone marrow‐derived stem cells. The existence of precommitted cells in the MSC population may explain transdifferentiation.

Post-traumatic soft tissue tumors: Case report and review of the literature a propos a Post-traumatic paraspinal desmoid tumor

BackgroundAntecedent trauma has been implicated in the causation of soft tissue tumors. Several criteria have been established to define a cause-and-effect relationship. We postulate possible mechanisms in the genesis of soft tissue tumors following antecedent traumatic injury.Case presentationWe present a 27-year-old woman with a paraspinal desmoid tumor, diagnosed 3-years following a motor vehicle accident. Literature is reviewed.ConclusionSoft tissue tumors arising at the site of previous trauma may be desmoids, pseudolipomas or rarely, other soft tissue growths. The cause-and-effect issue of desmoid or other soft tissue tumors goes beyond their diagnosis and treatment. Surgeons should be acquainted with this diagnostic entity as it may also involve questions of longer follow-up and compensation and disability privileges.

Suicide bombing injuries: the Jerusalem experience of exceptional tissue damage posing a new challenge for the reconstructive surgeon

Background: Suicide bomb injuries vary in form and magnitude. From the onset of the second Palestinian “intifada” in October of 2000 until January of 2004, 577 victims of suicide bombings were admitted to the Hadassah-Hebrew University Medical Center. A single bomber carrying a handbag or belt containing multiple metal objects and explosives carried out most of the attacks. As a result, many of the victims suffered massive tissue destruction in addition to conventional blast injuries. Methods: This article describes the management of this trauma-related “syndrome” of combined primary and high-magnitude secondary blast injury. Results: The management of the extensive soft-tissue damage is described and two representative cases presented. Conclusion: Suicide bombing–related injuries in their present form are a true challenge for the reconstructive surgeon.

Melanoma of the scalp : the invisible killer

A series of 20 patients (15 men and 5 women) suffering from malignant melanoma of the scalp is reported. Their epidemiologic data and outcome are described. The ages ranged from 48 to 78 years (mean 63 years). Analysis of the cases demonstrated that lesions occurring posterior to the tragal line (in hair-bearing area) have the worst prognosis. The 5-year survival rate was poor; 12 patients died within this period. Two representative cases are described, and the preventable aspects of the disease are emphasized.

Clinical results of skin remodeling using a novel pneumatic technology

Background  A myriad of technologies are available for the treatment of aging skin. These, however, still lack the ability to combine immediate, short‐term and long‐term aesthetic results with no downtime. Furthermore, the treatment of fine wrinkles on large surfaces remains challenging, as does the treatment of delicate regions, such as the dorsal hand, neck, and chest.

Cancer of the head and neck region in solid organ transplant recipients

Solid organ recipients are at an increased risk of developing various malignancies. We investigated the incidence, clinical features, and outcome of patients diagnosed with head and neck cancer after organ transplantation.

Reconstruction of nonhelical auricular defects with local flaps.

BACKGROUND The integrity of each of the components of the auricle is important for its overall aesthetic appearance. Cartilage-exposing nonhelical defects that are too large to be closed primarily without distorting the auricle may be reconstructed with local flaps. OBJECTIVE The objective was to present our experience with the reconstruction of nonhelical medium-sized defects using a variety of simple, one-stage local flaps. PATIENTS AND METHODS Eighteen patients who underwent reconstruction of nonhelical auricular defects with local flaps at our center from 2003 to 2006. Defect size ranged from about 10 to 20 mm. Various methods were used for reconstruction as follows: conchal defect (n=11)—pull-through postauricular flap or cutaneous rotation flap from the concha itself; triangular fossa defect (n=3)—transposition-rotation flap from the concha or cutaneous periauricular pull-through flap via the root of the helix; antihelical defect (n=2)—V-Y advancement flap from the skin of the antihelix; and tragus defect (n=2)—periauricular cutaneous flap. RESULTS All flaps survived. Transient congestion was noted in four patients. The aesthetic results were good, with no auricular deformation. CONCLUSION It is important that reconstructive surgeons be familiar with a variety of basic flaps for reconstruction of nonhelical defects. An algorithm for nonhelical flap reconstruction is suggested.

The effect of a nitroxide antioxidant on ischemia-reperfusion injury in the rat in vivo hind limb model

Microsurgical procedures such as free tissue transfer or replantations of amputated digits involve an obligatory ischemic period leading to regional tissue oedema, rhabdomyolysis, systemic acidosis, hypercalcemia and multiple organ dysfunction syndrome reflecting ischemia-reperfusion (I/R) injury. Since nitroxide stable radicals act as antioxidants their potential protective effects were tested. Anaesthetized Sabra rats were subjected to regional ischemia of the hind limb for 2 h using a tourniquet. Upon reperfusion rats were injected with 4-OH-2,2,6,6-tetramethylpiperidine-1-oxyl (TPL). Systemic I/R-induced damage was assessed by sampling blood for differential count, lactate dehydrogenase (LDH) and creatine phosphokinase (CPK) serum levels. Regional injury was evaluated by analysing excised muscle samples for oedema (tissue water content) and inflammatory infiltrate (number of cell nuclei in histomorphometric analysis). I/R-induced changes of biomarkers reflecting systemic damage peaked about 8 h following the start of reperfusion and fully disappeared as the biomarkers relaxed to their pre-ischemic values after 24 h. TPL facilitated the recovery of some of these parameters and partially affected release of cellular CPK and LDH. The parameters of I/R-induced regional tissue injury did not demonstrate any recovery and were not inhibited by TPL.