Heribert Hussl

Vascularized Bone Graft from the Iliac Crest for the Treatment of Nonunion of the Proximal Part of the Scaphoid with an Avascular Fragment

BACKGROUND It was hypothesized that nonunion of the proximal third of the scaphoid associated with avascular necrosis could be treated successfully with a free vascularized bone graft obtained from the iliac crest. METHODS Fifteen patients who had a nonunion of the proximal part of the scaphoid that had been present for an average of two years and three months (range, nine months to seven years) were managed with use of a free vascularized bone graft obtained from the iliac crest. Avascularity of the scaphoid, as assessed on preoperative radiographs, was characterized by loss of trabecular structure, collapse of subchondral bone, and formation of bone cysts. The results of the procedure were assessed in terms of osseous union, pain, active motion of the wrist, and osteoarthritis. Postoperatively, vascularity of the scaphoid was evaluated with use of magnetic resonance imaging and color Doppler ultrasonography. The average duration of follow-up was six years and one month (range, two years and one month to eight years and one month). RESULTS Preoperatively, one patient had had pain with any movement of the wrist and fourteen had had pain after strenuous manual labor or sports activity. The average pain score, derived with use of a 10-point visual analog scale, was 2.4 points (range, 1.0 to 6.7 points). Postoperatively, union was achieved in twelve patients; six were pain-free, and six had occasional pain during strenuous manual labor or sports activity, or both. The average pain score for these twelve patients was 1.1 points (range, 0.0 to 4.2 points) on the visual analog scale. Preoperatively, osteoarthritis was limited to the region between the radial styloid process and the distal part of the scaphoid in fourteen patients and to the radioscaphoid region in one patient. Postoperatively, the degree of osteoarthritis remained unchanged in seven of the twelve patients who had union and progressed to the radioscaphoid region in five. Vascularity, as seen on the imaging studies, was restored in all twelve patients who had union. The nonunion persisted in three patients, all of whom had progressive osteoarthritis leading to carpal collapse. CONCLUSIONS The index procedure was successful in twelve of the fifteen patients who had a symptomatic nonunion of the proximal part of the scaphoid associated with avascular necrosis and osteoarthritis that was limited to the radioscaphoid joint.

Small free vascularized iliac crest bone grafts in reconstruction of the scaphoid bone: a retrospective study in 60 cases.

Carpal instability may result in progressive degenerative arthritis of the wrist. The surgical goal of the reconstruction of scaphoid nonunion is to achieve bone union and to restore the scaphoid. Many procedures are described to treat scaphoid nonunion for different indications. This retrospective study reports on the anatomical fundamentals, the operative procedure, and the results of 60 patients (21 with recalcitrant scaphoid nonunion that lasted longer than 4 years, 26 with an avascular pole fragment, and 13 with scaphoid nonunion after previous surgery) who were treated by a small free vascularized iliac crest bone graft. All 60 patients have routinely been followed up clinically and with magnetic resonance imaging. Union was achieved in 91.7 percent by improvement of stability and the compromised vascularity of the scaphoid. The bone flap loss rate and persisting nonunion was 8.3 percent, leading to progressive arthritis and carpal collapse. Complaints concerning discomforts caused by the scar were heard from 40.1 percent of the patients, and 31.7 percent complained of discomforts caused by the bony deformity. Bone deformations on the donor site were detected radiologically in 63.3 percent of the patients. In 31.7 percent, an impairment of the lateral femoral cutaneous nerve was noted. Reconstruction of the scaphoid by means of implantation of a vascularized iliac bone graft proved efficient to treat avascular recalcitrant scaphoid nonunion and pseudarthrosis with avascular proximal pole fragments. (Plast. Reconstr. Surg. 108: 664, 2001.)

Primary simultaneous lip and nose repair in the unilateral cleft lip and palate.

Background: “Do not touch the nose in primary repair of the unilateral cleft lip and palate!” In the past, this dogmatic attitude caused functional and aesthetic (psychological) problems for the child until secondary corrections during adolescence were performed. In the 1950s, surgeons started to correct at least a few features of the nasal deformity and to develop radically corrective measures. Since 1970, a new and very comprehensive concept of correction has been used at the authors’ department of plastic and reconstructive surgery. Methods: Methods of primary nasal repair by various surgeons are presented chronologically. The main features of the authors’ strategy are special incision lines, extensive mobilization of all dislocated structures, straightening of the deviated septum, correction of the deformed ala and nasal tip, induction of bone growth in hypoplastic areas under the alar base and along the piriform aperture, and a special suture technique of the orbicularis muscle to form a better philtrum. Results: Improvement of the aesthetic and functional results can be achieved with this type of nasal repair. Since 1970, approximately 500 patients have been operated on with this method at the authors’ hospital and elsewhere, with 80 percent showing satisfactory results and 20 percent revealing deficiencies. Severe nasal deformities, which were common when no primary repair was applied, were not observed. This observation period provides evidence that no growth retardation occurs. Conclusions: Because of the good results of this method and the lack of growth retardation, this approach is to be recommended. It also benefits children in underdeveloped countries, where frequent surgery is not possible.

High-resolution ultrasound of the supraclavicular brachial plexus—can it improve therapeutic decisions in patients with plexus trauma?

Patients with major traumatic brachial plexus lesions benefit from early surgery, but they are seldom isolated by today’s diagnostic workup. Subjects with ambiguous findings after such workups usually undergo a trial of conservative treatment and those without improvement delayed surgery. Our study focuses on this problem. Hence, the purpose of this study was to evaluate the impact of high-resolution ultrasound (HR-US) on patient recruitment for non-delayed surgery. Twelve patients after blunt shoulder trauma and standardized HR-US assessment who underwent plexus surgery were included in this prospective observational study. Thereby, a total of 168 plexus elements were evaluated. All findings were compared to electrophysiological data if available and tested statistically against the gold-standard, i.e., surgical validation. Major plexus lesions were correctly detected by HR-US in nine patients (20 plexus elements). In two patients (five plexus elements), the lesion was underestimated by HR-US in relation to the gold standard (surgical inspection). Our analysis showed a high positive (1.0) and an acceptable negative predictive value (0.92) for the grading of traumatic plexus lesions with HR-US. Based on HR-US findings alone, 9 of 11 patients with objective major lesions would have undergone early surgery. In conclusion, HR-US proved a valuable tool for the triage of patients with traumatic lesions into surgical and non-surgical candidates.

The superficial inferior epigastric artery (SIEA) flap: indications for breast reconstruction.

The lower abdominal skin and fat have become a standard for breast reconstruction because the abdominal tissue can mimic the breast to a high degree. With todays increasing focus on safety and routine of microsurgical interventions, more attention must be paid to donor-site morbidity. The superficial inferior epigastric artery (SIEA) free flap is the least invasive microsurgical procedure for breast reconstruction because this operative technique does not require harvesting of the rectus muscle or the abdominal fascia. A total of 11 breast reconstructions were performed with this technique and had an average follow-up of 23 months. The anatomy, operative technique, and various indications for the SIEA flaps are demonstrated.

Schwannoma of the brachial plexus: cross-sectional imaging diagnosis using CT, sonography, and MR imaging.

Abstract. Primary brachial plexus tumors are rare, usually benign, and in general have a good prognosis after surgical excision. We present a case of a schwannoma in which sonography enabled the correct diagnosis of a probably benign brachial plexus tumor. Key to the diagnosis was the demonstration of a smooth-bordered, longish, and well-defined nodule along a brachial plexus nerve root. Cross-sectional imaging modalities that provide a high degree of soft tissue contrast and spatial resolution, such as sonography and MR imaging, were suitable methods to establish the correct preoperative diagnosis. Findings at CT, sonography, MR imaging, and surgery are discussed.

Modified free paraumbilical perforator flap: the next logical step in breast reconstruction.

&NA; The free paraumbilical perforator flap that was developed with only the perforator penetrating the rectus abdominis muscle seems nearly ideal from the donor‐site perspective, because it reduces morbidity virtually to that of an abdominoplasty. However, it requires “supermicrosurgery” skills for suturing of vessels with diameters of 0.7 mm or less, making the procedure technically demanding and risky. Another significant disadvantage of that technique is that the flap has very short vascular pedicles. To overcome the disadvantages of the free paraumbilical perforator flap, a minor modification in flap harvesting that improves the vessel size and length is described. Results for a total of 15 patients who underwent breast reconstruction with modified free paraumbilical perforator flaps are presented, and the advantages and disadvantages of this flap are discussed.

Zehn Jahre Handtransplantation Experiment oder Routine

In the 20th century the legend of Cosmas and Damian - an extremity being transferred from one person to another - became reality. The first hand transplantation was carried out in 1964 in Ecuador but the hand had to be removed again within three weeks due to rejection. Although he was the first one to be treated with more modern immunosuppressants, the same fate overtook another patient who received a hand from a brain-dead donor in 1998 in Lyon. Since then only 32 persons worldwide have been provided with parts of the upper extremity. The partly published histories of three patients who have had both hands transplanted will be summarised and indication critically assessed once again. It is also stressed how difficult, multi-layered and complex the patients education is. The patient has to be informed in many conversations beforehand about every stage of therapy but also about possible complications and even rejection. Can the psychological burden/stress while waiting for a donor, the difficult post-operative period, lifelong adherence to a rigorous drug-regimen, the complexity of the whole procedure be made comprehensible to a layman? To replace same with same is the goal of the best-possible reconstructive surgery. It is to hope that through future innovations in the immunosuppressing therapy patients can be offered transplantation of one or both hands as a routine-operation. Until then indication has to be strict and the operation can possibly only be performed in a few centres. Long-time prospects, disadvantages and complications, as well as side effects have to be presented openly.

Chronisch rezidivierende, lokal destruierende Silikonome nach Brustaugmentation durch flüssiges Silikonöl

Abstract. At the beginning of the sixties the injection of liquid silicon oil was frequently used for breast augmentation. It was thought to be safe, simple and effective. But as complications such as local silconomas, inflammatory reactions, induration, foreign body extrusion and foreign body migration were published this procedure was not used anymore. We report about a 45-year-old female patient who suffered from late complications, chronic recurrent local destructive siliconomas, which have not been described in the literature yet. Because of the destruction forced by the primary siliconimplant a bilateral subcutaneous mastectomy had to be performed and siliconomas were excised at regions different from the original injection site. Several breast reconstructions have been performed but this tissue has also been destroyed by the recurrent and aggressive siliconomas. As there can be a long period of latency before the aforementioned complications of liquid silicon injections can occur, we recommend careful follow-up for these patients.Zusammenfassung. Anfang der 60 er Jahre war die Augmentation der Brust durch Injektion von flüssigem Silikon eine sicher geglaubte Methode, welche ob des simplen Eingriffs und des raschen Erfolgs allzu oft unkritisch angewandt wurde. Als Komplikationen, welche diese Methode in Verruf brachten, wurden lokale Silikonome, entzündliche Infiltrationen und Indurationen, Fremdkörperextrusionen, sowie Fremdkörpermigrationen beschrieben. In der vorliegenden Arbeit wird über den Jahrzehnte langen Krankheitsverlauf einer 45 jährigen Patientin mit einer in der Literatur noch nicht erwähnten Spätkomplikation, der chronisch rezidivierenden, lokal destruierenden Form eines Silikonoms, berichtet. Die lokal destruierende Wirkung des flüssigen Silikons und der sekundären Silikonome erforderte eine beidseitige subcutane Mastektomie, sowie zahlreiche Silikonomexstirpationen auch außerhalb der ursprünglichen Applikationsstelle. Mehrfache plastisch-chirurgische Brustrekonstruktionen wurden durch den ungewöhnlich aggressiven und rezidivierenden Verlauf der Silikonome zerstört. Aufgrund der möglichen jahrelangen Latenz Silikon-assoziierter Komplikationen empfehlen wir eine konsequente Nachuntersuchung für betroffene Patienten aus den frühen Tagen der flüssigen Silikoninjektion.

MEDIAN NERVE INJURY CAUSED BY MISSED FOREIGN BODY Case report

A 56-year-old woman sustained a delayed median nerve division after a penetrating injury of the right wrist by a piece of wood had gone unnoticed. There was no neurological damage at the time of the injury. The foreign body spread the median nerve apart, which subsequently reduced the sensitivity in the index finger. Removal of the wood resulted in complete recovery.A 56-year-old woman sustained a delayed median nerve division after a penetrating injury of the right wrist by a piece of wood had gone unnoticed. There was no neurological damage at the time of the injury. The foreign body spread the median nerve apart, which subsequently reduced the sensitivity in the index finger. Removal of the wood resulted in complete recovery.