James Mahoney

Wound-healing complications after soft-tissue sarcoma surgery

One-hundred and eighty patients undergoing limb-salvage surgery for soft-tissue sarcoma from 1986 to 1991 were assessed retrospectively for risk factors associated with major wound-healing complications. Twenty-three of 137 patients (16 percent) treated with primary direct wound closure sustained complications. In univariate analysis, the cross-sectional area of tumor resection, the use of preoperative irradiation, the width of the skin excision, a history of smoking, and a history of diabetes and/or vascular disease were associated with wound failure. Multivariate analysis revealed that preoperative irradiation (p = 0.04) and resection diameter (p = 0.017) accounted for the risk of complications.Eighteen additional patients were treated empirically with distant vascularized tissue transfers following preoperative irradiation because of concerns regarding potential wound complications. The lower complication rate in this group suggested that vascularized tissue transfer may be beneficial in lowering wound complication rates. (Plast. Reconstr. Surg. 93: 980, 1994.)

Salvage after severe lower-extremity trauma: are the outcomes worth the means?

Advances in reconstructive surgery have allowed for impressive salvage after severe lower-extremity trauma but not without complications when compared with immediate below-knee amputation. Several amputation index scores have been developed to help predict successful salvage as defined by a viable rather than a functional extremity. The purpose of this study was to evaluate retrospectively the predictive value of the amputation index scores and to assess prospectively overall health status and specific dysfunction in successful limb salvage and primary and secondary amputation by administering standardized generic and specific outcomes questionnaires (Medical Outcomes Study 36-Item Short-Form Health Survey, Western Ontario and MacMaster Universities Osteoarthritis Index). A retrospective chart review identified 55 severe lower-extremity injuries (Gustilo Type IIIB and IIIC) over a 12-year period (1984 to 1996). Forty-six severe open tibial fractures in 45 patients underwent attempted salvage. All required soft-tissue coverage by either local or free flap or vascular repair for leg salvage. The attempted-salvage group was subdivided into successful salvage and secondary amputation. The other nine patients underwent a primary amputation. There were no statistically significant differences in terms of patient demographics or other injuries (Injury Severity Score) in the three groups. Forty-eight of 54 patients with an average 5-year follow-up completed a validated generic and specific outcomes health questionnaire. In the attempted-salvage group, 89 percent of patients had a successful salvage and 11 percent came to a secondary amputation. The amputation index scores correctly predicted an amputation in 32 percent of patients. The magnitude of the amputation index scores did not correlate with the physical outcomes scores and were not found to add any significant value of information to the surgeons decision making. Patients undergoing primary and secondary amputation had a worse physical outcomes score (28 versus 38) than successful salvage (p < 0.007). Even so, the SF-36 (physical component score) outcomes score for this group of injured extremities, regardless as to whether salvaged or amputated, was as low as or lower than that of many serious medical illnesses, suggesting that severe lower-extremity trauma impairs health as much as or more than being seriously ill. The mental component score in this group was comparable to that of a healthy population (49 versus 50), which implies the disability is primarily physical rather than psychological. Ninety-two percent of patients preferred their salvaged leg to an amputation at any stage of their injury, and none would have preferred a primary amputation.

Sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand

High-resolution ultrasound is capable of detecting foreign bodies of practically any composition. The purpose of this study was to determine in a controlled manner the sensitivity and specificity of ultrasound in the diagnosis of foreign bodies in the hand. Each of 15 fresh-frozen cadaver hands was divided into 21 standardized sites for potential foreign body insertion. Foreign bodies consisted of two sizes of three different materials (wood, glass, and metal). Foreign bodies were randomly assigned to 50% of the available sites. The empty sites served as controls. All hands were scanned by a single radiologist using high-resolution ultrasound at a frequency of 10 MHz. The radiologist was unaware of which specimens contained foreign bodies. Of the 166 foreign bodies inserted in total, 156 were detected by ultrasound. Ten sites were falsely analyzed as negative, for a sensitivity of 94%. There was one false positive result and 148 true negatives. The specificity was therefore 99%. The high specificity of ultrasound allows foreign body presence to be confirmed given a positive result. A combination of ultrasound and x-ray films should allow for diagnosis and localization of virtually all foreign bodies in the hand.

The Influence of Muscle Flap Coverage on the Repair of Devascularized Tibial Cortex: An Experimental Investigation in the Dog

Segments (2 cm) of canine tibial diaphyseal bone were devascularized and internally fixed with a plate. The medial cortex of the devascularized tibia was covered with skin in one experimental group (n = 7) and a local muscle flap in the other (n = 6). The animals were given intravenous fluorochrome dye and killed 42 days postoperatively. Enveloping callus formed around the cortex which was repaired by the formation of resorptive cavities on its external surface. New bone formation occurred within the resorptive cavities. Muscle flap coverage was associated with a sixfold increase in cortical porosity (p less than 0.005) and a fourfold increase in the area of enveloping callus (p less than 0.05). The area of intracortical new bone formation was greater in the cortex with muscle flap coverage (p less than 0.05). The maximum depth of intracortical new bone formation increased from 0.46 +/- 0.14 mm with skin coverage to 0.95 +/- 0.14 mm with muscle flap coverage (p less than 0.001). This study demonstrates that muscle flaps are superior to skin coverage in initiating the repair of devascularized cortical bone.

Preoperative Radiotherapy for Adult Head and Neck Soft Tissue Sarcoma: Assessment of Wound Complication Rates and Cancer Outcome in a Prospective Series

Combination surgery and radiotherapy (RT) is frequently used in soft tissue sarcoma (STS). Because lower doses and smaller irradiation volumes are possible in preoperative RT (pre-op RT), this approach can be especially valuable in anatomic settings where critical organs are in close proximity to the RT target area. A recent multicenter phase III trial (SR.2 trial of the National Cancer Institute of Canada Clinical Trials Group) comparing pre-op RT against post-op RT for extremity STS has shown significantly higher major wound complication rates (35%) with pre-op RT. We postulated that wound complication rates may be less frequent in the head and neck with better vascularity and wider use of secondary wound reconstruction. Using a prospective database, we identified 40 consecutive patients with head and neck STS treated with pre-op RT (50 Gy) and subsequent (4 to 6 weeks later) resection between 1/89 and 8/99 in a single institution setting. Major wound complications (MWC) were classified by the identical criteria used in the SR.2 trial. Intracranial extension was evident in 5 patients, whereas 50% of the patients had large tumors (> 5 cm). Deep tumor was present in 34 (85%), and 6 (15%) were superficial to fascia. In this series, 31 patients (77.5%) had secondary reconstruction of the acquired soft tissue deficit. The actuarial 2-year local relapse-free rate was 80%, and the metastatic relapse-free rate was 85%. Major wound complications occurred in 8 of 40 patients (20%) within 120 days of surgery according to the SR.2 criteria: secondary wound surgery (3), readmission or prolonged hospital admission for wound care (2), deep packing (0), prolonged dressing changes (2), and invasive procedure for wound care (1). The latter was a minor wound management problem (a single outpatient drainage of a seroma) for the combined rate of 8/20 or 20%. Our findings show that (1) pre-op RT in head and neck STS is associated with lower rates of major wound complications compared to extremity cases; (2) pre-op RT provides high rates of local control in an adverse group of cases of adult head and neck STS; (3) the choice of scheduling of RT should be based on anatomic issues with emphasis on the trade-offs between RT doses and volumes versus wound morbidity for individual patients. This is especially important when tumor may be adjacent to critical head and neck structures which may be protected from the high-dose RT area.

Digital two-dimensional photogrammetry: a comparison of three techniques of obtaining digital photographs.

Three methods of obtaining digital photographs in a clinical setting were compared using direct anthropometry as a reference standard. The methods included a digital camera, scanning negatives from a 35-mm single-lens reflex camera, and scanning Polaroid photographs taken with a Polaroid camera designed for medical documentation. A total of 11 angular and linear anthropometric measurements obtained from 30 healthy volunteers were used for the comparison. The data were analyzed using a variance covariance approach to repeated measures. The analysis revealed that the three cameras were not statistically different from each other. Other advantages and disadvantages, such as cost and ease of use, are discussed.

Anatomic basis of local muscle flaps in the distal third of the leg.

Soft-tissue defects of the distal third of the tibia are considered to be the realm of free-tissue transfer. We have found clinically that several local muscles can be used reliably in this area. The purposes of this study were: (1) to evaluate the potential use of the local muscles for soft-tissue coverage in the lower third of the leg and (2) to obtain numerical data that could be used preoperatively in the selection of potential local muscle flaps. All potential muscles, excluding the gastrocnemius, plantaris, and popliteus, from 10 fresh frozen legs were examined and the following details recorded: (1) the distance above the medial malleolus that the muscle bellies ended (musculotendinous junction), (2) the distance between the medial malleolus and the distal end of the transposed flaps (reach), (3) the area of tibia that could be covered, and (4) the vascular supply to these muscles. The soleus, extensor digitorum longus and peroneus tertius, extensor hallucis longus, peroneus brevis, and flexor digitorum longus were found to be the most anatomically suited muscles for local transposition to selected lower-third defects. We have worked with these muscles clinically and have found them to be useful and reliable when chosen appropriately.

Quality of life in patients with diabetic foot ulcers: validation of the Cardiff Wound Impact Schedule in a Canadian population

The purpose of this study was to evaluate and validate the Cardiff Wound Impact Schedule (CWIS), a disease‐specific quality‐of‐life measure, in a diabetic foot ulcer (DFU) population. Patients with DFUs have restrictions as part of their treatment and rehabilitation, which can affect health‐related quality of life (HRQoL). Because of the high number of comorbidities experienced in diabetes, a disease‐specific quality‐of‐life measure is needed to best assess the affect of a foot ulcer on HRQoL. Patients with DFUs completed the CWIS and a World Health Organization generic quality‐of‐life questionnaire. Validity was assessed by comparing domains of the questionnaires. Patients were categorised using the University of Texas wound classification system. Mean CWIS scores were compared between categories to assess the questionnaires ability to differentiate wound severity. Patients with open ulcers scored significantly lower on the CWIS than those with healed ulcers. Correlations between questionnaire domains were as follows: Social Life with Social Functioning (r = 0·641, P < 0·001); Well‐Being with General Health (r = 0·533, P < 0·01); Physical Symptoms and Daily Living with Physical Functioning (r = 0·631, P < 0·01) and Health‐Related Quality of Life with Vitality (r = 0·425, P < 0·01). However, there was no significant difference in mean CWIS scores between categories of wound severity. We have demonstrated the ability of the CWIS in assessing HRQoL in a DFU population and its ability to differentiate between healed and non healed states.

Step osteotomy: a precise rotation osteotomy to correct scissoring deformities of the fingers.

A scissoring deformity of the fingers frequently results from malunion of a phalangeal or metacarpal fracture. If union occurs with rotation, the injured digit will scissor with an adjacent digit on flexion of the hand. Malrotation can be corrected by a technique of step osteotomy of the metacarpal with removal of a longitudinal strip of bone. The placement of the transverse cuts of the osteotomy determines the direction of rotational correction and the width of dorsal strut determines the amount of rotational correction. Firm fixation with two interosseous wires ensures good bony union and allows early mobilization.

Cervical spine injury in association with craniomaxillofacial fractures

Background: The incidence of cervical spine injuries associated with facial fractures varies from study to study. There is general agreement that immediate management of cervical spine injuries is mandatory to prevent further neurologic injury. Nevertheless, disagreement exists as to the actual incidence of cervical spinal trauma in conjunction with various facial fracture patterns. The purpose of this study was to review the incidence of cervical spine injury associated with various types of facial fractures presenting to St. Michael’s Hospital Regional Trauma Center, Toronto, Ontario, Canada. Methods: The authors conducted a retrospective chart review of craniomaxillofacial fracture patients presenting to St. Michael’s Hospital from January 1, 1994, to December 31, 2003, inclusive. Results: The data from this 10-year time span revealed a total of 124 patients with cervical spine injuries drawn from a cohort of 3356 patients with craniomaxillofacial fractures. The overall incidence of cervical spine injury was 3.69 percent. Of these patients, 928 had isolated upper third facial or skull fractures, whereas isolated middle third facial fractures were seen in 716 patients and isolated lower third facial fractures were present in 798 patients. Combined facial fracture patterns, involving two or more facial thirds, accounted for the greatest number of cervical spine injuries, occurring in 8.86 percent (n = 914). Conclusions: The relationship between cervical spinal injuries and craniomaxillofacial trauma has been better defined as it relates to a regional trauma registry. The implications as related to the trauma assessment, diagnosis, and treatment of these injuries are reviewed.