L. Scott Levin

Digital sensibility following replantation

The amputated digit serves as an excellent model for the examination of digital nerve repair. When amputation is complete, there is no question of cross-over or anomalous innervation. The sensibility of 35 replanted digits in 29 patients was evaluated. Sensory return was related most closely to restored digital vascularity, as measured by Allen test, pulse volume flow, and Doppler. Level of amputation, mechanism of injury, and age of patient also affected ultimate sensation. All patients experienced cold intolerance and some were considerably disabled because of it. The severity of cold intolerance with pain and requiring prolonged rewarming was directly proportional to digital vascularity. When one digital artery thrombosed, ipsilateral digital sensation was not diminished as long as flow through the contralateral vessel was adequate. Two-point discrimation in our series was not as good as that reported for digital nerve repair in the nonamputated digit. Establishing and maintaining adequate digital flow at the time of replantation is essential to obtain good digital sensibility and to avoid symptoms of cold intolerance.

Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis.

OBJECTIVE Poststernotomy mediastinitis, although infrequent, is a potentially life-threatening complication of cardiac surgery that continues to have a significant morbidity and mortality despite aggressive therapy. Vacuum-assisted closure uses controlled suction to provide evacuation of wound fluid, decrease bacterial colonization, stimulate granulation tissue, and reduce the need for dressing changes. METHODS One hundred two patients from Duke University Hospital, The Durham Veterans Administration Hospital, and referring institutions underwent vacuum-assisted closure treatment. There were 63 men and 39 women, with a mean age of 67. The infection was noticed between postoperative days 8 and 34, at which time the wounds were opened and debrided. RESULTS Ninety-six of the 102 patients received vacuum-assisted therapy while the remaining 6 underwent daily multiple dressing changes without vacuum-assisted therapy. Fifty-three of the 96 patients required only sternal debridement, followed by wound vacuum therapy and closure by secondary intention, while the remaining 43 had an additional procedure. Of these, 33 patients underwent omental transposition and 10 patients had a pectoralis flap. The length of stay for all patients was 27 +/- 12 days. This was related in part to intravenous antibiotics. Hospital mortality for all patients was 3.7% (4 patients). Two of these patients underwent vascular flap and succumbed to multisystemic organ failure, while the other 2 received only wound vacuum therapy following debridement and succumbed to overwhelming sepsis. CONCLUSION Vacuum-assisted drainage is an effective therapy for mediastinitis following debridement or before placement of a vascularized tissue flap.

Proportionality in Asian and North American Caucasian Faces Using Neoclassical Facial Canons as Criteria

Abstract. Nine projective linear measurements were taken to determine morphometric differences of the face among healthy young adult Chinese, Vietnamese, and Thais (60 in each group) and to assess the validity of six neoclassical facial canons in these populations. In addition, the findings in the Asian ethnic groups were compared to the data of 60 North American Caucasians. The canons served as criteria for determining the differences between the Asians and Caucasians. In neither Asian nor Caucasian subjects were the three sections of the facial profile equal. The validity of the five other facial canons was more frequent in Caucasians (range: 16.7–36.7%) than in Asians (range: 1.7–26.7%). Horizontal measurement results were significantly greater in the faces of the Asians (en–en, al–al, zy–zy) than in their white counterparts; as a result, the variation between the classical proportions and the actual measurements was significantly higher among Asians (range: 90–100%) than Caucasians (range: 13.3–48%). The dominant characteristics of the Asian face were a wider intercanthal distance in relation to a shorter palpebral fissure, a much wider soft nose within wide facial contours, a smaller mouth width, and a lower face smaller than the forehead height. In the absence of valid anthropometric norms of craniofacial measurements and proportion indices, our results, based on quantitative analysis of the main vertical and horizontal measurements of the face, offers surgeons guidance in judging the faces of Asian patients in preparation for corrective surgery.

Management of Open Fractures and Subsequent Complications

Early, systemic, wide-spectrum antibiotic therapy is necessary for the treatment of open fractures. The bead pouch technique delivers antibiotics locally and prevents secondary wound contamination. The open fracture wound should be thoroughly débrided. To avoid the complication of gas gangrene, the wound should not be closed. Extensive soft-tissue damage may necessitate the use of local or free flaps. Techniques of fracture stabilization depend on the anatomic location of the fracture and the characteristics of the injury. Early bone grafting and supplemental procedures may be needed to achieve healing. Management of the infected open fracture is based on radical débridement, skeletal stabilization, microbial-specific antibiotics, soft-tissue coverage, and reconstruction of bone defects.

Sternal plating for the treatment of sternal nonunion

BACKGROUND Sternal nonunion, defined as sternal pain with clicking, instability, or both for more than 6 months in the absence of infection, is an uncommon complication of median sternotomy. Nonunion is frequently complicated by the presence of multiple transverse fractures, which make simple rewiring inadequate. METHODS Six patients with debilitating pain secondary to sternal nonunion were treated with the technique of sternal plating between 1989 and 1995. RESULTS Sternal plating corrected sternal instability and provided excellent pain relief in all 6 patients. All patients reported an improved quality of life and were able to resume recreational activities. Two patients have had plate removal for late bursa formation. Sternal healing was complete in both instances. CONCLUSIONS Sternal plating, which is based on the tension-band principle, is an effective treatment of sternal nonunion. The technique is applicable to both simple and complex nonunions. The stainless steel plates resist bending stresses, and the cortical bone resists compressive forces. The technique requires minimal dissection of the posterior sternal border, is not circumferential, and provides secure sternal approximation.

Osteoblasts express the inflammatory cytokine interleukin-6 in a murine model of Staphylococcus aureus osteomyelitis and infected human bone tissue

Staphylococcus aureus is the single most common cause of osteomyelitis in humans. Incidences of osteomyelitis caused by S. aureus have increased dramatically in recent years, in part due to the appearance of community-acquired antibiotic resistant strains. Therefore, understanding the pathogenesis of this organism has become imperative. Recently, we have described the surprising ability of bone-forming osteoblasts to secrete a number of important immune mediators when exposed to S. aureus in vitro. In the present study, we provide the first evidence for the in vivo production of such molecules by osteoblasts during bacterial infection of bone. These studies demonstrate the expression of the key inflammatory cytokine interleukin-6 by osteoblasts in organ cultures of neonatal mouse calvaria, and in vivo using a mouse model that closely resembles the pathology of trauma-induced staphylococcal osteomyelitis, as determined by confocal microscopic analysis. Importantly, we have established the clinical relevancy of these findings in infected human bone tissue from patients with S. aureus-associated osteomyelitis. As such, these studies demonstrate that bacterial challenge of osteoblasts during bone diseases, such as osteomyelitis, induces cells to produce inflammatory molecules that can direct appropriate host responses or contribute to progressive inflammatory damage.

Microsurgical free flap transfer to amputation sites: indications and results.

A series of microsurgical free flap reconstructions to amputation stumps of the upper as well as the lower extremities was reviewed in 7 male and 2 female patients. Indications included preservation of length after trauma in 6 patients and cure of local infection in 2 patients. In 1 patient an extensive defect after resection of a recurrent shoulder sarcoma required use of a complete arm fillet free flap for tumor reconstruction. Microvascular free flaps used included four scapular flaps, two fillet flaps from the amputated extremity, one anterolateral thigh flap, and one lateral arm flap. Seven of 9 patients were fitted with a prosthesis and underwent occupational therapy resulting in ambulatory and improved functional status. Microvascular reconstruction is indicated in emergency settings as well as for elective reconstruction of amputation sites. Using uninjured “spare parts” of the amputated extremity should be considered. Elective reconstruction is performed preferably with free flaps based on the subscapular vascular system.

Management of enterocutaneous fistulas using negative-pressure dressings.

Fifteen patients with enterocutaneous fistulas (ECFs) not amenable to surgical treatment were treated with negative-pressure dressings over the abdominal wound and ECF. Closure of the ECF and time to closure were examined. In 11 patients who had no visible intestinal mucosa on examination, the closure rate was 100%, with a mean time to closure of 14 days. In 4 patients who did have grossly visible intestinal mucosa, no closure occurred. This represents an overall closure rate of 73%. Fistula output rate did not have a significant effect on outcome. These results confirm the efficacy of negative-pressure dressings in the closure of ECFs. Presence or absence of visible intestinal mucosa is the single most important clinical factor when considering the use of a negative-pressure dressing in the management of a patient with ECF.

Management of severe musculoskeletal injuries of the upper extremity.

Summary: Limb salvage was successful in 25 patients treated for severe grade III upper extremity injuries. In a retrospective review of 20 men and five women, follow-up time averaged 26 months. These high-energy injuries were characterized by massive soft-tissue injury, highly comminuted fractures, and significant neurovascular injury. Farm, industrial, and vehicular accidents accounted for 80% of the cases. Over 50% of the patients had concomitant systemic and/or other significant extremity injuries. Initial treatment consisted of irrigation and debridement and fracture stabilization using external and/or internal fixation. An average of four additional surgical procedures was required to provide soft-tissue coverage and maximum possible functional recovery. Forty-eight percent of the extremities underwent free vascularized or pedicular flaps for coverage or reconstruction. At final follow-up observation, 12% of the extremities rated excellent, 20% rated good, 52% fair, and 16% were poor. Experience gained in managing these severe upper extremity fractures supports the following observations. (a) Grade III open fractures of the upper extremities are frequently associated with significant neural, vascular, and musculotendon injuries. (b) External fixation plays an important role in the stabilization of grossly contaminated fractures. (c) Residual functional disability is common, and most patients do not return to their previous occupation. (d) Staged reconstruction directed toward maximum functional return may take several years.

Direct end-to-end repair of flexor pollicis longus tendon lacerations☆

Between 1976 and 1986, 38 consecutive acute isolated flexor pollicis longus lacerations were repaired. This study excluded all replanted or mutilated digits and all lacerations with associated fracture. Average follow-up was 26 months. Tendon rehabilitation was standardized. Range of motion and pinch strength were measured postoperatively. Seventy-four percent (28/38) of the flexor pollicis longus injuries occurred in zone II. Neurovascular injury occurred in 82% of the lacerations, and this correlated with the zone of tendon injury. In 21% of the patients (8/38) both digital nerves and arteries were transected. Postoperative thumb interphalangeal motion averaged 35 degrees and key pinch strength was 81% that of the uninjured thumb. One rupture occurred in a child. Laceration of the flexor pollicis longus is likely to involve damage to neurovascular structures, and repair may be necessary. Direct end-to-end repairs within the pulley system do at least as well as delayed tendon reconstruction and do not require additional procedures.