Scott Levin

Von Frey's method of measuring pressure sensibility in the hand: An engineering analysis of the Weinstein-Semmes pressure aesthesiometer

The development of microsurgical techniques has generated a resurgence of interest in estimating local pressure sensibility as a measure of sensory improvement. Because our experience with Weinsteins modification of Von Freys probes yielded variable and poorly understood results, we measured two sets of probes and examined them in the light of the engineering principles on which their behavior is based. The mechanical behavior of the nylon monofilaments can be described as buckling with one end built in and the other end pinned. The probes are relatively uniform and consistent. However, no loss in sensitivity would accompany division of the set into two or three equivalent sets. Variations in the buckling stress as high as a factor of eight are difficult to avoid. Gross errors arise from careless application, variations in the elastic modulus due to changes in temperature and humidity, and variations in the attachment of fibers to handles and differences in the ends of the filaments. Interpreting results for this instrument requires an understanding of the factors which can influence those results. The rpobes are simple to use but easy to misinterpret.

the Concept of Fillet Flaps: Classification, Indications, and Analysis of Their Clinical Value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the “spare parts” concept. By definition, fillet flaps are axial‐pattern flaps that can function as composite‐tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects. From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps). Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytrens contracture, and two with high‐voltage electrical injuries). Thirty‐six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above‐knee or below‐knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet‐of‐thigh or entire‐limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper‐arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet‐of‐sole flap. In another case, wound infection required revision and above‐knee amputation with removal of the flap. Nine free plantar fillet flaps were performed—five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper‐arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one aboveknee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery. Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients. On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor‐site morbidity and facilitate stump‐length preservation or limb salvage. (Plast. Reconstr. Surg. 108: 885, 2001.)

Staphylococcus aureus Bacteremia After Median Sternotomy: Clinical Utility of Blood Culture Results in the Identification of Postoperative Mediastinitis

Background Mediastinitis is a complication of coronary artery bypass graft surgery (CABG) that can be difficult to diagnose. This study evaluated the utility of blood culture results in identifying patients with mediastinitis. Methods and Results All unique patients undergoing CABG at our institution over a 60‐month study period (n=5500) and all blood cultures performed on these patients ≤90 days after CABG were identified. Mediastinitis was identified by prospective active infection control surveillance. Eight hundred fifty‐five (15.5%) patients had ≥1 blood culture drawn within 90 days of CABG. Mediastinitis occurred in 46 of 60 (76.7%) patients with blood cultures positive for Staphylococcus aureus, 15 of 126 (11.9%) patients with blood cultures positive for other pathogens, 37 of 669 (5.5%) patients with blood cultures with no growth, and 44 of 4645 (0.9%) patients with no blood cultures obtained. The isolation of S aureus from even 1 blood culture drawn after ≤90 days of CABG was strongly associated with mediastinitis (likelihood ratio [LR], 25; 95% CI, 14.7 to 44.4). Bacteremia attributable to other organisms did not alter pretest suspicion for mediastinitis (LR, 1.0; 95% CI, 0.6 to 1.7). Patients with negative blood cultures were less likely to have mediastinitis (LR, 0.45; 95% CI, 0.35 to 0.58). The association between S aureus bacteremia and mediastinitis remained highly significant when all unique patients undergoing CABG were analyzed in a logistic regression model and when a case‐control analysis was used to evaluate patients with ≥1 blood culture obtained after CABG. Conclusions Among patients with blood cultures drawn after CABG, S aureus bacteremia strongly suggests the presence of mediastinitis. (Circulation. 2003;108:73‐78.)

Soft-tissue defects and exposed hardware: a review of indications for soft-tissue reconstruction and hardware preservation.

Background: Traditionally, management of exposed hardware has included irrigation and débridement, intravenous antibiotics, and likely removal of the hardware. Increasingly, the goal of wound closure without hardware removal using plastic surgical techniques of soft-tissue reconstruction has been emphasized. Identification of parameters for retaining exposed hardware may assist surgeons with management decisions and outcomes. Methods: A current literature review was performed to identify parameters with prognostic relevance for management of exposed hardware before soft-tissue reconstruction. Results: The following parameters were identified as important for the potential salvage of exposed hardware with soft-tissue coverage: hardware location, infection, duration of exposure, and presence of hardware loosening. Conclusions: Management of exposed hardware has included the removal of the hardware. However, if certain criteria are met—specifically, stable hardware, time of exposure less than 2 weeks, lack of infection, and location of hardware—salvage of the hardware with plastic surgical soft-tissue coverage may be a therapeutic option.

The use of particulate hydroxyapatite and plaster of paris in aesthetic and reconstructive surgery

The authors describe their early investigative results of using a mixture of hydroxyapatite (HA) and plaster of Paris (PP) in skull and frontal sinus defects in a large series of cats. Histologically, bone was found to form and infiltrate the HA-PP implant over a period of months, with gradual resorption of the plaster in 6–8 weeks. Clinically, the HA-PP combination has been used in 24 patients over the past seven years for various skull, zygomatic, and mandibular defects.

Endoscopically assisted sural nerve harvest for upper extremity posttraumatic nerve defects : An evaluation of functional outcomes

Background: Peripheral nerve injuries in the upper extremity often require interposition of sural nerve grafts for reconstruction. Due to the poor donor-site appearance with standard techniques, and the potential for trauma to the nerve because of poor visualization during the harvest when the stepladder technique is used, the endoscope has been employed for nerve harvest. Methods: From January of 1997 until December of 2003, 15 patients with an average age of 27.5 years with posttraumatic upper limb nerve defects of the ulnar, median, or posterior interosseous nerves (crush, cutting, or avulsion injuries) underwent reconstruction with endoscopically harvested sural nerve. The nerves were harvested using atraumatic techniques under video monitor visualization. The functional results of sensation and motor function were assessed using British Medical Research Council scales. Results: All patients regained at least cutaneous pain and tactile sensibility, with most regaining two-point discrimination (nine patients achieved S3+). Two patients achieved complete recovery (S4). The 11 patients with motor nerve involvement achieved between M1+ and M5 after the initial reconstruction. Eight patients required a total of one immediate and nine secondary procedures to achieve the final outcome. The procedures included tenolysis (three patients), intrinsic tendon transfers (four patients), and opponensplasty (three patients). At the 4-year mean follow-up, grip power was M5 in 13 patients (86.7 percent) and M4 in two patients (13.3 percent). Conclusions: Upper extremity sensory and motor nerve defects can be reconstructed with interposition of endoscopically harvested sural nerve grafts. The procedure is reliable, quick, and atraumatic, and results in reasonable motor and sensory recovery.

Reflections 1 year into the 21-center national institutes of health-funded wrist study: A primer on conducting a multicenter clinical trial

The Wrist and Radius Injury Surgery Trial (WRIST) study group is a collaboration of 21 hand surgery centers in the United States, Canada, and Singapore, to showcase the interest and capability of hand surgeons to conduct a multicenter clinical trial. The WRIST study group was formed in response to the seminal systematic review by Margaliot et al and the Cochrane report that indicated marked deficiency in the quality of evidence in the distal radius fracture literature. Since the initial description of this fracture by Colles in 1814, over 2,000 studies have been published on this subject; yet, high-level studies based on the principles of evidence-based medicine are lacking. As we continue to embrace evidence-based medicine to raise the quality of research, the lessons learned during the organization and conduct of WRIST can serve as a template for others contemplating similar efforts. This article traces the course of WRIST by sharing the triumphs and, more important, the struggles faced in the first year of this study.

Plastic surgery within the Veterans Affairs Medical System: Proposed modified indications for operative procedures

Many plastic surgery procedures span the divide between aesthetic (“cosmetic”) and reconstructive surgery. However, definitions and guidelines may be inconsistent, which may decrease patients’ access to legitimate procedures. The article aims to assist Veterans’ Health Administration-affiliated plastic surgeons in continuing to provide optimal care to the Nations Veterans and family members, and should be regarded as an open discussion.