Time Of Reconstructive Surgery Research Articles

Evaluation of (111) Indium-Labeled Autologous Leukocyte Scintigraphy for the Diagnosis of Chronic Osteomyelitis in Patients With Grade IV Pressure Ulcers, as Compared With a Standard Diagnostic Protocol

Diagnosing osteomyelitis in patients with pressure ulcers is complicated by overlying soft-tissue inflammation and reactive bone formation. We set out to evaluate the efficacy of indium scanning in the diagnosis of chronic osteomyelitis in spinal-cord-injury patients with grade IV pressure ulcers. The goal was to estimate the sensitivity and specificity of indium scanning as compared with diagnostic modalities previously evaluated by the principal investigator. Our method was a retrospective chart review of cases at a university hospital. Eleven patients with pressure sores and suspected chronic osteomyelitis underwent indium scanning. The results were compared with ostectomy specimens taken at the time of reconstructive surgery and/or bone biopsy. The sensitivity and specificity were 100% and 50%, respectively. Indium scanning appears to be more sensitive than specific. These data suggest that the value of indium scanning may primarily be to rule out osteomyelitis and not as a primary diagnostic modality.

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula.

Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN. Fistuloclysis was attempted in 12 patients with jejunocutaneous or ileocutaneous fistulas with mucocutaneous continuity. Feeding was achieved by inserting a gastrostomy feeding tube into the intestine distal to the fistula. Infusion of enteral feed was increased in a stepwise manner, without reinfusion of chyme, until predicted nutritional requirements could be met by a combination of fistuloclysis and regular diet, following which TPN was withdrawn. Energy requirements and nutritional status were assessed before starting fistuloclysis and at the time of reconstructive surgery. Fistuloclysis replaced TPN entirely in 11 of 12 patients. Nutritional status was maintained for a median of 155 (range 19-422) days until reconstructive surgery could be safely undertaken in nine patients. Two patients who did not undergo surgery remained nutritionally stable over at least 9 months. TPN had to be recommenced in one patient. There were no complications associated with fistuloclysis. Fistuloclysis appears to provide effective nutritional support in selected patients with enterocutaneous fistula.

Immediate breast reconstruction and psychological adjustment in women who have undergone surgery for breast cancer: a preliminary study

Current debate exists regarding the timing of reconstructive surgery following mastectomy for breast cancer, with research pointing in favour of immediate reconstruction. This cross-sectional study sought to compare the psychological outcome of breast cancer treatment in women who had either received mastectomy and immediate reconstruction using autogenous tissue (n = 30), or mastectomy alone (n = 34), and also determine adjustment factors in this population as a whole. Participants completed measures of depression, anxiety, body image, self-esteem, coping and perceived social support at a time point 3 – 15 months after initial surgery. No significant differences were revealed between the two groups on any of the outcome measures. Poor body image, low self-esteem, and a tendency to use coping strategies characterized by helpless/hopelessness and anxious preoccupation, rather than fighting spirit, were highly predictive of distress. Reasons for the lack of differences between the two groups are explored.

Persistent site-specific defects after reconstructive pelvic surgery.

Our objective was to determine the persistence rates of site-specific defects after reconstructive pelvic surgery. We conducted a retrospective analysis of the post-operative outcome for 77 patients with pelvic support defects. Forty-five patients in the abdominal group underwent a Burch procedure, paravaginal repair and sacral colpopexy when indicated; 32 patients in the vaginal group had a sacrospinous vault fixation with or without colporrhaphy. A chi2 test, Wilcoxon's two-sample test. Wilcoxon's signed-rank test and multivariate logistic regression model were used for data analysis. The two groups were similar in age, weight, parity and menopausal status. There was significant improvement of all defects except in the vaginal group, which showed a higher rate of persistent paravaginal defects (68.7 vs. 13.3%, P = 0.001). After adjusting for potential confounders, there was no difference in the rates of apical and anterior wall defects between the two groups. The odds ratio for persistent paravaginal defects in the vaginal group was 8.9 (95% CI: 2.3-34). The choice of surgical procedure is the most important factor determining the rate of persistent pelvic support defects. Lateral wall defects must be addressed at the time of reconstructive surgery.

The O'Donoghue triad revisited

We identified 60 consecutive patients with combined anterior cruciate and medial collateral ligament (ACL-MCL) disruptions that were incurred during athletic endeavors. Each underwent acute reconstruction of the ACL. The arthroscopic data obtained at the time of reconstructive surgery was reviewed in order to determine the incidence of O'Donoghue's triad (the "unhappy triad"), consisting of ACL, MCL, and medial meniscus tears. Patients were subdivided into two groups for analysis based upon the degree of MCL injury at time of presentation (Group I, 35 patients with a second-degree sprain; Group II, 25 patients with a complete, or third-degree injury). Medial meniscus tears were an uncommon finding. Lateral meniscus tears significantly out-numbered medial meniscus tears in both groups, occurring in 25 (71%) of Group I patients and 8 (32%) of those in Group II. Even chondral fractures of the lateral femoral condyle outnumbered medial meniscus tears [6 (17%) versus 4 (11%)] in patients with a second-degree MCL sprain. Furthermore, when present in Group I patients, tears of the medial meniscus were associated with a concomitant lateral meniscus injury. Group II patients were more likely (60%) than Group I not to have any meniscal abnormality at all. We conclude that the classic O'Donoghue triad is, in fact, an unusual clinical entity among athletes with knee injuries; it might be more accurately described as a triad consisting of ACL, MCL, and lateral meniscus tears. This injury combination appears to be more common when an incomplete, or second-degree, tear of the medial collateral has occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

The Failed Posterior Lumbar Interbody Fusion

The problems presented by unsuccessful posterior lumbar interbody fusion (PLIF) have not been addressed. The cases of 12 patients who presented with failed PLIF were reviewed. Five patients were male and seven female (age range, 24-50 years; mean age, 40 years). All patients underwent at least one PLIF; many had undergone other procedures. A total of 37 procedures had been performed on the 12 patients. Chronic radiculopathy was present in all patients, as detected with electromyographic or nerve conduction velocity examination. At the time of reconstructive surgery, in the 11 patients in whom the canal was explored, all had extensive epidural fibrosis. Nine of the 12 patients had pseudarthrosis of the previous PLIF. Four patients had evidence of motion segment dysfunction at nearby levels: two had positive discograms adjacent to the PLIFs; one developed a facet syndrome at L5-S1, caudal to an L4-5 PLIF; and one demonstrated frank segmental instability at L2-3, cranial to a previous PLIF at L3-4. Twelve patients underwent a total of 22 procedures after referral. Eleven patients initially underwent decompression and fusion, and one patient underwent a sympathectomy. Seven patients underwent an additional 10 procedures, including repeat decompression, repair of pseudarthrosis, and implantation of an epidural analgesic pump system. After all surgical treatment, five patients rated their pain as improved. Seven patients were thought to have a solid fusion. The presence of a solid fusion did not correlate with satisfactory relief of pain (chi-square). Continued extremity pain was the predominant complaint of all the patients. Two shortcomings of the PLIF were evident.(ABSTRACT TRUNCATED AT 250 WORDS)

口腔癌治療における大型皮弁および筋皮弁による即時再建手術の治療成績

One hundred and four immediate reconstructions for major orofacial defects following oral cancer surgery were performed in 103 patients using 115 various cutaneous and myocutaneous flaps during the 10-year period from 1979 to 1989. A retrospective analysis of the cases was carried out and the treatment result was presented.Reconstructive cutaneous or myocutaneous flaps were composed of pectorals major myocutaneous flap (PMMC) in 68 cases, latissimus dorsi myocutaneous flap (LDMC) in 19 cases, free radial forearm flap (FA) in 10 cases, deltopectoral flap (DP) in 10 cases, and other miscellaneous flaps in 8 cases. Near the half of the cases had a tongue cancer followed by cancers of the lower alveolus and gingiva, floor of the mouth, buccal mucosa and so on. Ninety-nine cases had squamous cell carcinomas. Seventy-seven cases were treated as primary treatment, whereas 27 cases were secondarily treated against recurrence after previous treatmentsincluding radiotherapy and/or surgery. TNM classification was also applied to recurrent cases at the time of reconstructive surgery, and 49 cases were classified into T4, 55 cases were N1 to N3, then 58.6% of the cases were Stage IV. The mean operation time of 104 cases was 10 hours and 16 minutes, and the average total blood loss was 3, 562 grams. Complete survival of the reconstructed flaps was obtained in about 60%, and 29% of the cases showed a minor loss, however, a major loss and total necrosis of the flap were observed in 10.4% and 1.7% respectively.Recurrence of tumor at any sites of the body was observed in 48%. The recurrence rate was 43% in Stage II, 27% in Stage III and 57% in Stage IV. Recurrence after reconstructive surgery was observed in 29% in the primary sites, 34% in the regional cervical lymph nodal areas, and 17% as distant metastases. Ten years cummulative survival rate was 42.8% in total cases, 67.2% in Stage II, 61.9% in Stage III, and 27.6% in Stage IV by Kaplan-Meier's method. The cummulative survival rates in the primary treatment group for each stage were compared with those of control groups treated without immediate reconstructive sur-gery, disclosing no difference in Stage II, slightly higher in the reconstructive group for Stage III, and 12% higher in the same group for Stage IV. However, the difference was not statistically significant.

Radiological assessment of hemifacial microsomia by three-dimensional computed tomography.

Hemifacial microsomia (HFM) is the commonest asymmetrical craniofacial deformity leading to underdevelopment of the craniofacial skeleton and soft tissues on the affected side. Timing of reconstructive surgery is based on a comprehensive analysis and classification of the deformity. Lateral cephalometric radiographs are of limited value because of superimposition of normal and abnormal bony structures. The skeletal and soft-tissue findings of six patients with HFM who underwent three-dimensional (3D) CT are presented. This method allows a comprehensive assessment of the deformity at a low radiation dose, 22% of that of a conventional CT scan, by the use of a low dose technique.

Facial reinnervation after facial paralysis: is it ever too late?

Following Conley's work on facial nerve cross-over surgery in long-standing facial paralysis, we have reviewed five cases of paralysis of 2.5-7 years' duration. All had complete absence of electrical activity on preoperative EMG and ENG studies. In four of the five cases the facial nerve was not severely atrophic and a "cross-over" technique was feasible. Post-operatively, the results were electrically and clinically good to excellent. To foresee the results of facial nerve cross-over surgery, we have found that the degree of atrophy of the affected nerve at the time of reconstructive surgery is a more important factor than the time lapse since the beginning of the paralysis. Those results also seem better in younger patients. Our findings suggest that hypoglossal-facial cross-overs be considered even 3 years after a paralysis, mostly in younger patients, when the nerve is not severely atrophic. In some cases this technique can be complemented by muscular transfers or selected cosmetic surgery.

Intravenous reserpine for treatment of reflex sympathetic dystrophy.

The efficacy of reserpine in relieving the pain of reflex sympathetic dystrophy was tested in 25 patients--21 with upper extremity and four with lower extremity involvement. Injection of the drug relieved the acute signs and symptoms in the upper extremity in 12 of 17 patients. Four patients with quiescent reflex sympathetic dystrophy of upper extremities had prophylactic injection at the time of reconstructive surgery; they had no flare of symptoms. Relief was obtained in the four cases of lower extremity dystrophy. Our patients had no significant side effects. The drug is confined to the extremity by a pneumatic tourniquet as used for intravenous regional anesthesia. After the extremity is exsanguinated and the cuff is inflated, 1 mg of reserpine diluted to 50 ml with normal saline is injected intravenously into the upper extremity. In the lower extremity, 2 mg of reserpine diluted to 100 ml is injected. The tourniquet is removed after 15 minutes. The procedure is safe and can be done in an office setting.

Timing of Breast Reconstruction After Mastectomy

Certain guidelines can be used to determine the optimal time for breast reconstruction. They include consideration of the nature and virulence of the tumor as well as its location, the use of radiation or chemotherapy, the type of mastectomy performed, the degree of nodal involvement, the likelihood of tumor recurrence, and the patient’s age and motivation. No absolute rules have been established regarding timing of reconstructive surgery, but the patient’s emotional and psychological needs should have considerable bearing on the decision.

The timing of reconstructive surgery in relation to the course of leprosy.

The timing of reconstructive surgery in relation to the course of leprosy.