[Application of immunochromatographic test for diagnosis and surveillance of bancroftian filariasis]

AIM

To evaluate the usefulness of immunochromatographic test (ICT) for rapid diagnosis and surveillance of Wuchereria bancrofti infection.

METHODS

The monoclonal antibody based-ICT assay was used to detect filarial antigens in the sera from bancroftian filariasis patients.

RESULTS

111 out of 116 bancroftian microfilaria cases showed positive ICT reaction, giving a positive rate of 95.7%. Serum samples from 12 malayian microfilaremia cases, 33 ascariasis cases, 20 schistosomiasis japonica cases and 6 trichinellosis cases were all found negative in ICT, demonstrating a specificity of 100%. In 73 chronic filariasis cases with elephantiasis, hydrocoele, and chyluria cases, 18 showed ICT positive, among whom 16 revealed microfilaremia, suggesting that the ICT positive cases were with active infections. Of the 30 microfilaremia cases before single dose ivermectin treatment, 29 were ICT positive (96.7%). A negative conversion of microfilaremia was observed in all cases 8-14 days post-treatment. Upon following up to 6 and 12 months, microfilaremia reappeared in 5 and 7 cases, respectively. 5 out of 13 ICT positive cases were found microfilaremic at 6 month post-treatment, while among the rest of 8, 5 were found microfilaremic at 12 month post-treatment. Parallel use of ICT with routine blood film examination in Houda village, Zhecheng County, Henan Province for a post-control surveillance survey in 132 local individuals revealed 9 microfilaremia cases were also ICT positive. Of the 123 persons with negative blood examination, only 1 was ICT positive.

CONCLUSION

ICT is a rapid and simple method with high sensitivity and specificity, and might be used for the diagnosis, efficacy evaluation as well as a tool for post-control surveillance of bancroftian filarasis.

Evidence for shared genetic programs from cluster analysis of hippocampal gene expression dynamics in development and response to injury

Cluster analysis is a computational method that groups together similarly-shaped patterns. It may be applied to large-scale gene expression data to form new hypotheses regarding gene function. In the present study, we clustered the temporal expression patterns of genes expressed in the rat hippocampus during normal development and after a kainate-induced seizure injury at postnatal day 25. We found that two different methods, Euclidean hierarchical and K-means clustering, produced slightly different results, and concluded that different clustering methods may he used to complement one another. We also found that certain genes cluster together both during development and after seizure injury, consistent with the idea of sets of genes that act in concert under various conditions.

Retinal degeneration mutants in the mouse

The Jackson Laboratory, having the world's largest collection of mouse mutant stocks and genetically diverse inbred strains, is an ideal place to look for genetically determined eye variations and disorders. Through ophthalmoscopy, electroretinography and histology, we have discovered disorders affecting all aspects of the eye including the lid, cornea, iris, lens and retina, resulting in corneal disorders, cataracts, glaucoma and retinal degenerations. Mouse models of retinal degeneration have been investigated for many years in the hope of understanding the causes of photoreceptor cell death. Sixteen naturally occurring mouse mutants that manifest degeneration of photoreceptors in the retina with preservation of all other retinal cell types have been found: retinal degeneration (formerly rd, identical with rodless retina, r, now Pde6b(rd1)); Purkinje cell degeneration (pcd); nervous (nr); retinal degeneration slow (rds, now Prph(Rd2)); retinal degeneration 3 (rd3); motor neuron degeneration (mnd); retinal degeneration 4 (Rd4); retinal degeneration 5 (rd5, now tub); vitiligo (vit, now Mitf(mi-vit)); retinal degeneration 6 (rd6); retinal degeneration 7 (rd7, now Nr2e3(rd7)); neuronal ceroid lipofuscinosis (nclf); retinal degeneration 8 (rd8); retinal degeneration 9 (Rd9); retinal degeneration 10 (rd10, now Pde6b(rd10)); and cone photoreceptor function loss (cpfl1). In this report, we first review the genotypes and phenotypes of these mutants and second, list the mouse strains that carry each mutation. We will also provide detailed information about the cpfl1 mutation. The phenotypic characteristics of cpfl1 mice are similar to those observed in patients with complete achromatopsia (ACHM2, OMIM 216900) and the cpfl1 mutation is the first naturally-arising mutation in mice to cause cone-specific photoreceptor function loss. cpfl1 mice may provide a model for congenital achromatopsia in humans.

A functional role for intra-axonal protein synthesis during axonal regeneration from adult sensory neurons

Although intradendritic protein synthesis has been documented in adult neurons, the question of whether axons actively synthesize proteins remains controversial. Adult sensory neurons that are conditioned by axonal crush can rapidly extend processes in vitro by regulating the translation of existing mRNAs (Twiss et al., 2000). These regenerating processes contain axonal but not dendritic proteins. Here we show that these axonal processes of adult sensory neurons cultured after conditioning injury contain ribosomal proteins, translational initiation factors, and rRNA. Pure preparations of regenerating axons separated from the DRG cell bodies can actively synthesize proteins in vitro and contain ribosome-bound beta-actin and neurofilament mRNAs. Blocking protein synthesis in these regenerating sensory axons causes a rapid retraction of their growth cones when communication with the cell body is blocked by axotomy or colchicine treatment. These findings indicate that axons of adult mammalian neurons can synthesize proteins and suggest that, under some circumstances, intra-axonal translation contributes to structural integrity of the growth cone in regenerating axons. By immunofluorescence, translation factors, ribosomal proteins, and rRNA were also detected in motor axons of ventral spinal roots analyzed after 7 d in vivo after a peripheral axonal crush injury. Thus, adult motor neurons are also likely capable of intra-axonal protein synthesis in vivo after axonal injury.

Linkage and association of CYP17 gene in hereditary and sporadic prostate cancer

Androgens are essential for prostate development, growth and maintenance and the association between androgen levels and prostate cancer is well established. Since the CYP17 gene encodes the enzyme cytochrome P450c17alpha, which mediates 17alpha-hydroxylase and 17,20-lyase activities in the androgen biosynthesis pathway, sequence variations in the gene and association with increased risk to prostate cancer has been studied. In particular, several groups have studied the association between a polymorphism in the 5' promoter region and prostate cancer using a population-based association approach. However, the results from these studies were inconclusive. To further study this polymorphism and its possible role in hereditary prostate cancer (HPC), we performed a genetic linkage analysis and family-based association analysis in 159 families, each of which contains at least 3 first-degree relatives with prostate cancer. In addition, we performed a population-based association analysis to compare the risk of this polymorphism to hereditary and sporadic prostate cancer in 159 HPC probands, 249 sporadic prostate cancer patients and 211 unaffected control subjects. Evidence for linkage at the CYP17 gene region was found in the total 159 HPC families (LOD = 1.3, p = 0.01, at marker D10S222). However, family-based association tests did not provide evidence for overtransmission of either allele of the CYP17 polymorphism to affected individuals in the HPC families. The allele and genotype frequencies of the polymorphism were not statistically different among the HPC probands, sporadic cases and unaffected control subjects. In conclusion, our results suggest that the CYP17 gene or other genes in the region may increase the susceptibility to prostate cancer in men; however, the polymorphism in the 5' promoter region has a minor role if any in increasing prostate cancer susceptibility in our study sample.

Frequency of anovulation and early menopause among women enrolled in selected adult AIDS clinical trials group studies

To obtain information on the prevalence of anovulation and early menopause and on pituitary-gonadal function among human immunodeficiency virus type 1-infected women, a study was undertaken that used stored serum samples from women aged 20-42 years who participated in selected Adult AIDS Clinical Trials Group protocols. Defined progesterone and follicle-stimulating hormone (FSH) levels were considered presumptive evidence of ovulation and of menopause, respectively. Anovulation occurred in 16 (48%) of 33 women for whom progesterone levels were tested; early menopause occurred in 2 (8%) of 24 women for whom FSH levels were tested. No statistically significant differences were seen in the demographic and clinical characteristics of anovulatory and ovulatory women, although women who ovulated had higher CD4 T cell counts and were less likely to have reported a recent change in menstrual periods. These data support the findings of prior studies of increased frequency of amenorrhea and/or irregular menstrual cycles, particularly among women with lower CD4 T cell counts.

Underappreciation of sleep disorders as a cause of motor vehicle crashes

Despite an increased risk of motor vehicle crashes (MVC) in patients with obstructive sleep apnea (OSA), we hypothesized that OSA was not considered in drivers admitted to trauma centers after an injury-producing MVC. A retrospective study on drivers involved in MVCs admitted to a level 1 trauma center was performed, with crash cause determined and the frequency of sleep studies recorded. A questionnaire was also mailed to 240 trauma centers seeking information on evaluation of patients with unexplained causes for MVCs, including screening for OSA. There were 122 drivers of MVCs admitted to our hospital, 60/122 (49%) had unexplained crashes and no sleep studies were performed. There were 70 survey respondents (30% return rate), 35/70 (50%) centers routinely screened for syncope after unexplained MVC, however, no center screened for OSA. US trauma centers do not screen for sleep disorders despite the associated increased crash risk and the high prevalence of crashes that can not be explained by other causes. We believe this reflects a lack of awareness of sleep disorders by health care professionals caring for trauma victims and education is of utmost importance.

The evolution of acetyl-CoA synthase

Acetyl-coenzyme A synthases (ACS) are Ni-Fe-S containing enzymes found in archaea and bacteria. They are divisible into 4 classes. Class I ACS's catalyze the synthesis of acetyl-CoA from CO2 + 2e-, CoA, and a methyl group, and contain 5 types of subunits (alpha, beta, gamma, delta, and epsilon). Class II enzymes catalyze essentially the reverse reaction and have similar subunit composition. Class III ACS's catalyze the same reaction as Class I enzymes, but use pyruvate as a source of CO2 and 2e-, and are composed of 2 autonomous proteins, an alpha 2 beta 2 tetramer and a gamma delta heterodimer. Class IV enzymes catabolize CO to CO2 and are alpha-subunit monomers. Phylogenetic analyses were performed on all five subunits. ACS alpha sequences divided into 2 major groups, including Class I/II sequences and Class III/IV-like sequences. Conserved residues that may function as ligands to the B- and C-clusters were identified. Other residues exclusively conserved in Class I/II sequences may be ligands to additional metal centers in Class I and II enzymes. ACS beta sequences also separated into two groups, but they were less divergent than the alpha's, and the separation was not as distinct. Class III-like beta sequences contained approximately 300 residues at their N-termini absent in Class I/II sequences. Conserved residues identified in beta sequences may function as ligands to active site residues used for acetyl-CoA synthesis. ACS gamma-sequences separated into 3 groups (Classes I, II, and III), while delta-sequences separated into 2 groups (Class I/II and III). These groups are less divergent than those of alpha sequences. ACS epsilon-sequence topology showed greater divergence and less consistency vis-à-vis the other subunits, possibly reflecting reduced evolutionary constraints due to the absence of metal centers. The alpha subunit phylogeny may best reflect the functional diversity of ACS enzymes. Scenarios of how ACS and ACS-containing organisms may have evolved are discussed.

Intraocular pressure and pulsatile ocular blood flow after retrobulbar and peribulbar anaesthesia

AIMS

This study investigated the effect of peribulbar and retrobulbar local anaesthesia on intraocular pressure (IOP) and pulsatile ocular blood flow (POBF), as such anaesthetic techniques may adversely affect these parameters.

METHODS

20 eyes of 20 patients who were to undergo phacoemulsification cataract surgery were prospectively randomised to receive peribulbar or retrobulbar anaesthesia. The OBF tonometer (OBF Labs, Wiltshire, UK) was used to simultaneously measure IOP and POBF before anaesthesia and 1 minute and 10 minutes after anaesthesia. Between group comparisons of age, baseline IOP, and baseline POBF were performed using the non-parametric Mann-Whitney test. Within group comparisons of IOP and POBF measured preanaesthesia and post-anaesthesia were performed using the non-parametric Wilcoxon signed ranks test for both groups.

RESULTS

There was no statistically significant IOP increase post-anaesthesia in either group. In the group receiving peribulbar anaesthesia, there was a significant reduction in POBF initially post-anaesthesia which recovered after 10 minutes. In the group receiving retrobulbar anaesthesia, there was a persistent statistically significant reduction in POBF.

CONCLUSIONS

Retrobulbar and peribulbar injections have little effect on IOP. Ocular compression is not needed for IOP reduction when using local anaesthesia for cataract surgery. Conversely, POBF falls, at least for a short time, when anaesthesia for ophthalmic surgery is administered via a retrobulbar route or a peribulbar route. This reduction may be mediated by pharmacologically altered orbital vascular tone. It may be safer to use other anaesthetic techniques in patients with ocular vascular compromise.

Treadmill injuries to the upper extremity in pediatric patients

Injury is the leading cause of preventable death and disability in childhood and early adulthood. Approximately 25,000 children are injured on exercise equipment each year. Although hand injuries sustained on stationary bicycles in the home have been well documented, little has been reported on home treadmill injuries. Between September 1996 and March 2000, the authors treated 12 children at The Children's Hospital of Philadelphia for injuries to the upper extremity sustained on a treadmill. The age at the time of injury ranged from 14 months to 7 years, with a median age of 2.4 years. Average length of follow-up was 11.4 months. Ten of the 12 children sustained partial- or full-thickness burns to the volar aspect of the hand and digits. Overall, 6 patients required surgical repair. A total of 25% of the volar flexion creases involved required surgery. All patients had good functional results. The authors discuss the mechanism of injury, management, and measures to prevent treadmill injuries to children. To their knowledge, this is the first report of such injuries resulting from the use of a treadmill.

Evidence for a prostate cancer linkage to chromosome 20 in 159 hereditary prostate cancer families

Prostate cancer is the most common malignancy diagnosed in men in the US. Genetic susceptibility to prostate cancer has been well documented. A region at chromosome 20q13 (HPC20) has been reported to be linked to a prostate cancer susceptibility gene. To confirm this finding, we genotyped 16 markers spanning approximately 95 cM on chromosome 20 in 159 hereditary prostate cancer (HPC) families. Positive (but not statistically significant) linkage scores were observed from 20pter to 20q11, with the highest non-parametric linkage (NPL) score for the complete dataset of 1.02 (P=0.15) being observed at D20S195 at 20q11. Evidence for linkage from parametric analyses with a dominant or a recessive model was weak. Interestingly, consistent with the original findings of linkage to 20 g higher linkage scores were observed in the subsets of families with a later age at diagnosis (> or =65 years; n=80, NPL=1.94, P=0.029 at D20S186), fewer than five affected family members (n=69, NPL=1.74, P=0.037 at D20S889), or without male-to-male disease transmission (n=60, NPL=1.01, P=0.15 at D20S117). The region with positive linkage scores spanned approximately 60 cM from 20pter to 20q11 in these subsets of families. Our results are consistent with a prostate cancer susceptibility locus on chromosome 20.

Ultraviolet-Assisted Punch Biopsy Mapping for Lentigo Maligna Melanoma

Lentigo maligna melanoma (LMM) accounts for a substantial incidence of all locally recurrent melanoma. In addition, the head and neck area accounts for 60% to 90% of all LMMs, which has important functional and cosmetic implications. The difficulty in the identification of the true borders of LMM may account for the high incidence of local recurrence. The purpose of this study was to evaluate the efficacy of ultraviolet-assisted punch biopsy mapping to identify clear margins using identified, 2-mm circumferentially arranged punch biopsies at the junction of the pigmented and nonpigmented borders. A retrospective chart review of 20 patients with biopsy-confirmed LMM of the head and neck was performed. Using ultraviolet identification, 2-mm circumferentially arranged biopsy specimens were obtained and sent for formal pathological review, including immunohistochemical staining. The average time for completion of pathological review was 5 to 7 days. If the punch biopsies were positive for lentigo maligna or LMM, punch biopsies were obtained more peripherally. Once clear, margins were obtained and definitive resection was performed. Twenty patients with biopsy-proved LMM were evaluated. Follow-up ranged from 6 months to 3 years (mean follow-up, 1 year). Fourteen patients were cleared after their first series of biopsies, 3 patients required a second series of biopsies, 2 patients required a third session, and 1 patient required a fourth biopsy session. To date, there has been no evidence of recurrence. No patients required reexcision for positive surgical margins. One complication has been local cellulitis of a punch biopsy site requiring a short course of antibiotics. Ultraviolet-assisted punch biopsy mapping of LMM is a safe, well-tolerated, and accurate technique for identifying the true histological margin of LMM. The procedure reduces the need for repeat surgical excisions to obtain clear margins and may decrease the risk for recurrence by mapping accurately the true histological margin.

Primary retroperitoneal seminoma with utrasonically abnormal testes

Primary retroperitoneal seminomas account for approximately 2% of all seminomas. Differentiating the primary retroperitoneal tumor from a metastatic tumor with an occult testicular primary remains difficult despite the availability of ultrasonic examination. We present a case of primary retroperitoneal seminoma with ultrasonically demonstrated abnormalities in both testes. The patient underwent a unilateral orchiectomy and ultrasound-guided biopsy of the opposite testis. All surgical specimens were negative for testis cancer. Controversial issues in the diagnosis and treatment of primary retroperitoneal germ cell tumors are discussed.

Laparoscopic orchidopexy: a review of a large clinical series

OBJECTIVE

To report the overall success rate of a laparoscopic orchidopexy (LO) series over 5 years including over 100 procedures.

PATIENTS AND METHODS

The records were reviewed of children who underwent laparoscopic procedures for an impalpable testis at our institutions. The laparoscopic procedures included the standard LO and one-stage and staged Fowler-Stephens (F-S) LOs. The success of orchidopexy was defined as a testis in the scrotum with no atrophy after surgery.

RESULTS

From 1994, 80 children (101 impalpable testes) were treated using LO. Of these patients, 20 (25%) had impalpable testes on the right, 39 (50%) were on the left and 21 (25%) were bilateral. The testicular location was identified during laparoscopy as: intra-abdominal in 46, iliac in 14, in the internal ring in 22, 'peeping' in 12, behind the bladder in three and intracanulicular in four. Standard LO was used in 72 testes, a one-stage F-S in 20 and a two-stage F-S in nine (first stage two, second stage seven). The median (range) age of the patients was 18 months (0.5-12 years); the mean (range) follow-up was 5 (1-36) months. After orchidopexy the testis was scrotal in 90 (low 78, mid four and high eight), at the pubis in one and not stated in seven (no follow-up available). Four patients (4%) had testicular atrophy from failed F-S orchidopexies, two of whom had undergone previous testicular surgery and one caused by additional dissection around the vas. The overall success rate, including only those with follow-up, was 96% (90 of 94). Of the 20 one-stage F-S orchidopexies, 17 testes were successfully placed in the scrotum with no atrophy. The overall success rate for all F-S procedures was 85% (23 of 27). However, excluding patients who had previous testicular surgery or who required extensive dissection near the vas, 96% (23 of 24) of the testes were successfully placed into the scrotum with no atrophy.

CONCLUSION

The high overall success rate in placing the testis into the scrotum through laparoscopic procedures is considerably better than reported in other series to date. LO is an effective method for managing intra-abdominal testes in children. Patients who had undergone previous surgery had a higher risk of developing testicular atrophy. The additional dissection around the vas almost inevitably leads to testicular atrophy.

Linkage of prostate cancer susceptibility loci to chromosome 1

Three prostate cancer susceptibility genes have been reported to be linked to different regions on chromosome 1: HPC1 at 1q24-25, PCAP at 1q42-43, and CAPB at 1p36. Replication studies analyzing each of these regions have yielded inconsistent results. To evaluate linkage across this chromosome systematically, we performed multipoint linkage analyses with 50 microsatellite markers spanning chromosome 1 in 159 hereditary prostate cancer families (HPC), including 79 families analyzed in the original report describing HPC1 linkage. The highest lod scores for the complete dataset of 159 families were observed at 1q24-25 at which the parametric lod score assuming heterogeneity (hlod) was 2.54 (P=0.0006) with an allele sharing lod of 2.34 (P=0.001) at marker D1S413, although only weak evidence was observed in the 80 families not previously analyzed for this region (hlod=0.44, P=0.14, and allele sharing lod=0.67, P=0.08). In the complete data set, the evidence for linkage across this region was very broad, with allele sharing lod scores greater than 0.5 extending approximately 100 cM from 1p13 to 1q32, possibly indicating the presence of multiple susceptibility genes. Elsewhere on chromosome 1, some evidence of linkage was observed at 1q42-43, with a peak allele sharing lod of 0.56 (P=0.11) and hlod of 0.24 (P=0.25) at D1S235. For analysis of the CAPB locus at 1p36, we focused on six HPC families in our collection with a history of primary brain cancer; four of these families had positive linkage results at 1p36, with a peak allele sharing lod of 0.61 (P=0.09) and hlod of 0.39 (P=0.16) at D1S407 in all six families. These results are consistent with the heterogeneous nature of hereditary prostate cancer, and the existence of multiple loci on chromosome 1 for this disease.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE

The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay.

METHODS

This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis.

RESULTS

The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47).

CONCLUSION

Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Depression in sarcoidosis

Sarcoidosis, a chronic, multisystem disease, impacts quality of life and may increase depression risk. No previous study has reported the depression prevalence among U.S. sarcoid patients. This cross-sectional study examined sociodemographic and disease morbidity factors associated with depression. Patients diagnosed for > or = 1 yr and treated at one of six centers were eligible (n = 176); 154 completed a questionnaire of demographics, treatment, access to medical care, and a short-form Center for Epidemiologic Studies- Depression Scale (CES-D). The primary outcome variable was a CES-D score of > or = 9, indicating clinical depression. The prevalence of depression was 60%. Gender, income, access to medical care, dyspnea on exertion, and number of systems involved were associated with depression. Female sex, decreased access to medical care, and increased dyspnea predicted depression (odds ratio [OR] = 3.33, 11.64, and 2.78, respectively) after adjusting for race, income, and steroid therapy. Despite tertiary care access, patients reported medical care limitation. Health care providers must be sensitive to multiple barriers faced by chronic sarcoid patients; acknowledging depression risk and improving access to medical care will promote better overall health among sarcoid patients. Future studies of sarcoidosis will need to address depression diagnosis and treatment.

Rotation of the clavicular portion of the pectoralis major for soft-tissue coverage of the clavicle. An anatomical study and case report

BACKGROUND

The purposes of this study were to describe the anatomical features of a rotational flap consisting of the clavicular portion of the pectoralis major and to report the surgical technique and the outcome of use of this flap in a patient with poor soft-tissue coverage following multiple operations for a clavicular fracture complicated by nonunion and infection.

METHODS

Ten shoulders from five cadavera were dissected to isolate the clavicular portion of the pectoralis major. The vascular pedicle, thoracoacromial artery, and axillary artery were identified, and the length of the vascular pedicle from the axillary artery to the muscle was measured. The angle of rotation of the flap about its intact clavicular origin was measured before and after division of the acromial branch of the thoracoacromial artery. The clavicular origin was then incised, and the overall length, width, and thickness of the muscle as well as the distance from each end of the muscle to the vascular pedicle were measured.

RESULTS

The average length of the vascular pedicle from the axillary artery to the pectoralis muscle belly was 5.3 centimeters (range, 3.7 to 6.5 centimeters). The average maximum angle of rotation with the clavicular origin intact was 60 degrees (range, 55 to 67 degrees) before division of the acromial branch and 73 degrees (range, 65 to 82 degrees) after division. The average total length of the clavicular head was 20.2 centimeters (range, 18.0 to 23.0 centimeters). The average width of the clavicular head was 2.9 centimeters (range, 2.0 to 4.0 centimeters), and the average thickness was 0.5 centimeter (range, 0.2 to 0.7 centimeter). The vascular pedicle entered the muscle an average of 8.7 centimeters (range, 5.2 to 10.7 centimeters) lateral to the most medial extent of the muscle and an average of 11.5 centimeters (range, 9.5 to 14.0 centimeters) medial to the most lateral extent of the muscle. The rotational flap was successfully used clinically to provide soft-tissue coverage after bone-grafting and internal fixation of a clavicular nonunion that had been complicated by infection.

CONCLUSIONS

The clavicular head of the pectoralis major may be used as a local rotational flap to cover soft-tissue deficiencies over the clavicle. It can be harvested with relative ease without damaging the sternocostal head.