Application of Antibiotic-Impregnated Polymethyl-Methacrylate Bone Cement for the Treatment of Infected Cranioplasties: Initial Experience

BACKGROUND

Management of infected cranioplasty implants remains a surgical challenge. Surgical debridement, removal of the infected implant, and prolonged antibiotic therapy are part of the acute management. In addition, cranioplasty removal poses the risk of dural tear. Reconstruction of the cranial defect is usually delayed for several months to years, increasing the difficulty due to soft tissue contraction and scarring.

OBJECTIVE

The aim of the study was to propose an alternative to delayed reconstruction in the face of infection with a dual purpose: treat the infection with a material which delivers antibiotic to the area (polymethyl-methacrylate antibiotic) and which functions as a temporary or permanent cranioplasty.

METHODS

We reviewed the records of 3 consecutive patients who underwent single-stage polymethyl-methacrylate antibiotic salvage cranioplasty.

RESULTS

All patients underwent debridement of infected tissue. Titanium mesh was placed over the bony defect. Polymethyl methacrylate impregnated with vancomycin and tobramycin was then spread over the plate and defect before closure. Patients also received extended treatment with systemic antimicrobials. Early outcomes have been encouraging for both cosmesis and treatment of infection.

CONCLUSIONS

Benefits of this treatment strategy include immediate reconstruction rather than staged procedures and delivery of high concentrations of antibiotics directly to the affected area in addition to systemic antibiotics.

Quantitative Assessment of Scalene Muscle Block for the Diagnosis of Suspected Thoracic Outlet Syndrome

PURPOSE

To measure changes in upper limb work and power capacity before and after anterior scalene muscle block (ASMB) to suggest thoracic outlet syndrome caused by costoclavicular space compression.

METHODS

We evaluated 34 patients disabled by symptoms suggesting thoracic outlet syndrome. An ASMB was performed via a supraclavicular injection. The sternocleidomastoid muscle was injected as a control. We captured data obtained from work simulator measurements before and after ASMB. Each patient performed a push-pull test with the forearm at waist level (test 1), an overhead bar push-pull test with the arm elevated (test 2), and the extremity abduction stress test with repetitive hand gripping during static arm elevation (test 3). We measured the work product, time to fatigue, and power generation. Sensory testing was performed after ASMB to rule out improved performance associated with possible sensory nerve block.

RESULTS

In contrast to sternocleidomastoid injection controls, symptomatic and functional improvement was noted in all patients (n = 34) after ASMB. Work product measurement improved 93%, 108%, and 104% for tests 1, 2, and 3, respectively. Time to fatigue and power output also increased after the block.

CONCLUSIONS

Temporary symptomatic improvement after ASMB may be anticipated in patients with TOS. This study documents a significant concurrent increase in upper limb motor function after the block. Increased work and power measurements after ASMB may draw diagnostic inference regarding a dynamic change in the scalene muscle and the costoclavicular space associated with symptomatic thoracic outlet syndrome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Pulse oximetry measurements in the evaluation of patients with possible thoracic outlet syndrome

PURPOSE

We present our experience in using pulse oximetry as an aid in the diagnosis of thoracic outlet syndrome (TOS). Our attention was given to those symptomatic patients without objective confirmatory data on imaging or electrodiagnostic evaluation.

METHODS

Using a pulse oximeter, we measured the oxygen saturation and the pulse rate during a provocative extremity abduction stress test exercise maneuver in 18 patients with symptoms and signs consistent with a diagnosis of nonspecific neurogenic TOS. The oxygen saturation and pulse rates in 18 asymptomatic subjects were used as a control.

RESULTS

Resting oxygen saturation above 97% was present in both groups initially. After the provocative exercise maneuver, there was a significant reduction in the oxygen saturation levels, which dropped to 86% in the symptomatic TOS group compared with 94% in the control group. There was a significant increase in pulse rate in those subjects suspected of having TOS compared with a minimal increase in pulse rate in control subjects.

CONCLUSIONS

Pulse oximetry produced objective confirmatory measurements, which support a hypothesis that hypoperfusion in the upper limb during provocative activities or exercise may cause disabling symptoms associated with nonspecific neurogenic TOS. This method may be a useful, noninvasive, rapid, and inexpensive clinical tool in the diagnosis of TOS, a condition frequently lacking in objective, confirmatory diagnostic data.

Complications related to carpal tunnel release

Complications of operative carpal tunnel release continue to occur in the clinical practice of hand surgery. Anatomic localization of nerve injury has been reviewed in the area of the palmar cutaneous nerve, the median motor branch, and in the combined sensory/motor median nerve itself. Diagnosis and appropriate treatment plans have been reviewed to facilitate early appropriate treatment which usually diminishes disability. General complications have also been discussed including recurrent scar formation which is probably the most commonly encountered complication following carpal tunnel release. Possible neurovascular complications involving the development of reflex sympathetic dystrophy have received some attention in this presentation in order to alert the clinical surgeon to the possibility of this entity providing further disability to an already injured median nerve.

Bilateral thenar hammer syndrome as a result of cumulative trauma: a case report

This report describes an unusual case of bilateral radial artery thrombosis associated with multiple weblike stenoses and pseudoaneurysms secondary to cumulative trauma in a manual laborer who used both hands for impacting at both the thenar and hypothenar aspects of the hand. In this case, thenar hammer syndrome was associated with acute ischemia of the long finger. The condition was treated surgically with arterial resection and reestablishment of blood flow to the hand. Noted improvement occurred with restoration of arterial competence.

Single-anastomosis femoral arteriovenous shunt as recipient vessels for free-flap reconstruction of a massive lumbosacral wound

In any reconstructive microsurgical procedure, an adequate recipient circulation is required. None is readily available when reconstructing problem wounds of the lumbosacral spine, leading in some cases to the use of long vein grafts to the axilla to provide vascular access. A case of a massive back wound that was reconstructed microsurgically with a prefabricated preliminary arteriovenous shunt, based on the femoral vessels, is presented. This method takes advantage of the normal anatomic arrangement of the saphenous venous system, requires only one anastomosis, and provides an accessible vascular supply. The technical advantages of the procedure are discussed.

The retrograde radial fascial forearm flap: surgical rationale, technique, and clinical application

The retrograde radial fascial forearm flap may be used to provide appropriate tissue coverage for nerve, tendon, or soft tissue defects in the forearm and hand. The procedure is differentiated from the standard radial forearm flap in that the radial artery remains intact when the retrograde radial fascial flap is designed. The rationale, technique, and clinical application of the flap are presented in order to allow surgeons to maintain the radial arterial trunk in continuity while obtaining the advantage of appropriate soft tissue cover in this critical area.

Coverage of bilateral lower extremity calcaneal fractures with osteomyelitis using a single split free gracilis muscle transfer

A case is presented in which a single gracilis muscle was split and used for free-tissue coverage of two sites in a patient with bilateral calcaneal fractures and posttraumatic osteomyelitis. Muscle-flap coverage of osteomyelitis and the use of the gracilis muscle for free-tissue transfer are discussed.