Two-stage treatment of ischial pressure ulcers in spinal cord injury patients: Technique and outcomes over 8 years

BACKGROUND

Despite newly introduced techniques, reconstruction of ischial pressure ulcers remains a difficult problem with high-reported failure rates.

METHODS

A retrospective chart review was performed on all spinal cord injury patients who underwent ischial pressure ulcer reconstruction by the senior author (V.L.) between 2004 and 2012. The two-stage procedure consisted of debridement and bone biopsy, followed by bursectomy, partial ischiectomy, fascial release, and gluteus maximus and hamstring advancement flaps. Postoperative care included 2-week supine bed rest on an air-fluidized bed, sitting tolerance rehabilitation, and thorough behavioral training.

RESULTS

Sixty-five patients (74 flaps) were identified. A 45.9% had a previous attempt at reconstruction. The median follow-up period was 622 days. Overall, 67.6% of flaps were intact at the last follow-up. Superficial and deep dehiscence rates were 16.2 and 28.4%, respectively. Seven out of 35 flaps suffered late recurrence after being well healed for more than 1 year. History of previous reconstruction was found to be associated with increased odds of superficial (OR 6.02, 95% CI 1.55-23.3) and deep dehiscence (OR 12.3, 95% CI 1.99-76.9).

CONCLUSIONS

The evolution of the senior author's decades of practice has led to the development of a simpler repair, which relies on plane-by-plane release of scarred tissues to improve the mobility of muscle and skin flaps without large tissue movements, even in the setting of apparent extensive tissue loss. This technique is a reliable option, particularly for the primary ischial pressure ulcer.

Use and Limitations of Dextranomer in Cutaneous Ulcerations

In an attempt to evaluate the limitations and utility of dextranomer, 39 patients with a variety of cutaneous ulcerations were studied. Highly exu dative venous stasis ulcers (11 patients) responded best, with clearing of superficial infection within 48 hours and development of granulation tissue in the ulcer bed within 5 days. Nonexudative venous stasis ulcers (7 patients) responded more slowly to this therapy. Ischemic ulcerations and pressure sores as well as ulcers containing bone or tendon were not improved by dextranomer therapy. Rapid relief of pain and uniform patient acceptance of the method of treatment recommend it for further evaluation.

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.

Urologic and plastic surgical collaboration for continent diversion when urine leakage is complicated by pressure ulcers or obesity

BACKGROUND

Patients with neurogenic bladder dysfunction and urine leakage combined with pressure ulceration, fistulae, and/or obesity present a major surgical challenge. Given the urgent need to control urine leakage, suprapubic cystostomy or incontinent urinary diversion such as ileal conduit often are chosen for definitive intervention, despite the fact that continent urinary diversion generally is the preferred method of management for the motivated patient.

DESIGN

Case series.

METHOD

This article presents 4 patients in whom urine leakage was complicated by pressure ulcers, urethral erosion, and/or morbid obesity. Due to the complicated nature of their problems, these patients were managed in a collaborative fashion by the departments of urology, plastic surgery, and physiatry. Each of these patients underwent a combined surgical intervention that addressed issues of skin ulceration or morbid obesity and allowed for continent urinary diversion.

RESULTS

After intervention, all 4 patients were independent in bladder management and were completely continent.

CONCLUSION

This series demonstrates how collaboration between the urologist and plastic surgeon in evaluation and treatment planning allows for the formulation of surgical options that include continent urinary diversion.

The value of Jamshidi core needle bone biopsy in predicting postoperative osteomyelitis in grade IV pressure ulcer patients

We present a retrospective review of 108 patients with spinal cord injury who underwent reconstruction of grade IV pressure ulcers between 1989 and 1994. Complications of reconstruction secondary to undetected osteomyelitis, namely, deep abscess and sinus tract formation, and their effect on hospital course after the flap reconstruction were quantitatively evaluated. Specifically, this study assesses whether the use of Jamshidi core needle bone biopsy allows for the accurate diagnosis, and therefore treatment, of osteomyelitis before pressure ulcer closure. Early diagnosis and treatment of osteomyelitis would presumably reduce the complication rate of reconstruction. The 108 patients in the study all underwent intraoperative Jamshidi core needle bone biopsy, and postoperative complications were evaluated by reviewers blinded to results of the biopsies. Of the 25 (23 percent) postoperative complications noted, 14 (13 percent) were attributed to underlying osteomyelitis. Patients with pressure ulcer complicated by osteomyelitis were hospitalized significantly longer than those with no osteomyelitis. On average, the former group stayed for 57 days and the latter 21 days (p < 0.001). All 14 patients who developed complications because of deep abscess and sinus tract formation had intraoperative Jamshidi core needle bone biopsy abnormality consistent with osteomyelitis (positive Jamshidi core needle bone biopsy results). The Jamshidi core needle bone biopsy compares favorably with other published modalities used to diagnose osteomyelitis, including white blood cell count, erythrocyte sedimentation rate, radiologic study, and bone biopsy culture. We propose an algorithm for the management of spinal cord injury patients with grade IV pressure ulcers. This algorithm incorporates the use of preoperative Jamshidi core needle bone biopsy to allow for the diagnosis and treatment of osteomyelitis before the flap reconstruction and to prevent complications of undiagnosed osteomyelitis after reconstruction.

Lateral force compared with frontal impact nasal fractures: need for reoperation

Patient concern over the outcome of correction of nasal fractures is usually extremely high; often, a secondary procedure is necessary. Therefore, thorough consultation is mandatory. The clinical data of 50 patients who sustained nasal fractures was retrospectively reviewed to determine if there was any predictive value to classification of nasal fractures and the likelihood of a secondary surgical procedure. Using Stranc and Robertson's nasal fracture classification, 41 of 50 patients were described as lateral force fractures and 9 of 50 were frontal impact fractures. Five of 50 patients underwent a secondary surgical procedure, 4 from the frontal impact and 1 from the lateral force fracture group. The number of patients reoperated on approximately equaled the number who were dissatisfied with the result of the initial procedure (5 versus 6). However, objective assessment by the primary surgeon revealed 21 patients with an anatomic or functional defect. Of these, 15 were lateral force fractures (15 of 41, or 37%) and 6 were frontal impact fractures (6 of 9, or 67%). These results illustrate the difficulty in restoring preinjury nasal anatomy and function, especially in the more severe and complicated frontal impact types of nasal fracture. Using this information can aid in obtaining satisfactory informed patient consent.

Peripheral vascular disease in spinal cord injury patients: a difficult diagnosis

The timely detection of peripheral vascular disease (PVD) in spinal cord injury (SCI) patients is difficult because the usual symptoms of claudication and rest pain are absent. In fact, the initial manifestation of PVD in SCI patients is often advanced gangrene, so that healing, primarily or following major amputation, is either difficult and prolonged or impossible. In addition, sacral and ischial pressure sores common among SCI patients may be exacerbated and reconstruction made more difficult by PVD. Five SCI patients presented with lower extremity gangrene as the initial recognized manifestation of PVD at our institution between January 1992 and January 1994. All 5 patients had risk factors for PVD. Four out of ten limbs in these patients required amputation, either above the knee or below the knee. Three patients required concurrent vascular reconstruction of the aortoiliac segments, including an aortobiprofunda femoral bypass, an iliac embolectomy with femoral-femoral bypass, and iliac angioplasty. Three patients had ischial and/or sacral pressure sores that had recurred following multiple musculocutaneous flap reconstructions before vascular disease was recognized. The timely diagnosis of PVD involving the iliac segment in the SCI patient is sometimes overlooked and is often necessary to optimize the treatment of both lower extremity ulcers and sacral/ ischial pressure sores common among these patients.

Human immunodeficiency virus infection and subsequent melanoma

Immunosuppression has been known for many years to be associated with the development of skin cancer, particularly squamous cell carcinoma. The association with melanoma is less clear. This report describes 4 patients with known human immunodeficiency virus (HIV) positivity who subsequently developed malignant melanoma. The subtypes and precursors of the tumors vary. Three of 4 patients treated using accepted surgical standards remained disease free an average of 33 months postoperatively. Treatment of the melanoma as in the non-HIV infected melanoma patient is advised. Epidemiological studies remain to be done to determine the significance of this association. In the meantime, melanoma remains a surgical disease and early, aggressive, standard surgical treatment is encouraged for these patients. Despite the immunocompromised state that their HIV status implies, surgical treatment offers local and regional control of disease and possibly cure.

Chronic expanding hematoma within a periprosthetic breast capsule

Three cases of chronic expanding hematoma occurring within the capsule surrounding breast implants are described. All developed at least 4 years after the last operation. No identifiable etiology could be demonstrated. Although this pathologic entity has been widely reported in other anatomic locations, a periprosthetic chronic expanding hematoma of the breast has not been described previously.

Antiphospholipid antibody syndrome: a new cause of nonhealing skin ulcers

Antiphospholipid antibody syndrome causes many problems that are usually treated by rheumatologists. Included within the manifestations of the syndrome, however, are painful, refractory leg ulcers, which, with the causative vascular damage, may lead to limb loss. The report of such a case, the patient's course and treatment, and the causes and diagnosis of the syndrome are presented.

A literature assessment of the use of miscellaneous topical agents, growth factors, and skin equivalents for the treatment of pressure ulcers

BACKGROUND

Agents reviewed for this manuscript were both rare and popular topical treatments for pressure ulcers.

OBJECTIVE

To review topical treatments for pressure ulcers and evaluate them based on available literature of controlled, blinded, and randomized trials.

METHODS

A MEDLARS database (1966-1993) search and a thorough review of reference article lists of key articles produced over 100 manuscripts. Studies were considered for review if they were conducted on humans with chronic stage II to IV pressure ulcers, in a properly controlled and randomized fashion.

RESULTS

The use of zinc acetate and aluminum hydroxide ointment, phenytoin, recombinant platelet-derived growth factor-BB (rPDGF-BB), and basic fibroblast growth factor (bFGF) have been evaluated in a controlled and blinded fashion. Many of the newer agents, cytokine growth factor (eg, rPDGF-BB and bFGF) and skin equivalents, are currently being scrutinized in clinical trials.

CONCLUSION

A paucity of data exist that adequately address the efficacy of any topical agent for the treatment of pressure ulcers.

A muscle-sparing technique for reconstruction of the defect left after excisional hip arthroplasty

Muscle flap closure is the treatment of choice for coverage of the failed hip arthroplasty defect. Several described muscle flaps work well, but they sacrifice functioning parts of the abdominal wall or quadriceps femoris mechanisms. The authors describe the use of the tensor fascia lata musculocutaneous flap for this purpose. The technique described has been previously used successfully to reconstruct over 100 trochanteric pressure sores. This flap spares more important muscles, requires no skin graft, and exposes the deep wound well for debridement.

Tensor fascia lata V-Y retroposition myocutaneous flap: clinical experience

A modification of the standard tensor fascia lata myocutaneous flap, namely, the tensor fascia lata V-Y retroposition flap, is a reliable, durable, efficient, well-tolerated, and technically straightforward procedure. Indications include trochanteric pressure ulcers, nonhealing, failed hip arthroplasties, and soft tissue defects after regional tumor excisions. In 70 TFL V-Y retroposition flap reconstructions performed, the overall postoperative complication rate was 23%, with 4 total flap failures. Sixty-three percent of complications were treated with local wound care, thus avoiding repeat surgery. Rerotation of this flap is not only possible, but also just as reliable as the initial procedure. The tensor fascia lata retroposition flap offers advantages over many of the other tensor fascia lata flap variations.

The physician cost of treating maxillofacial trauma

Treatment of maxillofacial trauma patients can be difficult for the surgeon because of patient noncompliance, frequent litigation, and poor payment habits. Numerous studies have examined the socioeconomic aspects of trauma as they affect hospitals and communities, but none to date has looked at the socioeconomic aspects of trauma as they affect the surgeon. This study is based on a retrospective sequential review of the medical records of 50 patients who suffered malar complex fractures and were treated with operative reduction at a university medical center. These patients are compared with a sequential series of 20 patients with basal cell carcinoma of the cheek treated by the same surgeon. The maxillofacial trauma group paid an average of 57 percent of their bills and had cases that involved lawyers 30 percent of the time, and only 54 percent of the patients kept all their postoperative appointments. All these figures were statistically different from those of the basal cell carcinoma patients, who paid an average of 90 percent of their bills and had no cases that involved lawyers and 95 percent of whom kept all postoperative appointments. These findings support the premise that maxillofacial trauma patients are difficult patients to treat and that unless the trauma reimbursement system is revised, plastic surgeons may limit their treatment of trauma in the future.

Cryoglobulinemia: dilemma for the reconstructive surgeon

Cryoglobulinemia was initially noted to occur predominantly in patients with myeloma, but it is now being detected in a growing number of infectious, collagen-vascular, and lymphoproliferative disorders. Two patients with leg ulcers due to cryoglobulinemia are presented. The reconstructive surgeon should consider cryoglobulinemia in the differential diagnosis of skin necrosis that is refractory to conventional therapy, since they may be consulted for wound management. In the vast majority of instances, the patient will be referred with a diagnosis of cryoglobulinemia having already been established. In other circumstances, patients may present to the plastic surgeon with no known history of cryoglobulinemia. The informed reconstructive surgeon can make the diagnosis on the basis of clinical findings. Combination therapy (corticosteroid, immunosuppression, and plasmapheresis) may be of use when areas of skin necrosis, typically in the form of leg ulcers, fail to heal with routine measures.

Hip joint communication with pressure sore: the refractory wound and the role of Girdlestone arthroplasty

Fifteen patients who underwent Girdlestone arthroplasty (proximal femoral head resection) were reviewed at The Johns Hopkins Hospital and Northwestern Memorial Hospital. Ages ranged from 24 to 57 years (mean 36.7 years). All patients were paraplegics or quadriplegics (C7-L3). All patients presented with signs of sepsis and had evidence of osteomyelitis. Soft-tissue reconstruction was most commonly performed with the vastus lateralis, and no femoral stabilization was used. There were no deaths. Recurrent ulcers at the site of the Girdlestone arthoplasty were found in 23 percent of patients in whom follow-up was possible. No recurrence was noted at the original site in 77 percent with a mean follow-up of 20 months. Additional pressure sores occurred at other nonsurgical sites in six patients at a mean of 23.3 months. Girdlestone arthroplasty with soft-tissue coverage is mandatory for successful treatment of pressure sores with hip joint involvement.

Benign mesodermal tumors producing nasal deformity

Tumors of neurogenic (ectodermal) origin are well-described causes of nasal deformity. We present a patient with a benign mesodermal tumor (unclassified spindle cell) producing nasal deformity. A retrospective review of the two senior authors' records provided an additional three patients with nonvascular benign mesodermal nasal masses (fibroma and leiomyoma). Benign mesodermal masses can occur in the midline of the nose and need to be differentiated from dermoids and gliomas. Misdiagnosis is the rule. Excisional biopsy is required for definitive diagnosis. In addition, excisional biopsy is curative and can help to minimize the subsequent nasal deformity if performed early in the disease process. Immunohistochemical and electron microscopy may be required for comprehensive diagnosis and treatment.

Improving acute skin-flap survival through stress conditioning using heat shock and recovery

We present our initial experience with a new method of increasing the survival of acute skin flaps through stress conditioning using heat shock and recovery. The heat-shock response is a basic form of stress response that exists on the cellular level. When cultured cells or whole organisms are exposed to supraphysiologic levels of heat, they respond by synthesizing a number of highly conserved proteins known as heat-shock proteins. These proteins have been shown to offer the cell or organism a survival advantage over nonstressed controls. The study demonstrates a significant survival advantage in acute dorsal skin flaps of Sprague-Dawley rats (p = 0.001). Study animals (n = 10) were subjected to a heating blanket set at 45 degrees C for 30 minutes and were allowed 6 hours' recovery before developing the flaps. Heat-shock protein was demonstrated in immunohistochemically stained sections of skin from the study animals but not in control animal skin (n = 14). We postulate that through stress conditioning a latent mechanism present within all cells was activated, thereby allowing the cells of our experimental flaps to better survive the stress of the acute flap model.

Immunologic associations of keloids

The mechanisms underlying the pathogenesis of keloids have not been fully characterized despite extensive past and present research. Results of past and present studies have shown that the immune system is actively involved in the development of these lesions. Future investigations into the biochemistry and immunologic factors of keloids are anticipated and expected to produce additional insight. The inability to identify cellular (fibroblast) abnormalities has led most investigators to focus on the humoral regulators of wound healing, that is, biochemical substances, immunologic mediators and growth factors. Future studies are needed to confirm or refute the presence of AFA. AFA, if they exist, may prove to be useful as immunologic markers of keloids and may help distinguish keloids from hypertrophic scar in the early stages of wound healing. The influence of immunologic mediators may be more impressive early in the development of scars. "Young" or "early" is defined as less than two years of age, whereas "old" or "late" keloids are more than two years of age. We suggest that future studies stratify keloids into early versus late and also measure the rates of collagen synthesis of fibroblasts derived from the normal and abnormal specimens from the same patient. Analysis of the leukocyte factors will clarify the role the immune system has in the regulation of collagen synthesis. Preliminary investigations have shown that immunotherapy may be of value in the treatment of keloids. The role of fibroblast heterogeneity needs to be investigated. It is not known which aspects of fibroblast heterogeneity are responsible for the localized and accelerated rates of collagen synthesis of keloid fibroblasts.

The role of cutaneous lymphoscintigraphy in determining regional lymph node drainage of truncal melanomas

In the absence of clinically positive regional nodes, any value of prophylactic dissection in malignant melanomas depends on accurate preoperative determination of the pathway of lymphatic drainage. We report on the use of noninvasive radionuclide lymphoscintigraphy in the determination of regional patterns of lymph node drainage in patients with melanomas. Ten patients were studied; treatment was altered by test results in 2. Eleven node groups were excised in 7 patients. There have been no metastatic melanomas found in any nodal basins not detected by lymphoscintigraphy 23 to 42 months after operation.

Pressure sore anemia: response to erythropoietin

Anemia in patients with grade IV pressure sores is usually refractory to therapy with iron salts, and red cell transfusions are commonly required when reconstructive surgery is performed. The anemia is characterized by hypoferremia, reticulocytopenia, and normal-to-increased serum ferritin. Five patients with this anemia were treated with recombinant human erythropoietin (rHuEPO) in doses of 50 to 100 U/kg, given subcutaneously three times per week. The hemoglobin increased in every patient; the mean (+/- SD) value at the initiation of treatment was 8.8 +/- 1.0 g/dL, and after a median of 4 weeks of therapy, it was 12.4 +/- 1.6 g/dL (p less than .001). No adverse effects of treatment were observed. It is concluded that rHuEPO is a promising new agent for pressure sore anemia, but randomized, controlled clinical trials will be required to firmly establish its place in the management of patients with this type of anemia.

Desmopressin decreases operative blood loss in spinal cord injury patients having flap reconstruction of pelvic pressure sores

To test the effectiveness of desmopressin in decreasing operative blood loss in major flap reconstructions, 44 hemostatically normal patients with spinal cord injury and pelvic pressure sores participated in a randomized, prospective, double-blind clinical trial. Each patient received a single dose of desmopressin (0.3 micrograms/kg) or saline placebo intravenously at the initiation of a reconstructive surgical procedure. Preoperative and postoperative hemoglobin, hematocrit, von Willebrand factor, and factor VIII determinations and measurement of intraoperative blood loss and transfusions of packed red cells were recorded. Desmopressin-treated patients experienced a smaller decline in hemoglobin and hematocrit levels postoperatively. In those patients requiring major flap reconstructions, the use of desmopressin significantly decreased intraoperative blood loss and subsequent transfusion requirements. The levels of von Willebrand factor and factor VIII tended to be higher, although not significantly so, in subjects receiving desmopressin. No patient experienced an adverse reaction to the drug. We conclude that a single dose of desmopressin, given immediately preoperatively, is safe and effectively decreases blood loss and transfusion requirements in patients undergoing major flap reconstructive surgery.

Buried inferiorly based gluteus maximus musculocutaneous flap for reconstruction of large, recurrent ischiopubic pressure sores

The ischium is the most common site for recurrence of pressure sores in the paraplegic population. Successful reconstruction of these wounds depends on the total excision of ulcer, soft tissue debris, bony prominence, and the durability of the soft tissue repair. The V-Y gluteus maximum musculocutaneous flap based on the inferior gluteal vessels can be advanced medially, deepithelialized, and buried to fill large, deep soft tissue ischial wounds. Local rotational flaps close the superficial wound. This buried flap, although not previously described, is useful for the reconstruction of large ischiopubic pressure sores initially or at the time of recurrence.

Infection following cranial bone grafting--a need for caution?

A case of delayed infection following the use of split-cranial bone graft is presented. Trauma and bacterial contamination of the donor area six months before harvest were the likely causes. We advise caution and the use of alternate donor sites in cases where a history of previous contaminating trauma exists, even if the cranial bone is clinically completely healthy.

The fasciocutaneous flap: a conservative approach to the exposed knee joint

The exposed knee joint poses a challenge to the reconstructive surgeon. The currently popular approach to the repair of exposed knee joints is use of muscle flaps. However, this leaves the patient with a deficit. We have therefore begun using the fasciocutaneous flap as an initial approach to this problem. In seven patients, aged 28 to 74 years, fasciocutaneous flaps have been the reconstructive procedure of choice for repair of exposed knee joints. One patient with a very large open wound required a concomitant medial gastrocnemius muscle flap. One minor wound separation occurred in a paraplegic patient with severe spasm. No other complications occurred. Follow-up ranged from 3 to 12 months, with good success in wound closure. An approach to small and intermediate wounds is presented in which the V-Y technique is used to obviate the need for skin grafting of the donor site.

A reliable approach to the closure of large acquired midline defects of the back

A systematic regionalized approach for the reconstruction of acquired thoracic and lumbar midline defects of the back is described. Twenty-three patients with wounds resulting from pressure necrosis, radiation injury, and postoperative wound infection and dehiscence were successfully reconstructed. The latissimus dorsi, trapezius, gluteus maximus, and paraspinous muscles are utilized individually or in combination as advancement, rotation, island, unipedicle, turnover, or bipedicle flaps. All flaps are designed so that their vascular pedicles are out of the field of injury. After thorough debridement, large, deep wounds are closed with two layers of muscle, while smaller, more superficial wounds are reconstructed with one layer. The trapezius muscle is utilized in the high thoracic area for the deep wound layer, while the paraspinous muscle is used for this layer in the thoracic and lumbar regions. Superficial layer and small wounds in the high thoracic area are reconstructed with either latissimus dorsi or trapezius muscle. Corresponding wounds in the thoracic and lumbar areas are closed with latissimus dorsi muscle alone or in combination with gluteus maximus muscle. The rationale for systematic regionalized reconstruction of acquired midline back wounds is described.

Free flap reconstruction of the lower back and posterior pelvis: indications, principles, and techniques

Reconstructive microsurgery can be successfully applied to major defects of the lower back and posterior pelvis. When present, the superior and inferior gluteal vessels can be excellent free flap recipient vessels. However, if they are absent as a result of trauma or tumor ablation, a wrist carrier can be used to transfer large blocks of tissue in a staged procedure. Five patients are presented with challenging defects for which these techniques were used.

The diagnosis of osteomyelitis in patients with pressure sores

A prospective blind trial was undertaken to assess the usefulness of commonly used tests to diagnose osteomyelitis underlying pressure sores. Sixty-one pressure sores were studied, with a histopathologic diagnosis from the ostectomy specimen being available in 52. White cell count, erythrocyte sedimentation rate, plain pelvic x-ray, technetium-99m bone scan, computerized tomography, and Jamshidi needle bone biopsy were studied. The most useful individual test was a needle bone biopsy, with a sensitivity of 73 percent and a specificity of 96 percent. Technetium-99m bone scans and computerized tomography are not indicated in the diagnosis of osteomyelitis associated with pressure sores. Plain pelvic x-ray, white cell count, and erythrocyte sedimentation rate, with a diagnosis of osteomyelitis if any test is positive, is the most sensitive (89 percent), specific (88 percent), noninvasive workup. Jamshidi needle biopsy may be useful where these tests are negative and a clinical suspicion of osteomyelitis remains. Extent of surgical debridement and antibiotic therapy can then be rationally decided on the basis of this information.

Accelerating recovery after trauma with free flaps

Free flap versatility and dependability make the final result of microvascular reconstruction highly predictable. Free tissue transplantation should be considered as a primary treatment after trauma. The early use of free tissue transfer will result in fewer operations and a shortened duration of hospitalization in the initial post-trauma period.

Some ancillary procedures for correction of depressed adherent tracheostomy scars and associated tracheocutaneous fistulae

A procedure for the surgical correction of depressed tracheostomy scars and tracheocutaneous fistulae is described which involves reapproximation of the strap muscles and the selective application of a subcutaneous Z-plasty. The results are predictable, satisfactory, and the procedure is quite simply accomplished. Utilization of the Z-plasty improves contour in patients with atrophic tissue and assists the distribution of tension forces in subcutaneous and muscular layers.

The sural artery and vein as recipient vessels in free flap reconstruction about the knee

The sural artery and vein were used successfully as recipient vessels in nine patients who required free flap reconstruction about the knee. The anatomy of the sural vessels and the potential advantages of their use as free flap recipients are reviewed and discussed. Indications include popliteal vessels that are absent or severely damaged, as determined by preoperative angiography. No anastomotic complications were encountered in this series, indicating that the sural artery and vein can be used successfully as recipient vessels.

Chronic expanding hematoma

Two cases of chronic expanding hematoma are presented. Although the location and presentation vary, chronic expanding hematoma has a distinct histopathologic pattern. A diagnosis of neoplasm is suggested by its slow growth pattern. The criteria for their formation are incompletely understood, and in one case, a hematoma occurred despite apparent adequate drainage. Computed tomography is helpful in distinguishing chronic expanding hematoma from other soft-tissue masses.

The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.

Computed tomography of dural sinus thrombosis

The four patients presented here demonstrate the value of contrast enhanced CT in the diagnosis and serial evaluation of dural sinus thrombosis. Two patients were young women using oral contraceptives; another patient had lateral sinus thrombosis complicating mastoiditis; a fourth patient developed superior sagittal sinus thrombosis following hip surgery. Improvements in CT diagnosis, including the use of thin sections for evaluation of the deep venous structures and lateral sinuses complemented by multiplanar reconstruction or direct coronal scanning, are discussed. Sequential scans for following the progress of two patients treated by barbiturate coma added to the understanding of dural sinus occlusive disease.

Use of a pedicled parascapular flap for anterior shoulder and arm reconstruction

We present a case of soft-tissue reconstruction of the shoulder and upper arm utilizing a pedicled parascapular flap and discuss its potential as a flap for regional reconstruction.

Care of pentamadine ulcers in AIDS patients

Two cases of soft-tissue infection resulting from antibiotic therapy given AIDS patients are presented. Operative treatment resulted in a closed wound in one patient. In the other patient, who suffered from recurrent acute illnesses, nonoperative treatment resulted in slow wound contraction and epithelialization without secondary wound complications. Wound sepsis did not occur, despite the absence of normal immune function. Operation and additional hospitalization, with their attendant risks, were avoided.

Facial injuries associated with cervical fractures: recognition, patterns, and management

Publications in both the orthopedic and maxillofacial literature have noted the association of cervical spine and facial injuries. However, because the incidence of spinal injury is low, we found no study which documented the relationship between maxillofacial and cervical spine injuries. The present study reviewed 982 cervical spine injuries in two major trauma centers, finding a 19.3% incidence of facial injury. Fourteen per cent of patients had soft-tissue injuries and 8.6%, facial fractures. Important relationships were noted between fractures of the mandible and upper cervical spine, and soft-tissue injuries of the upper face and fractures of the lower cervical spine. Methods of care adapted to the combined injuries are described. The study concludes that examination of the face for soft-tissue and bony injuries may give important clues on the direction and intensity of the force injuring the cervical spine.

Persistent trigeminal artery with internal carotid artery occlusion

A patient with a persistent trigeminal artery and occlusion of the internal carotid artery is presented. The development and protective hemodynamic significance of this persistent embryological anastomosis are briefly discussed.

Bone end sclerosis in renal osteodystrophy simulating osteonecrosis

Osteosclerosis of the bone ends is an unusual manifestation of renal osteodystrophy. In evaluating this finding one should be careful to exclude clinical and radiographic evidence for osteonecrosis. In the two known cases of this entity, bone end sclerosis has been found to develop over one to two years with symmetrical involvement of multiple bones.

The use of antihistamine to retard the growth of fibroblasts derived from human skin, scar, and keloid

Sixty percent of the fibroblast strains derived from normal skin, scar, and keloid reached elevated growth plateaus when cultured in the presence of histamine. A pharmacologic level of the antihistamine diphenhydramine hydrochloride was able to suppress the stimulation in all the keloid strains that were histamine-sensitive.

Extensive suprapubic vesicocutaneous fistula following trauma

There are few reports on extensive suprapubic vesicocutaneous fistulas. We report the problems encountered in the closure of these fistulas following lower abdominal trauma. Two patients are described in whom the trauma produced extensive loss of skin, fascia and muscle, leaving the bladder exposed and open. Despite several attempts at bladder closure the bladder repair always failed and the fistula remained open. It was necessary to cover the subsequent bladder closure with overlying muscle, fascia and skin to obtain a successful closure. The techniques of closure are explained.

The tensor fascia lata V-Y retroposition flap

The design of the tensor fascia lata myocutaneous flap can be modified, allowing its use as a V-Y retroposition flap for treatment of trochanteric pressure ulcers. This technique eliminates the rotation point, puts the thickest portion of the flap over the defect, and obviates the need for skin grafts. It has been successfully employed to treat 11 trochanteric pressure ulcers in 10 patients in the past two years.

Carcinoma arising in sebaceous and epidermoid cysts

Malignant degeneration of sebaceous and other epidermoid cysts in uncommon, but it does occur in approximately 2.2% of cysts examined. It should be suspected in patients with atypical appearance or a history of cyst recurrence. All cysts should be examined histologically and the histological grade carefully noted. This paper reports a well-differentiated squamous cell carcinoma arising in an epidermoid cyst. Wide excision was performed, including superficial parotidectomy, because of histological evidence of extension beyond the cyst. Based on the literature, recurrence or metastasis of our patient's tumor appears unlikely.

The nondelayed thoracoepigastric flap: coverage of an extensive electric burn defect of the upper extremity

A large, nondelayed thoracoepigastric flap extending 6 cm beyond the posterior axillary line was used to cover an extensive electrical injury of the right upper extremity.