Revolutionary advances in organic foods

'Organic' is a labelling term that denotes products produced under the authority of the Organic Foods Production Act. Before a product can be labelled 'organic', a government-approved certifier inspects the farm where the food is grown to make sure the farmer is following all the rules necessary to meet the US Department of Agriculture (USDA) organic standards. Companies that handle or process organic food before it gets to your local supermarket or restaurant must be certified, too. Along with the national organic standards, the USDA developed strict labelling rules to help consumers know the exact content of the food they buy. It is important to emphasise that the USDA has not made any health claims for organic foods. It is indeed fortunate that the US Department of Health and Human Services, Centers for Disease Control and Prevention, USDA and the Environmental Protection Agency are now expanding their research to explore the scientific basis for the health benefits of organic foods.

A technique for the treatment of sternal infections using the Vacuum Assisted Closure device

BACKGROUND

Sternal infections after median sternotomy remain a serious cause of postoperative morbidity and mortality. The treatment of sternal infections has evolved over the past few decades, and now aggressive surgical debridement with rotational muscle flap closure has provided an acceptable means of managing this complication. However, there are several disadvantages with this approach, mainly related to the morbidity associated with serial debridements with dressing changes and open packing until the wound is closed. Other disadvantages include potential morbidity and mortality associated with the shearing forces between the beating heart and the debrided sternal edges, and the need to paralyze the patient during the period after debridement.

METHODS

Our method of managing sternal infections is based on the triad of prompt surgical debridement, serial quantitative wound cultures, and the use of the Vacuum Assisted Closure (VAC) device (KCI International, San Antonio, TX). Following debridement and irrigation, a biopsy of the healthy appearing bone is sent for quantitative culture. If culture results are favorable, the wound is then fitted with the VAC device, which consists of a non-collapsible, open-cell, polyurethane sponge with embedded vacuum tubing, a vacuum pump, and transparent adhesive dressing. When systemic signs of infection and quantitative cultures indicate the resolution of the local infection, regional muscle flap or primary wound closure is performed.

CONCLUSIONS

The VAC serves as a bridge to sternal wound closure and is a safe and effective therapeutic strategy for patients with impaired physiologic reserve and/or highly contaminated wounds. We feel that it is also reasonable to consider the VAC as a preventive strategy against right ventricular rupture. Furthermore, because the firmness of the vacuum sponge apparatus acts as an impressive sternal stabilizer, post-debridement extubation is possible, reducing the need for prolonged paralysis and mechanical ventilation. This stabilization also allows early postoperative ambulation with the VAC in place. In summary, we believe that the VAC device offers an effective means of managing patients with sternal infections.

Comparison of the thrombogenicity of internationally available fibrin sealants in an established microsurgical model

Previous studies comparing the thrombotic complications of cryoprecipitated fibrin sealant containing bovine thrombin on microvascular venous anastomoses in a rat epigastric free flap model revealed deleterious outcomes regarding flap survival with higher concentrations of topical bovine thrombin. This study was designed to compare three internationally available fibrin sealants, one experimental fibrin monomer sealant that does not require thrombin, and human thrombin alone as to their effects on the survival of an established rat epigastric free flap model. Ninety Sprague-Dawley rats (400 to 600 g) were prepared for abdominal surgery, and an epigastric-based skin flap was raised. The single vein draining the flap was clamped, divided, and reconnected using standard microvascular suturing techniques. Before release of the clamps, the chosen additive was applied precisely to the anastomosis. Additional material was then added to the raw surface of the flap. The animals were divided into seven treatment groups, each receiving 1 ml of commercial or investigational fibrin sealant or human thrombin alone: one control group receiving no additive treatment, four fibrin sealant groups receiving treatment with commercial or investigational fibrin sealant preparations, and two groups receiving different concentrations (500 IU/ml and 1000 IU/ml) of human thrombin applied to the anastomoses and the surrounding tissue. Flap survival was assessed at 7 days postoperatively. This study supports the contention that microvascular free flap survival based on microvascular venous anastomotic patency was adversely effected by high concentrations of thrombin. Lower concentrations (500 IU/ml and less) of thrombin did not seem to affect flap survival. One test product was composed of a fibrin monomer sealant, which obviates the need for the thrombin additive. This group's survival rate was not statistically different from that of the control group. Thus, for microvascular anastomoses, lower concentrations of thrombin or a sealant devoid of thrombin seem to be best for microvascular anastomotic patency.

An innovative absorbable coating for the polybutester suture

The polybutester (PBE) suture has been coated with an absorbable polytribolate polymer that is composed of glycolide (9%), epsilon-caprolactone (51%), and poloxamer 188 (40%) to reduce its drag forces. It is the purpose of this study to document the influence of this coating on the biomechanical performance of both PBE sutures and polypropylene (PP) sutures. The performance parameters evaluated were breaking strength, elongation, stiffness, knot security, knot run down, and tissue drag. The breaking strength of PP sutures was remarkably similar to that of coated and uncoated PBE sutures. In size 5/0 PP sutures, the sutures exhibited considerably greater elongation at knot break than did comparably sized PBE sutures. The PBE suture elongated under low loads, but returned to its original length when the load was removed. In contrast, the PP suture elongated irreversibly at high loads, exhibiting creep. Coated and uncoated PBE sutures exhibited less stiffness than PP sutures and exhibited limited memory after removal from the suture package. Coating the PBE suture markedly reduced its drag forces in musculoaponeurotic, colonic, and vascular tissue. Knot security with the coated PBE suture was achieved with only one more throw than with comparably sized uncoated PBE sutures. On the basis of the results of this study, coating the PBE suture represents another major advance in suture performance.

Fibrin sealants in microvascular surgery: current status

During the last two decades, advances in fibrin sealant formulation have resulted in its investigational and clinical use in various surgical endeavors, including microvascular surgery. Several investigations have comparatively evaluated fibrin adhesive-enhanced microvascular anastomoses vs. conventional suture repair. The purpose of this review is to summarize the collective documentation on fibrin adhesives in microvascular surgery on the basis of the scientific performance parameters of vessel patency, bursting strength, anastomotic competence, and reendothelialization. In addition, other applications of fibrin sealants and other qualities unique to fibrin adhesives are addressed.

An outcome study of breast reconstruction: presurgical identification of risk factors for complications

BACKGROUND

Breast reconstruction following mastectomy has been shown to have a salutary effect on the overall psychological well-being of women being treated for breast cancer. Unfortunately, however, not every patient is an ideal candidate for reconstruction. Complications stemming from reconstructive surgery can cause significant morbidity, the most important of which may be the delay of subsequent adjuvant antineoplastic therapies, and therefore may not be in the best interests of the patient.

METHODS

A retrospective study was performed on a consecutive series of 123 breast reconstructions in 98 patients, performed by one of two plastic surgeons, in a university setting over a 5-year period, for all surgical outcomes. Specifically, wound-healing complications, infections, and reoperations leading to the potential delay of subsequent chemotherapy or radiotherapy were recorded, and possible risk factors leading to these were sought.

RESULTS

Three presurgical risk factors were found to have a statistically significant influence on the development of complications following breast reconstruction. These were: (1) increasing obesity, defined by the body mass index, (2) an active or recent (<5 year) history of cigarette smoking, and (3) a history of previous radiation exposure. Odds ratios were used to describe the magnitude of the effect of each factor for the development of complications. An ordinal regression analysis was used to create a nomogram based on this information that can be used to calculate any individual patient's presurgical risk for developing major complications following breast reconstruction, based on the presence of these factors.

CONCLUSIONS

It is possible, based on the presence of specific presurgical risk factors, to predict the probability of developing major complications following breast reconstruction. This information can be useful to the referring physician and plastic surgeon alike in determining which patients are the best candidates for breast reconstruction and which type of reconstruction would be best suited for each individual patient.

Fibrin sealant: a novel method of fixation for an implantable ultrasonic microDoppler probe

While free tissue transfer affords the reconstructive microvascular surgeon the ability to provide coverage for complex wounds, the postoperative monitoring of these flaps continues to evolve. The most recent advance has been the development of an implantable microDoppler probe to provide an early warning signal for vascular obstruction. The current system relies on the use of a silicone cuff to secure a 1-mm probe to the outflow vein. The release force to remove the probe from the cuff is reported to be 1/10 of a pound (45 g). A disadvantage of this system is the need for a circumferential, relatively inelastic device around the vein. Should the cuff be too tightly secured to the vein, the potential for outflow obstruction exists. Moreover, if the probe is not well-approximated to the vein, no signal is produced. Finally, the fact that a foreign body remains in the wound after completion of the monitoring period remains a concern. The authors have investigated a new method to adhere the probe, using a commercially available fibrin sealant. The use of this biocompatible substance has the potential to obviate the need for the current method of fixation, and the associated concerns.

The vacuum-assisted closure device as a bridge to sternal wound closure

Sixteen patients were treated for sternal wound infections after undergoing cardiac procedures. Their management involved prompt surgical debridement and quantitative wound biopsies. At the time of the initial debridement, the Vacuum-Assisted Closure Device (V.A.C.) was placed in the open sternal wound. A subatmospheric environment was maintained by the device at a level of 75 to 150 mmHg. The V.A.C. sponge was changed every 2 to 3 days, and operative debridement was performed until quantitative biopsies showed resolution of infection or until systemic signs of sepsis had resolved. At this time the sternal wounds were closed with regional muscle flaps. Patients were excluded from the use of the device if the pleural cavity was entered during operative debridement. Fifteen of the 16 patients survived and went on to complete wound healing and discharge from the hospital (average length of stay, 16.7 days). One patient sustained a cardiac dysrhythmia during the muscle flap procedure and died. There were no complications related directly to the use of the V.A.C. It is the opinion of the authors that the V.A.C. offers several advantages over their traditional methods of treatment. They noted improvement in sternal wound stabilization during the perioperative period and a decreased need for paralysis and mechanical ventilation. Wound management was improved by avoiding the need to perform debridement or to make desiccating dressing changes to an open sternum. Moreover, they also think that this device may lessen the risk for ventricular rupture because of better control of the wound environment and markedly improved stabilization of the debrided sternal elements.

Thrombogenic effects of a nonthrombin-based fibrin sealant compared with thrombin-based fibrin sealant on microvenous anastomoses in a rat model

The efficacy and safety of tissue adhesives needs to be clearly defined. A thrombin-based preparation of fibrin sealant has recently been shown to have deleterious effects on microvascular anastomoses in an animal model. The authors found that fibrin sealant constructed with a high concentration of bovine thrombin (1,000 IU per milliliter) was detrimental to microvascular patency when applied to the anastomosis in a rat free flap model. The microvenous anastomosis had the highest rate of thrombosis and failure in this model. A nonthrombin-based fibrin sealant has recently become available for experimental investigation. This study examined the thrombogenic effect of this nonthrombin-based fibrin sealant on microvenous anastomoses in a rat free flap model compared with the effect of traditionally prepared fibrin sealant with varying concentrations of thrombin. The conclusions reveal that flap survival with application of the nonthrombin-based fibrin sealant to the anastomosis was comparable with flap survival of the control animals. Flap survival with application of the traditionally prepared thrombin-based fibrin sealant was also comparable with flap survival of the control animals when a concentration of 500 IU per milliliter of thrombin was used. However, flap survival decreased significantly (p <0.005) when a concentration of 1,000 IU per milliliter of thrombin was used in the construct of the fibrin adhesive. These results support the previous findings of the harmful effects of thrombin when used in high concentrations and applied to the microvenous anastomosis of this free flap model. Moreover, this initial investigation with a nonthrombin-based fibrin sealant did not show any deleterious effects on the microvenous anastomosis compared with control animals.

A pilot study of short- and long-term sequelae to rigid fixation across metacarpal physes in a baboon model

The use of rigid fixation for fractures of the extremities has become commonplace. The short- and long-term effects of rigid fixation on the growing hand, however, have not been studied thoroughly. In this project, the use of rigid fixation across metacarpal growth plates (physes) in growing primate hands was examined. The hypothesis to be tested was that long-term placement of rigid fixation devices across physes during stabilization of mid-shaft osteotomies will cause the physes to close prematurely. Fixation devices with screws placed in the epiphysis and left in place for 4 months or 1 year resulted in open physes, in support of the null hypothesis. However, in physes plated for 1 year, biochemical changes associated with increased bone differentiation were apparent. Findings suggest that rigid fixation across physes for as long as 1 year can be used appropriately in growing individuals when necessary. However, until additional investigation establishes whether the open physes are still capable of producing bone-lengthening hypertrophic chondrocytes, caution should be used in long-term placement of rigid fixation devices.

Wound complications of abdominoplasty in obese patients

The records of 90 patients who underwent an abdominoplasty at the University of Virginia Health Sciences Center were analyzed to determine the effect of obesity on the incidence of complications after this surgery. The study patients were divided into three groups-obese, borderline, and nonobese-based on the degree to which their preoperative weights varied from their ideal body weight. A history of previous bariatric surgery was also analyzed to determine what impact that might have on subsequent abdominoplasty. Results showed that 80% of obese patients had complications compared with the borderline and nonobese patients, who had complication rates of 33% and 32.5% respectively (p = 0.001). Previous gastric bypass surgery had no significant effect on the incidence of postabdominoplasty complications. Based on these findings the authors conclude that obesity at the time of abdominoplasty has a profound influence on the wound complication rate following surgery, regardless of any previous weight reduction surgery.

A new technique for the treatment of flexor digitorum profundus tendon avulsion

Current treatment of flexor digitorum profundus (FDP) avulsion with complex external wire or button fixation is associated with significant morbidity. A new method of internal fixation avoids the complications that are associated with previous techniques. Through a volar Bruner incision, the profundus tendon is retrieved. A transverse dorsal incision is made and two holes are drilled. A double-arm suture is passed through the tendon and bone, and is tied dorsally. Both incisions are closed, leaving the repair entirely internal. This simple technique produces a solid reinsertion of the FDP tendon and avoids damage to the nail bed and matrix. Internal fixation eliminates nail plate deformities, reduces cost, speeds recovery, and produces a stable reconstruction.

Acute thrombogenic effects of fibrin sealant on microvascular anastomoses in a rat model

Topically applied bioadhesives and hemostatic agents have gained wide acceptance in various surgical endeavors. However, the effect of thrombin-based fibrin sealant (fibrin glue) when applied to microvascular anastomoses has not been evaluated thoroughly. Although fibrin sealant has been used directly on vascular anastomoses in macrovascular surgery, there has been little exploration into the utility and potential complications when used in the microsurgical setting. This study explored the influence of fibrin sealant containing increasing concentrations of bovine thrombin on microvascular anastomoses in a rat epigastric free flap model. The survival of the free flap in this model appeared to be inversely proportional to the concentration of thrombin in the fibrin sealant. When thrombin alone was applied to the anastomoses, the rate of thrombosis was the highest. Venous anastomosis was the most sensitive to the deleterious effects of topically applied thrombin.

A temporal analysis of the effects of pressurized oxygen (HBO) on the pH of amputated muscle tissue

The effect of hyperbaric oxygen (HBO) on ischemic muscle tissue pH was evaluated continuously. The hind limbs of male Sprague-Dawley rats (N=11, both groups) were amputated and stored in room air (20.1% oxygen [O2], 1.0 ATM, 24 degrees C) or in HBO (100% O2, 2.9 ATM, 24 degrees C) for 240 minutes. Rat muscle tissue pH was continuously monitored with a micro-pH electrode following amputation. There was no significant difference between the average starting tissue pH of control and treated limbs (p=0.45). At 240 minutes of ischemia the control group tissue pH decreased 0.80 pH units whereas the treatment group decreased 0.68 pH units (p < 0.05). The tissue pH of control limbs declined 30.7 times faster than treated limbs during the first 36 minutes of ischemia (p < 0.05). From 36 to 240 minutes the rates of acidosis were similar and did not differ significantly (p=0.46). In a separate study, male Sprague-Dawley rats were anesthetized with pentobarbital and ketamine. Aortic arterial blood gases were obtained at 5 minutes (N=8) and 15 minutes (N=8) postanesthesia. The average serum pH, carbon dioxide, oxygen, and bicarbonate levels remained within normal limits in both groups and did not differ significantly (p > 0.05 for all parameters). Anesthesia produced no serum respiratory or metabolic acidosis and did not contribute to the initial ischemic tissue pH. These results suggest that HBO delays the progression of metabolic acidosis in this amputated limb model. This is further supporting evidence for the tissue-preserving effect of oxygen when delivered in hyperbaric conditions. However, the clinical application of this technique may be limited due to the difference in the volume of tissue presented for major limb replantation and the short window of beneficial effects.

Magnetic resonance imaging in the early diagnosis of group A beta streptococcal necrotizing fasciitis: a case report

Early diagnosis of invasive group A beta streptococcal (GABS) infection has been achieved in a patient using magnetic resonance imaging (MRI) complemented by needle aspiration. Life-saving treatments of GABS infection that include immediate surgical debridement along with the administration of i.v. antibiotics, gamma globulin, and hyperbaric oxygen were then implemented successfully to prevent the development of streptococcal toxic shock syndrome. While MRI is valuable in making early diagnosis of GABS, it should not delay surgical intervention.

A new computerized control unit for small bone surgical instruments

The SmartDrive console represents an important advance in small bone surgery because it monitors and coordinates the operation of its handpieces. The SmartDrive console has the following unique features: 1) a handpiece recognition system; 2) an instrument speed display; 3) a handpiece display and monitoring system; 4) a torque instrument control system; 5) a temperature monitoring system; 6) and an irrigation system. Mechanical performance studies have been undertaken that have validated the accuracy of the monitoring systems of the consoles. The consoles provided reliable recordings of the rotational speeds of their hi-speed drills. The MicroAire console automatically shuts off its power as the temperature increased to 110 degrees F (43 degrees C). In contrast, the Stryker Command 2 console has a limited monitoring system that can not alter the operation of the handpieces.

Influence of latex glove hydration on bacteriophage penetration

The purpose of this study was to determine whether glove hydration influenced bacteriophage penetration. Using an electronic glove hole-detection device, one brand of latex glove was identified that hydrated rapidly (3.25 min +/- 0.71 min), while another brand was selected that resisted hydration (120 min +/- 0 min). Using a standard bacteriophage penetration model, the amount of bacteriophage penetration in both the rapidly hydrating gloves and the gloves that resisted hydration was extremely small and did not differ significantly from each other.

Metacarpophalangeal joint dislocation: indications for open surgical reduction

In complex dislocations of the metacarpophalangeal joint, the volar plate is separated from the proximal phalanx and the metacarpal head is entrapped within surrounding tissue structures. These complex dislocations must be managed by open surgical reduction to reduce the dislocation and realign the volar plate. A 58-year-old male presented to the emergency department with a complex dislocation of the metacarpophalangeal joint of the left little finger, which was successfully treated by open reduction in the operating room. The indications for open reduction of metacarpophalangeal joint dislocations are reviewed.

Molten metal burns: further evidence of industrial foundries' failure to comply with Occupational Safety and Health Administration regulations

The purpose of this report is to describe another case of a molten metal burn to the foot of a foundry worker. The foundry in which he worked failed to comply with Occupational Safety and Health Administration regulations with regard to protective apparel. This injury could have been prevented with annual, unscheduled inspections by the Occupational Safety and Health Administration and with enforcement of additional regulations regarding protective apparel.

Search for a scientific basis for continuous suture closure: a 30-yr odyssey

Continuous percutaneous and dermal suture closures have an important role in the approximation of long, linear lacerations in the emergency department. This report documents the scientific basis for these continuous closure techniques. In addition, a detailed description of these surgical closure techniques is presented.

Technical considerations in knot construction. Part I. Continuous percutaneous and dermal suture closure

The purpose of this investigation was to determine the security of the square knot tied with one looped end and one free end versus the security of the square knot tied with two free ends. Size 4/0 and size 6/0 monofilament nylon, polypropylene, and Biosyn sutures were selected for this evaluation. The mechanical performance of these sutures was judged according to knot breakage force and number of throws required to attain security. Knots with one looped end and one free end require more throws to ensure knot security than do knots constructed from two single suture strands of comparable sizes and types of sutures.

Industrial high-voltage electrical burn of the skull, a preventable injury

Deep burns of the scalp and skull are often caused by high-voltage electrical injuries. Patients with such injuries should be referred to regional burn centers that are prepared to excise necrotic burn tissue and cover the devitalized bone with a well-vascularized flap. Strategies for prevention of these electrical burns are discussed.

Natural rubber latex allergy: spectrum, diagnostic approach, and therapy

Latex allergy has reached epidemic proportions in the United States and is increasingly recognized as a significant contributor to morbidity and mortality during medical and surgical procedures. Ultimately, many of the affected patients with recognized latex sensitivity and those who are not yet diagnosed will receive treatment for their allergic reactions to latex in emergency departments. Consequently, emergency physicians must have a comprehensive understanding of the etiology, epidemiology, pathogenesis, treatment, and management of these challenging patients. Groups at high risk include spina bifida cystica patients, health care workers, latex industry workers, specific food-allergy patients, and patients with a history of atopy or multiple surgical procedures. Sensitization to latex antigens is commonly encountered in health care workers wearing latex gloves with high latex allergen concentrations and in workers using powdered latex surgical gloves. Exposure to air-borne allergens and water-soluble IgE reactive latex antigens from natural rubber latex products in sensitized individuals can result in type I (immediate) hypersensitivity reactions. Clinical manifestations include contact urticaria, dermatitis, allergic rhinitis, conjunctivitis, asthma, angioedema, and anaphylaxis. Diagnostic tools include serological assays and skin prick testing. At present, latex avoidance is the only available treatment and is the key to preventing allergic reactions in latex-sensitized individuals. Health care worker sensitization to latex antigens in natural rubber products is becoming an increasing contributor to workers' liability and disability claims. Specific action can be taken to reduce occupational and patient exposure to latex antigens.

Peritoneal healing with adhesion formation: current comment

Intra-abdominal adhesions are fibrotic structures, which lie in the form of a string or attachment between the abdominal organs and connect these together. They are responsible for serious clinical complications that include intestinal obstruction, infertility, and pelvic pain. During the last century, surgeons' comprehensive understanding of the biology of peritoneal healing and wound repair has allowed them to identify a variety of new therapeutic techniques that limit the development of adhesion formation. New drugs, dextran 70 and poloxamer 407, have been developed to prevent adhesion formation. In addition, three new biomaterials (oxidized regenerated cellulose, hyaluronate membrane, and polytetrafluoroethylene) are synthetic barriers being used to prevent adhesions.

Grease burns of the hand: preventable injuries

Grease burns to the hand represent a serious and preventable hazard. These injuries account for over 10% of all major burns seen in the emergency department. These burns occur when the cook attempts to move a pan with burning cooking oil and inadvertently spills the oil on the hand holding the pan. These burns are usually full thickness because of either the high temperatures of the flaming oils or the subsequent ignition of clothing. This article describes a patient who received severe partial and full thickness burns to the dominant hand following a grease burn in the domestic setting. Prevention through improved consumer education and warning labels for cooking oils should reduce the incidence of these serious injuries.

Steam press hand burns: a serious burn injury

Steam presses cause full-thickness burns when the operator's extremity is caught between the buck and the head of the steam press. Patients with serious steam press burns should be referred to a regional burn center for excision of the full-thickness burn and coverage by either a split-thickness skin graft or a flap. The safety features in steam presses that could prevent this serious injury include: (1) emergency safety releases, (2) peripheral safety bars, and (3) two-hand operator control.

Effect of puncture resistant surgical gloves, finger guards, and glove liners on cutaneous sensibility and surgical psychomotor skills

New puncture and cut resistant hand protection systems have been developed to enhance the barrier to cuts and needle puncture injuries during surgical procedures. It is important, however, that these new hand protection systems do not reduce tactile sensitivity or dexterity during surgery. Consequently, it was the purpose of this report to compare the cutaneous sensibility and dexterity of physicians' hands covered by these new puncture and cut resistant hand protection systems to that of the standard surgical latex glove. The hide (Medak) portion of the Life Liner and the polyethylene (Spectra) portion of the FingGuard, which offered the greatest resistance to needle puncture, were associated with the greatest reduction in cutaneous sensibility, as determined by moving and static two-point discrimination, aesthesiometer pressure sensation, and discrimination of suture size and configuration. In addition, the physicians believed that the puncture and cut resistant Life Liner glove liner markedly interfered with their handling of surgical instruments. The ultimate benefit of these puncture and cut resistant hand protection systems must be determined in well-controlled clinical trials.

Reconstruction for limb-sparing procedures in soft-tissue sarcomas of the extremities

An understanding of the biology of soft-tissue sarcomas and knowledge of refined techniques of adjuvant therapy have allowed limb-sparing procedures to become predominant in the management of these tumors. Immediate bony reconstruction with prosthetic implantation has met with consistent success largely because of the vascularized coverage provided by local and distant flaps. Microvascular reconstruction allows wound closure with vascularized tissue in one stage. The use of a distant donor site does not alter the function of an already compromised limb as would a local muscle flap, and, in selected cases, the transplant may augment the functional ability of the limb. The use of a distant site also does not require extensive dissection in regional tissue planes, which theoretically could spread the local disease.

Wound healing considerations in chemotherapy and radiation therapy

Adjunctive radiation and chemotherapy have evolved to increase the survival rates and disease-free intervals that can be accomplished with surgical resection. We have reviewed the salient effects these agents have on wound healing. Further investigations into the specific wound-healing deficits caused by these agents and the development of interventional therapies will enable us to manipulate the wound milieu in order to accomplish the goal of oncologic cytoreductive therapy without detrimental effects on wound healing.

New instruments, bone liners, and tray for finger joint arthroplasty

Titanium circumferential grommets have been developed for finger joint arthroplasty that fit on the base of the silicone implant stems to protect the flexible hinge from tearing and fracture. To facilitate grommet insertion, new intramedullary bone rasps have been devised with a reverse cutting tooth pattern, an extended shaft for an improved view of the surgical field, and a redesigned cutting head to allow for grommet insertion. Surgical accessibility and ease of recognition have been facilitated by the development of color-coded sizers. All of the instruments necessary for finger joint surgery are available in a molded tray that has also been redesigned with a transparent lid and clearly labeled compartments for accurate determination of instruments and implant sizers.

An overview of first metatarsophalangeal joint implant arthroplasty

The metatarsophalangeal joint of the great toe often requires an arthroplasty to correct joint disease and pain. Today, joint replacement systems are combinations of components manufactured to optimize biological ingrowth, mechanical interlock, press fit, and cementing. Three different types of arthroplasties are available to foot surgeons: the double stem hinged silicone implant, the two-component joint mimicking implant, and a hemi-implant available for the phalanx. No comprehensive studies on very large populations have been conducted to accurately evaluate the beneficial long-term effects of these implants. This review article describes the development of the toe arthroplasty, details the commercially available implants, and addresses the advantages and adverse effects of each implant.

Magnetic resonance imaging of in situ mammary prostheses

A study was conducted at the University of Virginia Health Sciences Center to examine the effectiveness of magnetic resonance imaging in detecting rupture or deflation of in situ mammary prostheses. Thirty-three women with 59 prostheses were included in the study. Fifteen of the 33 patients had undergone surgery for removal or replacement of 21 implants. Positive findings for rupture were accurately predicted for 15 implants and confirmed at surgery. Negative findings for rupture were accurately predicted in the remaining 6 implants and confirmed at surgery. Although it is a more costly procedure than either mammography or ultrasonography, we believe that magnetic resonance imaging is also more accurate in detecting damaged implants, particularly when they are contained within an intact capsule or when the implants are stacked. Unlike mammography, magnetic resonance imaging requires no ionizing radiation or breast compression. Magnetic resonance imaging of the in situ breast prosthesis may be a useful adjunct when other modalities yield inconclusive results or when a contained rupture is suspected.

Calvarial deformity regeneration following subtotal craniectomy for craniosynostosis: a case report and theoretical implications

We describe an infant with combined sagittal and unilateral coronal synostosis who underwent "total vault" craniectomy for skull reshaping. The operative procedure was interrupted without replacement of the calvarial bone grafts. Follow-up over the ensuing 2 months revealed regeneration of the entire cranium and supraorbital rims, as well as (in contrast to earlier reports) redevelopment of fusion within the suture at the same site noted in the initial operation, associated with similar skull deformity. These observations are reviewed with special emphasis on the theoretical implications for the etiology of craniosynostosis and skull deformity.

Digital sympathectomy for refractory Raynaud's phenomenon in an adolescent

We describe the case of an adolescent with severe Raynaud's phenomenon refractory to conventional medical management. Her course was complicated by fingertip ulceration and necrosis. The localized surgical technique of digital sympathectomy was successfully used in the management of her disease, and should be considered for intractable Raynaud's phenomenon.

Shave excision and dermabrasion for facial angiofibroma in tuberous sclerosis

Tuberous sclerosis is an inheritable disease of varied manifestations. Hallmarks of the disease have historically been identified as infantile seizures, severe mental retardation, and facial growths. The facial lesions were formerly termed adenoma sebaceum, but are now known to be angiofibroma. We present a patient who was referred for management of large facial lesions complicated by intermittent hemorrhage. A combination of shave excision and dermabrasion led to a symptomatic and cosmetic improvement.

Coloanal anastomosis in the management of benign and malignant rectal disease

The aim was to determine the efficacy, safety, and long-term clinical and functional results of coloanal anastomosis in patients with complicated benign and malignant rectal disease. Twenty-nine patients underwent coloanal or colopouch-anal anastomosis for either carcinoma of the rectum not technically amenable to conventional low anterior resection, severe radiation injury, large benign lower third tumors, or complications of previous operations. The mean age of the patients was 61 years and 82% were men. A diverting colostomy was constructed in 55% of the patients. The mean (+/- SEM) length of follow-up was 20 +/- 3 months. There was no operative mortality. Transient urinary retention, however, occurred in 40%, anastomotic stricture in 28%, and anastomotic leakage in 3.4%. Four patients (14%) could not have intestinal continuity restored and therefore were considered failures. The stool frequency for all remaining patients (N = 25) was 3 +/- 1 per day (mean +/- SEM) and did not vary with age, sex, or indication for operation. Complete continence was achieved by 84% of patients, but no patient was incapacitated by poor bowel function. In patients in whom a conventional colorectostomy is impractical or unwise, coloanal anastomosis is a safe and efficacious alternative operation that preserves anal continence.