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Biomedical subjects

H J Buncke

Publications and source records attributed to H J Buncke.

At least 91 records · Page 5Linked to original sources
PubMed1993

Management of chronic achilles tendon infection with musculotendinous gracilis interposition free-flap coverage.

Management of infected Achilles tendon repair poses a significant reconstructive problem. Thorough debridement is most important and resection of non-viable tendon substance is required. Reconstruction of such tendon defects requires vascularized soft-tissue coverage that is stable and that offers the possibility of functional restoration. Gracilis free-tissue transfer is an effective means of providing stable, durable, well-vascularized, soft-tissue coverage in an infected Achilles tendon repair. The microsurgical anastomoses are technically straightforward. Cybex II dynomometer measurements, performed 6 months following free-tissue transplantation, revealed strength (torque) and power, at an angular velocity of 45 degrees per second, of: 59 percent and 52 percent, respectively, compared to the uninjured side. Endurance was assessed at an angular velocity of 120 degrees per second over a 15-second test interval, and was noted to be 81 percent, compared to the normal ankle. Excellent functional results and acceptable soft-tissue contour can be expected with this technique.

Achilles Tendon↗
PubMed1993

Unrecognized injuries in patients referred for emergency microsurgery.

Replantation of amputated parts and emergency microvascular repair of injured extremities are the two most common applications of clinical microsurgery. A major complication of emergency referral of such cases is the existence of the other injuries unrecognized at the time of initial evaluation. We have reviewed this complication within a series of emergency microsurgical cases referred to this unit. Several reports examining this problem of missed injuries exist in the general trauma literature. To our knowledge this study is the first to look at this important problem in the context of acutely injured patients referred for emergency microsurgery. A retrospective analysis of patients referred to Davies Medical Center over a 7-year period was performed. Nine of 1100 patients (0.8%) transferred to our unit for microsurgical evaluation and treatment had unrecognized coexisting injuries that put those patients at high risk for injury-specific morbidity and demanded immediate changes in the original care planned at the time of referral. Brief case histories of these patients are outlined. We review the trauma literature of such injuries. A concise protocol elucidating the guidelines and pitfalls of emergency microsurgical referral is offered.

Adolescent↗
PubMed1993

Soft-tissue reconstruction in orthopedic surgery. Secondary procedures.

The original consulting microsurgeon should be present to assist in the identification and protection of the vascular pedicle during secondary procedures on microvascular transplants. Flap elevation, trimming, and bone graft placement should be completed during a single tourniquet time, whenever possible. Flaps can easily be resutured on the original bed while the tourniquet is still inflated. Although proximal pedicle transection is possible, it should be avoided by careful planning, because the transplanted tissue cannot be predictably expected to survive, especially with muscle transplants. The distal muscle should be transected only in situations in which the muscle inset is extremely complex. Transection in the extramuscular portion of the main pedicle may require prompt microsurgical repair in immature muscle transplants. The safest approach is to avoid the pedicle whenever additional secondary procedures are necessary following free microvascular tissue transplantation. Placement of vascular pedicles such that the anterior crest of the tibia is avoided if the Ilizarov technique is required permit uncomplicated distraction osteosynthesis. Simultaneous Ilizarov fixation and microvascular tissue transfer are safe, practical procedures for limb salvage. Placement of the Ilizarov fixator at the time of microvascular transplantation provides stable fixation and eliminates the need for a subsequent anesthetic for fixator placement. This form of stabilization, when performed at the time of microvascular tissue transfer, allows the orthopedic surgeon direct visualization of the fracture site as the fixator is placed and eliminates the need for placement of the fixation device through the transplanted tissue. Tissue expansion or suction lipectomy are sometimes needed to optimize the clinical result.

Bone Transplantation↗
PubMed1993

Problems unique to microsurgical epididymovasostomy. Comparison of four techniques in a laboratory rat model with review of the literature.

The new microsurgical techniques, tubule and loop intussusception, are compared to end-to-end and side-to-end in an experimental rat model. Sixty adult male Sprague-Dawley rats were operated on bilaterally under the same conditions. The four microsurgical techniques differ in approach to the inner mucosal layer, while the outer adventitial layer was sutured similarly in all cases. Luminal patency was checked 3 months postoperatively. There was no statistically significant difference in the patency rate among these four techniques (P = 0.3196). However, the incidence of macroscopically (P < 0.001) and microscopically (P < 0.01) detected spermatic granulomas was highly significant despite the optimum size match for each method. We found side-to-end techniques superior and easier to perform than end-to-end. The loop intussusception offers the highest patency rate (100%) with the lowest incidence of spermatic granuloma (10%). It was, therefore, concluded that selection of surgical technique is of utmost importance for durability of anastomosis.

Anastomosis, Surgical↗
PubMed1992

Blood loss associated with anticoagulation in patients with replanted digits.

The incidence of blood loss and blood transfusion in patients receiving one anticoagulant in addition to aspirin (n = 40) was compared with that in patients receiving two or more anticoagulants in addition to aspirin (n = 15). Multiple-agent therapy produced a greater drop in the hematocrit than single-agent therapy (15% compared with 6%). Only 2% of the patients receiving a single agent had transfusions, as compared with 53% of the patients receiving multiple agents. We conclude that administration of multiple anticoagulants greatly increases the incidence of blood loss and blood transfusion as compared with the administration of a single agent plus aspirin. The importance of salvaging a replanted digit or digits must be weighed against the risks of a blood transfusion.

Anticoagulants↗
PubMed1992

The hyperflexed seemingly useless tetraplegic hand: a method of surgical amelioration.

In a series of 65 tetraplegic hands with severe disabling spasticity and/or flexion contracture, selective flexor tendon elongation procedures were employed to improve their static and kinetic postures. A kinetic approach was adopted, utilizing local anesthesia in a wide-awake patient. This was employed to allow for the patient's cooperation in determining at surgery the desired length of digital extension at the time of wrist tenodesis action. Elongation of the extensor digitorum communis (EDC), extensor indicis proprius (EIP), and extensor digiti quinti (ED V) were added to correct an 'extrinsic-plus' posture observed in 16 patients following flexor tendon lengthening. With the resultant improvement in the static posture of the digits, tendon transfers could then be employed to provide a more functional tenodesis action. These measures provided both improved palmar contact and prehension.

Adolescent↗
PubMed1992

Aeromonas hydrophila infections following use of medicinal leeches in replantation and flap surgery.

Aeromonas hydrophila infections are a recognized complication of postoperative leech application, and can occur with measurable frequency in populations of patients treated with leeches. We review 11 previously reported leech-related Aeromonas infections and analyze seven unreported cases. These infections range from minor wound complications to extensive tissue loss and sepsis. Often, these infections followed leech application to tissue with questionable arterial perfusion. Onset of clinical infection in these patients ranged from within 24 hours of leech application to 10 days or more after leech application. Late infections may represent bacterial invasion from colonized necrotic tissue. Based on these observations, we recommend that leech applications be restricted to tissue with arterial perfusion to minimize contamination of necrotic tissue. We also recommend that patients treated with leeches receive antibiotics effective against Aeromonas hydrophila before leech application. Patients treated with leeches and discharged with eschars or open wounds might benefit from oral antibiotic therapy until wound closure. These precautions may minimize or eliminate this complication of leech use.

Adolescent↗
PubMed1992

Postprandial Aeromonas hydrophila cultures and antibiotic levels of enteric aspirates from medicinal leeches applied to patients receiving antibiotics.

Increasing use of medicinal leeches has been accompanied by increasing numbers of reports of Aeromonas hydrophila infections after leech application on or near damaged tissue. We examined the enteric contents of postprandial leeches after their application to patients receiving antibiotics. We found measurable levels of antibiotic in the leech enteric contents, and in leeches applied to patients receiving an antibiotic effective against Aeromonas hydrophila, there was a significant decrease in positive Aeromonas enteric cultures. Suppression of leech enteric bacteria by antibiotic administration to the patient may be an effective strategy to prevent invasive infection by Aeromonas hydrophila as well as bacterial colonization of devitalized tissue that could be the source of late infection. Clinical studies will be required to clarify whether suppression of leech enteric flora results in a decrease in infections associated with leech use.

Aeromonas hydrophila↗
PubMed1992

Recipient vessels for microvascular transplants in patients with hemifacial microsomia.

Hemifacial microsomia is a developmental abnormality involving structures derived from the first and second branchial arches. Microvascular transplants are increasingly being used to improve facial contour in patients with this condition. We have reviewed 9 patients with this abnormality to determine which recipient vessels have been used. In 6 patients, the facial vessels were located and used for flap revascularization. In 3 patients, the facial vessels could not be identified intraoperatively, and the occipital artery and a branch of the external jugular vein were used as recipient vessels. In this series of hemifacial microsomia patients, therefore, the facial vessels could not be located in 3 patients. We recommend that surgeons performing microsurgical transplants in cases of hemifacial microsomia be prepared to explore the external carotid and external jugular systems for recipient vessels.

Face↗
PubMed1992

Arterial supply of the anterior ear.

Twenty cadaver auricles were injected with a latex solution to define the arterial supply of the anteroauricular surface. Two arterial networks exist, the network of the triangular fossa-scapha and the network of the concha. Both eventually communicate on the anthelix. The triangular fossa-scapha network originates from one subbranch of the upper auricular branch of the superficial temporal artery and from branches of the posterior auricular artery that come through the earlobe and triangular fossa and over the helical margin. The conchal network is provided by two to four perforators that come from the posterior auricular artery, piercing the conchal floor. Auricular branches of the superficial temporal artery in the preauricular region and their communications with the posterior auricular artery also were confirmed. We believe that a greater understanding of the detailed arterial anatomy in this area allows one to develop safely a variety of surgical techniques for reconstruction of the ear.

Arteries↗
PubMed1992

Improved salvage of complicated microvascular transplants monitored with quantitative fluorometry.

Quantitative fluorometry has been used to monitor circulation in transplanted toes and cutaneous flaps in our unit since 1982. Analysis of 177 uncomplicated transplants monitored by quantitative fluorometry shows that this technique has low false indication rates for arterial occlusion (0.6 percent of patients) and venous occlusion (6.2 percent of patients). None of these patients was reexplored because of a false monitor reading, and except for single abnormal sequences, monitoring appropriately indicated intact circulation throughout the postoperative period. Quantitative fluorometry has correctly indicated vascular complications in 21 (91.3 percent) of 23 transplants over an 8-year period. The salvage rate (85.7 percent) of the fluorescein-monitored reexplored transplants was significantly higher than the salvage rates of similar reexplored transplants not monitored with fluorescein and of reexplored muscle flaps (which cannot be monitored with the fluorometer used at this unit). These clinical data indicate that quantitative fluorometry is a valid and useful postoperative monitor for transplanted toes and cutaneous flaps.

Fluorometry↗
PubMed1992

Hand reconstruction with partial toe and multiple toe transplants.

Microsurgical transplantation of toes to the hand can serve as an excellent method of reconstructing the severely traumatized hand. This article reviews the authors' experience with 188 great-toe and second-toe transplants. Detailed operative sequence and postoperative care are also discussed.

Finger Injuries↗
PubMed1992

Thumb and finger reconstruction by toe-to-hand transfer.

Toe transplantation provides a means of restoring a thumb or finger in a single microsurgical procedure with tissues anatomically similar to those lost or absent. Although formidable, these toe transplantation procedures can be accomplished by experienced teams of microsurgeons with a high rate of success.

Female↗
PubMed1992

Muscle flap monitoring in a rat model with a variable gain quantitative fluorometer.

A variable gain dermofluorometer with a wide range of sensitivities capable of quantifying fluorescein emission from both skin and muscle was tested in a rat latissimus dorsi island muscle flap model. Quantitative fluorometric readings directly from muscle and skin sites that did not undergo surgery were taken at intervals over 2 hours after intravenous fluorescein injection. Muscle flaps with intact pedicles gave an inflow-outflow pattern. A no-outflow pattern was seen in muscle flaps with ligated pedicle veins and a no-inflow pattern was seen in muscle flaps with ligated pedicle arteries. These patterns were similar to the flow pattern seen with quantitative fluorometric monitoring in flaps with cutaneous components. These results suggest that quantitative fluorometry may be applicable to circulation monitoring in muscle flaps.

Animals↗
PubMed1991

Microvascular transfer of anterior and posterior gracilis muscles in rats.

A microvascular free muscle flap in rats using the anterior and posterior gracilis muscles with femoral vessels as its pedicle is presented. The gracilis muscles form a single unit supplied by the muscular branch artery and vein, averaging 0.3 mm and 0.4 mm in diameter, respectively. These small sizes preclude their use in transplantation. However, the muscular branch vessels in continuity with the femoral vessels can be used for the vascular pedicle in this muscle transplant. This muscle flap was transplanted to the contralateral femoral vessels by end-to-end anastomosis in 15 rats. Thirteen animals survived and 11 flaps were viable at 3 days for a success rate of 85%. The gracilis flaps averaged 674 mg in weight, 1.87 cm X 1.36 cm in size, and 7.23 mm in pedicle length. This free muscle flap model is reliable, relatively easy to perform, and provides adequate muscle bulk for pharmacologic and biochemical studies in transplanted muscle. No lower extremity complications were noted following femoral vessel ligations.

Anastomosis, Surgical↗
PubMed1991

Microsurgical tissue transfer in patients more than 70 years of age.

Between 1982 and 1989, three women and seven men older than 70 years of age underwent elective free-tissue transfer. Nonhealing wounds of 1 scalp, 2 upper extremities, and 7 lower extremities were covered with 3 serratus anterior, 3 latissimus dorsi, 2 gracilis, and 2 lateral arm flaps. Major coincidental medical problems included hypertension, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitus, metastatic lung cancer, tachyarrhythmias, syncope, elevated liver function tests, and previous arterial bypass in the affected lower extremity. One flap failed and 2 others were compromised by venous thromboses but salvaged by reoperation. There were no major anesthetic complications. This series demonstrates that elective free-tissue transfers can be safely performed in patients older than 70 years of age.

Age Factors↗