Biomedical subjects
Publications and source records attributed to J Upton.
"Pacifier polydactyly" is defined in babies with a large edematous postaxial duplication attached by soft-tissue stalks that contain neurovascular elements. These serve in utero as pacifiers. Imminent ischemic necrosis was induced in all three by local trauma. Simple excision is the treatment of choice.
The performance of fructosamine assays in 35 laboratories was assessed over a six month period in 1987. While agreement between laboratories was poor in the range expected in diabetic patients, most laboratories were internally consistent. The interlaboratory differences are largely attributed to the calibration methods used for this test. Fructosamine results from any one laboratory must not be interpreted by comparison with data from other laboratories or the literature. Other common biochemical tests were found to suffer from similar problems, but to a less serious extent.
A latissimus dorsi muscle flap was used to repair a severe traumatic avulsion defect of the dorsum of the foot in a 3-year-old girl. The severed peroneal nerve apparently regenerated across a large gap and spontaneously reinnervated the denervated muscle flap. This resulted in a functional flap as demonstrated clinically and electromyographically. Surgical methods of muscle reinnervation and the influence of neurotrophic factors are discussed.
Motor conduction times of median and ulnar nerves at the wrist were determined in 60 paraplegic male patients. In 30 of the patients (50%), 56 of the 240 nerves studied (23%) were abnormal. The incidence of abnormal conduction times was not reliably correlated with either age or duration of paralysis. The fact that patients a few years after injury had conduction times as severe as patients with long-standing paraplegia, regardless of age, indicates that an early disease process may take place in the patient's hands, although previous authors have reported different findings. Of patients with abnormal conduction times 44% were asymptomatic. Median nerve decompression was performed on these patients when they became symptomatic. Periodic examinations are recommended for all paraplegic patients so that early diagnosis can be made and differentiated from symptoms more proximal in the extremity. Although nerve conduction studies are not recommended for all asymptomatic patients, we now request them more liberally in younger patients with early symptoms to confirm the diagnosis.
A modification of the great-toe-to-thumb transfer is presented, which includes sculpting the transferred toe with removal of soft-tissue pulp and bone from the lateral side of the toe. This modification provides the aesthetic advantages of the wrap-around flap while avoiding problems of bone graft resorption, pulp mobility, and a very difficult dissection. Function in our three patients has been excellent.
At a time when microsurgical reattachment of amputated limbs is commonplace, successful reattachment of total ear amputations is rare. Avulsed vessels, small diameters (0.3 to 0.7 mm), and technical difficulties provide primary obstacles. Three clinical cases of ear reattachments are presented which encompass the clinical spectrum of an uncomplicated success, a salvage of an impending failure, and a late failure due to venous thrombosis. In all cases there was difficulty with identification of vessels, with differentiation of arteries from veins, and in the performance of venous anastomoses. Vein grafts were necessary in two of the three patients. Anticoagulation was essential in alleviating venous thrombosis. Medicinal leeches (Hirudo medicinalis) were used to salvage one case with venous thrombosis. Despite the technical difficulties and long operative times, successful microvascular reattachment of an amputated ear is superior to any other means of reattachment or reconstruction.
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Ischemic necrosis of the occipital scalp followed embolization and surgery for a large convexity meningioma in one of our patients. This complication was successfully managed by free tissue transfer. Suggestions for the prevention of this serious complication are presented.
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Vascularized temporoparietal fascia can be used to cover deficits up to 14.0 X 12.0 cm in the hand or fingers. The tissue is thin, pliable, and has a smooth gliding surface advantageous to tendon function. Through scalp incisions, with meticulous yet straightforward dissection, this fascia can be isolated as a vascular island based on the superficial temporal artery system. Vessels are large and the anatomy is constant. Technique and clinical applications are discussed in detail.
Four cases of squamous cell carcinoma arising from chronic pressure sores in paraplegic and tetraplegic patients are presented and the literature reviewed. These pressure-sore carcinomas are characterized by a shorter latency period and a fulminant clinical course with a very high metastatic rate. Very aggressive treatment including even hemicorporectomy must be considered if a cure is to be achieved.
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Intravenously administered drugs with potentially devastating consequences should be given only by personnel highly knowledgeable regarding the side effects and skilled in intravenous cannulation. A strict protocol should be followed. The earliest signs heralding extravasation should be recognized and infusion discontinued immediately. If extravasation occurs, prompt surgical consultation is necessary. Injection into the volar wrist, dorsum of the hand, and antecubital fossa should always be avoided. Polyethylene catheters are preferable to butterfly needles for administering chemotherapeutic agents. A careful history of the venous problems of patients who require long-term therapy should be maintained in their chart. Ideally, vascular access should avoid these problems.
The temporoparietal fascia is an ideal tissue source for free transfer to distant sites where ultrathin coverage is either desirable or mandatory. The fascia's dependable vascular anatomy facilitates the technical aspects of microvascular transfer by means of its large vessels, ample pedicle, and ability to be grafted on either side. Furthermore, this highly vascular tissue is available in surprisingly large quantities, and its donor scar is hidden in the hair. The authors have found this flap useful (1) in covering exposed bone and tendon without adding unwanted bulk, (2) in providing thin flap coverage or lining in major facial reconstruction, (3) in covering vital structures such as exposed nerves and vessels, (4) in providing neovascularity both as a recipient graft bed and for control of chronic infection, and (5) in reestablishing gliding-tendon mechanisms. The authors have successfully employed this free flap in 15 cases which involved deformities of the ankle, foot, Achilles tendon, forearm, hand, nose, and contralateral ear and scalp. Seven cases are utilized to illustrate the broad application of this unique and versatile free flap.
Demineralized bovine bone blocks and powder were used to reconstruct phalangeal defects created by excision of bulging endochondromas . Bony reconstruction was documented by roentgenography at 9 weeks and by biopsy at 7 months. Follow-up at 22 months has shown stability of the implants, further ossification, and no recurrence of the phalangeal endochondromas . The use of xenogeneic demineralized bone implants promotes induced osteogenesis and rapid healing, avoids harvesting procedures, and offers a potentially unlimited supply of banked material.
Five hundred and eighty birthmarks were reviewed; 356 were hemangiomas and 224 were malformations. Bony alterations occurred in association with only 1 percent of hemangiomas, in contrast with 34 percent of patients with vascular malformations. These alterations in bone development were classified according to size, shape, and density changes. Hypertrophy and distortion were typical of lymphatic malformations. Hypoplasia and demineralization were characteristic findings in the extremity venous malformations. Destructive and intraosseous changes were more commonly noted in the arterial or high-flow lesions. Possible mechanisms of altered skeletal growth include mechanical, physiological, and developmental processes.
A series of 10 microvascular autotransfers of impalpable intraabdominal testes has been reported. The viability rate was 60 percent as determined by growth and size of the transferred testis. Long-term endocrine and fertility studies are needed to determine the function of these gonads. The spermatic vasculature was unpredictable and showed many variations. Indications should be very carefully individualized.