Biomedical subjects
Publications and source records attributed to L S Levin.
Single stage transfer using a compound vascularized flap is sometimes necessary for severe dorsal defects. The use of vascularized tendon grafts in conjunction with the radial artery forearm flap and the dorsalis pedis flap is described.
Endoscopic techniques for surgery of the upper extremity show great promise based on recent discoveries of anatomic tissue planes. These planes can be dissected using new technology consisting of endoscopic balloons that create optical cavities that permit "incisionless" surgery. This article contains a review of the anatomic principles, new surgical technology, and development of endoscopic tools, as well as an example of endoscopic tissue expansion placement for soft-tissue augmentation in the upper extremity. Endoscopic techniques as they relate to fractures, synovectomy, and peripheral nerve decompression are discussed.
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Osteitis pubis is a painful inflammatory process resulting in bony destruction of the margins of the symphysis pubis. Despite six decades of speculation, the pathogenesis of, criteria for diagnosis of, natural history of, and optimal therapy for osteitis pubis remain controversial. We present four cases of postoperative pubic osteomyelitis that were initially thought to be typical cases of osteitis pubis. These cases illustrate that pubic osteomyelitis can mimic the principal features of osteitis pubis including characteristic pelvic pain and gait disturbance, symmetrical bony destruction of the symphysis pubis, absence of fever, a long interval between surgery and onset of symptoms, lack of response to antimicrobial therapy, and apparent spontaneous cure. We believe that many previously reported cases of osteitis pubis were actually cases of unrecognized pubic osteomyelitis. We advise an aggressive diagnostic approach to cases of apparent postoperative osteitis pubis including biopsy and needle aspiration of the symphysis pubis guided by computer-assisted tomography. If cultures of biopsy specimens are not diagnostic, open biopsy of the symphysis pubis is recommended.
Extremity tourniquets are widely used to achieve bloodless dissection in the surgical field. Excision of venous stasis ulcers (VSU) is aided by tourniquet use because of large dilated veins associated with venous stasis disease. We present 3 patients with hypotensive shock occurring 10 to 15 minutes after tourniquet release after excision of venous stasis ulcers. All patients had long histories of venous stasis changes and two-thirds had prior histories of deep vein thromboses and pulmonary embolism. Mean tourniquet inflation time was 34 minutes and there were electrocardiographic changes in two-third of the patients. All patients responded rapidly to standard resuscitation measures and in all 3 postoperative testing for pulmonary embolus and myocardial infarction was negative. Wound cultures revealed no organisms in 1 patient, mixed Gram-positive cocci in another, and greater than 10(5) Serratia marcescens in the third patient. Although small decreases in blood pressure and blood pH, and increases in blood lactate, PcO2, and creatinine phosphokinase, are normally associated with the use of extremity tourniquets, hypotensive shock has not been reported. The combined effect of tourniquet ischemia and venous stasis changes may cause hypotensive shock by (1) an endotoxic bolus upon tourniquet release, (2) pulmonary microembolization of platelet, fibrin, and leukocyte aggregates causing vasoactive substance release, and (3) synergistic effects of platelet-activating factor, a known mediator of endotoxic shock. The untoward events noted in these patients may be prevented by (1) proximal to distal dissection of the ulcer with initial ligation of large veins, (2) pretreatment with steroids and/or platelet-activating factor antagonists, and/or (3) slow release of the tourniquet.
Plastic surgeons are frequently called upon to evaluate wounds in diabetic patients with compromised vascular inflow. Although a few authors have reported success in coverage of such wounds with microsurgical techniques, enthusiasm for this procedure has remained low due to concerns about flap viability, occlusion of flow to the distal limb, and the usually poor systemic status of such patients. We report here on our experience with 19 diabetic patients with peripheral vascular disease and a nonhealing wound of the lower extremity treated over the last 4 years with microvascular tissue transfer. Two patients (10.5 percent) suffered anastomotic difficulties and there was one flap loss (5 percent). Major morbidity rates were acceptable, with only one perioperative death (5 percent) and three cases of nonfatal major systemic difficulties in the immediate postoperative period (16 percent). Despite the importation of well-vascularized tissue, local morbidity at the recipient site was seen in nine patients (47 percent). The overall limb salvage rate was 72 percent during the period of follow-up, which averaged 22 months. Despite this loss of five limbs, all but three of the patients eventually returned to ambulation. The overall death rate in our series was only 2/19 (10.5 percent) over the period of follow-up. Although further work needs to be done in this difficult group of patients to ascertain the long-term benefit (especially relative to the cost/benefit ratio), we feel that this series confirms the safety and short-term efficacy of microsurgical treatment of such individuals.
Analysis of three measures of periodontal health (plaque index, gingival index, and attachment loss) was carried out on 178 individuals in 75 families examined as part of a family study of periodontal health. Original participants in this study were volunteers recruited from the University of Maryland Dental Clinic, and were selected independently of any specific dental disease or condition. Relatives were invited to participate in the family study so that the extent of familial aggregation of indices of periodontal health could be assessed. By means of an analysis of variance model for persons nested within families, evidence for familial aggregation of plaque index was found both before and after adjustment for covariates such as age, gender, race, and reported oral hygiene habits. While a substantial fraction of variance in gingival index and attachment loss was also due to differences among families, neither attained statistical significance in these data. Examination of familial correlations (e.g., parent-offspring, sib-sib, spouse correlations) confirmed that plaque index showed greater familial resemblance compared with other measures of periodontal health. Both mean gingival index and mean attachment loss showed a stronger correlation between mothers and offspring compared with fathers and offspring. This suggests that further analysis of models for separating genetic and environmental effects may be appropriate for plaque index, but complete analysis of other periodontal indices will require more flexible statistical models for separation of genetic and cultural inheritance while considering gender-specific expression and transmission, as well as incorporation of information from covariates.
The reconstructive ladder has many rungs. The reconstructive surgeon may go from one level to another and, in many instances, simultaneously employ different aspects of the ladder for different problems (i.e., a free-muscle transplant to a large lower extremity defect being covered by split-thickness skin grafts uses two rungs on the ladder). Familiarly with local as well as distant tissue options ensures success when the soft-tissue envelope is treated using this reconstructive ladder.
Soft-tissue problems associated with fractures of the calcaneus are common and can present many pitfalls. A classification of soft-tissue problems has been devised to facilitate treatment: Type 1, closed fractures treated by open reduction and internal fixation with an inability to close the skin. Type 2, wound break down after open reduction. Type 3, open fractures of the calcaneus with traumatic large soft-tissue loss but with adequate bone stock. Type 4, traumatic loss of soft tissue and bone. Type 5, calcaneal osteomyelitis. Type 6, chronic unstable soft tissue over the calcaneus. There are various surgical options of skin graft, rotational flaps, and free-tissue transfers that best reconstruct each of these individual problems.
BACKGROUND: Allogeneic bone marrow transplantation is an accepted therapy for hematologic cancer, aplastic anemia, and inherited immunodeficiencies. Chronic graft-versus-host disease (GVHD) is the principal complication in patients surviving more than 100 days. Thalidomide has been shown experimentally to be effective in treating GVHD. METHODS: We treated 23 patients with chronic GVHD refractory to conventional treatment and 21 patients with "high-risk" chronic GVHD (identified as having at least two of the following three risk factors: chronic GVHD that has evolved from acute GVHD, lichenoid skin or mucous-membrane changes, and hepatic dysfunction. Such patients have a high mortality rate.) with thalidomide in a dose that produced a plasma level of 5 micrograms per milliliter two hours after administration. Therapy was continued for three months after a complete response or for six months after a partial response. RESULTS: The overall actuarial survival of all enrolled patients was 64 percent. Survival was 76 percent among the patients receiving salvage therapy for refractory GVHD and 48 percent among those with high-risk GVHD. A complete response was observed in 14 patients, a partial response in 12 patients, and no response in 18. Side effects were minor, most notably sedation in almost all patients. CONCLUSIONS: In this preliminary trial, thalidomide appeared to be safe and effective for the treatment of chronic GVHD. A trial comparing thalidomide with prednisone in patients with newly diagnosed chronic GVHD will be required to demonstrate its relative efficacy.
Between 1976 and 1986, 38 consecutive acute isolated flexor pollicis longus lacerations were repaired. This study excluded all replanted or mutilated digits and all lacerations with associated fracture. Average follow-up was 26 months. Tendon rehabilitation was standardized. Range of motion and pinch strength were measured postoperatively. Seventy-four percent (28/38) of the flexor pollicis longus injuries occurred in zone II. Neurovascular injury occurred in 82% of the lacerations, and this correlated with the zone of tendon injury. In 21% of the patients (8/38) both digital nerves and arteries were transected. Postoperative thumb interphalangeal motion averaged 35 degrees and key pinch strength was 81% that of the uninjured thumb. One rupture occurred in a child. Laceration of the flexor pollicis longus is likely to involve damage to neurovascular structures, and repair may be necessary. Direct end-to-end repairs within the pulley system do at least as well as delayed tendon reconstruction and do not require additional procedures.
Shoulder pathology and its diagnosis must be considered in evaluation of the patient suspected of having thoracic outlet syndrome (TOS). Overlooking usually treatable conditions in the shoulder may lead to unfavorable results, if treatment is directed, instead, to neurolysis of the brachial plexus or first rib resection.
Cystic hygromas are large lymphangiomas that are most often found in the posterior triangle of the neck and the axilla in children. They are most frequently found before age 2 and may be massive. After upper respiratory infection, they may become infected and enlarged, causing dysphagia and toxemia. The diagnosis can usually be made by history and physical examination and confirmed by biopsy. Treatment is by surgical excision of small lesions and staged debulking excisions in more severe cases. A patient with a cystic hygroma having many clinical characteristics of a plunging ranula is presented. The cyst fluid was aspirated and analyzed for its amylase, sodium, potassium, chloride, urea nitrogen, glucose, and total protein content. The characteristics of the fluid were also compared with those of lymph and saliva. This report demonstrates the difficulty in determining the diagnosis of a tumor that has the clinical features of a cystic hygroma, as well as a plunging ranula. The necessity of a proper presurgical diagnosis is essential since the form of therapy for each is different and conflicting. A method that distinguishes between the cervical cystic hygroma and a plunging ranula by means of aspirated fluid is discussed.
Oral mucositis and hepatic veno-occlusive disease (HVOD) are common complications after bone marrow transplantation (BMT). Forty-seven patients were prospectively examined for development of ulcerative oral mucositis (UOM) and HVOD after allogeneic BMT. In 17 patients (36%) UOM developed between 2 days before and 18 days after transplant (median 4 days after BMT). In seven patients (15%) HVOD developed with onset between 3 and 21 days after transplant (median 18 days after BMT). In a time-dependent analysis, in patients given busulfan plus cyclophosphamide or busulfan, etoposide, and cyclophosphamide UOM was 19 times more likely to develop than in patients treated by cyclophosphamide plus total body irradiation or by cyclophosphamide alone (p less than 0.001). Patients in whom UOM developed were 6.5 times more likely to develop HVOD than those in whom UOM did not develop (p less than 0.03). The sensitivity (86%), specificity (73%), and negative predictive value (97%) of UOM to predict HVOD were high, but the positive predictive value (35%) was low. The association of UOM and HVOD support the concept that both are toxic effects of treatment. Patients with hepatic abnormalities but without UOM are unlikely to have HVOD, and other causes of the hepatic dysfunction should be investigated.
A newly described Ro 'sandwich' ELISA was compared to the gel double diffusion technique to detect anti-Ro(SSA) antibodies in Sjögren's syndrome, systemic and subacute cutaneous lupus erythematosus patients. This study demonstrates that the ELISA assay increased the frequency of detection of anti-Ro(SSA) antibodies in these well defined connective tissue disease patients by approximately 5-10% compared to the gel double diffusion anti-Ro(SSA) antibody assay. The study also confirms that some patients make anti-Ro(SSA) antibodies directed solely at unique human Ro(SSA) antigen epitopes. We also detected the existence of a significant Sjögren's syndrome patient population failing to make significant anti-Ro(SSA) antibodies. We conclude from our study that the gel double-diffusion technique employing human spleen extract as a source of the Ro(SSA) antigen is, at present, the most cost-effective test to detect anti-Ro(SSA) antibodies.
Familial adenomatous polyposis is an autosomal dominant disease characterised by the development of hundreds of colorectal adenomas in young adults. Occult radio-opaque jaw lesions and pigmented ocular fundus lesions (formerly called congenital hypertrophy of the retinal pigment epithelium) are extraintestinal phenotypic markers for this disorder. We evaluated the usefulness of the combination of these markers for identifying patients who have inherited familial adenomatous polyposis. Forty three affected patients and 12 unaffected first degree relatives from 24 families with familial adenomatous polyposis, including four families without extraintestinal manifestations, were examined for both phenotypic markers. Thirty three of the 43 patients (77%) with familial adenomatous polyposis were positive for both markers, including patients from two families without extraintestinal manifestations. By contrast, only one of 12 (8%) unaffected first degree relatives over 35 years of age had both markers. The sensitivity of the combination of these markers in identifying patients who inherited familial adenomatous polyposis was 77%, the specificity 92%, the predictive value of a positive test 97%, the predictive value of a negative test 52%, and the efficacy 80%. The combined markers had improved efficacy over either marker alone (70% for occult radio-opaque jaw lesions and 67% for pigmented ocular fundus lesions). We conclude that the presence of both occult radio-opaque jaw lesions and pigmented ocular fundus lesions in a person at risk indicates a high probability of inheritance and expression of familial adenomatous polyposis.
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