Biomedical subjects
Publications and source records attributed to R L Jacobs.
A descriptive audiometric study was performed on 394 patients hospitalised in the geriatric department of our hospital. The mean age of these patients was 82 years. No significant correlation could be found between hearing thresholds and age of the patients. Eighty-six percent of our patients had a socially handicapping hearing loss.
When presented with an ischemic limb with forefoot necrosis of varying amounts, the surgeon often categorizes the need for amputation into toe, ray, transmetatarsal, below-knee, and above-knee. Adherence to this type of algorithm ensures a primary above- or below-knee amputation rate of 10% to 20%. The utility of the more uncommon amputations advocated here is an increase of limbs deemed eligible for revascularization and limb salvage. Furthermore, delaying the amputations until the vascular supply is normalized maximizes tissue salvage and minimizes prolonged hospitalizations with multiple amputations performed as a prelude to major amputation. Although these amputations are often looked upon as an afterthought by many vascular surgeons, careful execution here is as important to effective limb salvage as any distal bypass procedure.
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PURPOSE: Limb salvage in the presence of ischemic foot necrosis requires revascularization followed by debridement or partial foot amputation. Necrosis extending beyond the toes and metatarsal heads may require the use of unconventional types of amputations. METHODS: Over a 15-year period 2105 ischemic limbs were treated with infrainguinal revascularization. In 98 cases, extensive foot necrosis was than managed with amputations, including 59 modified Chopart, 14 Lisfranc, 17 Pirogoff and 8 Syme amputations. Patients were not allowed to bear weight for several days to weeks. RESULTS: Skin flap necrosis in 14 cases was managed successfully by debridement and skin grafting. Ambulation required the use of a "clamshell" prosthesis and foot spacer. The overall limb salvage rate in this group was 84% (82 of 98). In general, the modified Chopart amputation most frequently produced ambulatory limb salvage and is technically easier to perform than a Syme amputation. Patient satisfaction and long-term ambulatory function was highest with the modified Chopart. CONCLUSION: Ischemic foot necrosis extending beyond the limits of conventional transmetatarsal amputation need not be treated with major amputation. This requires the surgeon to be well versed in the use of less common types of partial foot amputations. Acceptable limb salvage and good functional results may be attained by the motivated patient and surgeon with the use of these procedures in the revascularized limb.
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Reconstructive foot and ankle surgery is a salvage procedure in the deformed neuropathic foot, despite condemnation by some authors. Clinical union and stability was achieved in 91% of the patients, and soft-tissue coverage without skin breakdown was achieved in 100% of the cases. Although one patient had moderate to severe pain in her ankle after operation and was able to do only bed-to-wheelchair transfers, she had good clinical stability, no skin ulceration, and was satisfied overall with the procedure. In addition, a significant component of her pain was believed to be from diabetic neuropathy and not pain that was directly attributable to her reconstructive surgery. All other patients were able to ambulate to some degree. More than half had unlimited use of the affected lower extremity. More than half of the patients had mild or no pain, and all patients had a functional limb. Surgical arthrodesis of the deformed neuropathic foot as a salvage procedure can preserve the limb as a stable functional unit, and create an acceptable alignment of the ankle-foot complex that will promote viability of the overlying soft-tissue structures.
Fifty consecutive heel ulcers were managed in three groups by debridement, split-thickness skin graft (STSG), bypass procedures, and orthotics. Group I consisted of 24 ulcers in patients with diabetes (DM) and peripheral vascular disease (PVD), 14 patients in Group II with DM only, and 12 patients with PVD only (Group III). Healing occurred in 56.5%, 64.3%, and 83.3%, respectively. An average of 2.2 procedures were performed per patient. Follow-up periods were for a minimum of two years or until amputation. Time for complete healing and the number of amputations performed were similar in all groups. Of the diabetics (combined from Groups I and II), a subgroup of 27% required partial excision of the os calcis to facilitate closure. After saline dressing changes, STSG was accomplished over thin granulation tissue. Forty percent of this subgroup healed, 30% remained open, and 30% were amputated. Aggressive management, soft-tissue coverage, and orthotic use can lead to a functional weight-bearing extremity.
When amputation becomes necessary in a patient with peripheral vascular disease, it is important to preserve as much tissue as possible to preserve maximum function. This is especially important because the other extremity may have similar involvement in the future. With appropriate care, an amputation at the Chopart (calcaneocuboid-talonavicular) level can give a good functional result.
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Using a single lateral approach, triple arthrodesis was performed on six cadaveric feet. An attempt was made to obliterate the talocalcaneal, talonavicular, and calcaneocuboid joints. The limbs were subsequently disarticulated to allow for an inspection of the talonavicular, talocalcaneal, and calcaneocuboid joints. An estimate of cartilage and subchondral bone removed from each articular surface was made by a single observer (J.V.B.) by direct visual inspection. Results were as follows: calcaneocuboid joint, 90% of cartilage removed; talocalcaneal joint, 80% of cartilage removed; talonavicular joint, 38% of cartilage removed. Failures at the talonavicular joint were attributed to a poor appreciation of the anatomy of the talar head and poor observation. Complications involved in obliteration of the talonavicular joint from a single lateral approach included: inadvertent division of the talar neck; inadvertent division of the talar head; removal of excessive bone stock; medial skin punctures; and creation of an iatrogenic cut through the talar dome. Therefore, a triple arthrodesis through a single lateral approach, as described by Ryerson, Hoke, and Campbell, cannot be recommended. The talonavicular joint should be approached through an auxiliary medial incision, as recommended by Cracchiolo. This paper documents the experience of a beginner with this operation, and demonstrates the value of using the anatomy laboratory.
Pseudoaneurysm formation is usually associated with laceration, fracture, or iatrogenic arterial injury. However, it may also develop as a result of blunt trauma. We report the case of a pseudoaneurysm of the dorsalis pedis artery after a Lisfranc amputation in an individual with diabetes mellitus, Charcot joint changes in the left forefoot, and atherosclerosis of the distal vessels.
A 60-year-old woman had had recurrent acute migratory pneumonias for 9 months. The results of an evaluation, which included tests for serum precipitins, a transbronchial biopsy, and a bronchial provocation, confirmed a diagnosis of hypersensitivity pneumonitis caused by an Aspergillus species. The findings from gravity air cultures in the home showed a heavy infestation of mold. The installation of electrostatic dust filters in the return ducts of the central air conditioning system resulted in the lowering of mold colony counts to normal levels. This change in the environment enabled the patient to live at home without having the signs and symptoms of hypersensitivity pneumonitis, or a need for medication. Thirty months after the electrostatic dust filters were installed, total mold colony counts were still normal, the patient remained free of the signs and symptoms of hypersensitivity pneumonitis, and serum precipitins could no longer be demonstrated. The results of a bronchial challenge to Aspergillus species, however, remained positive; these positive results suggest that long-term memory immune mechanisms may play an important role in the pathogenesis of hypersensitivity pneumonitis and lessen the importance of precipitins in establishing a diagnosis. We report that electrostatic dust filters may be an effective treatment for patients with hypersensitivity pneumonitis when avoidance of the causative antigen cannot be easily and rapidly achieved.
The clinical, histopathologic and functional consequences of the genetic deficiency of leukocyte Mac-1, LFA-1 and p150,95 were assessed among three affected patients, heterozygotes and unaffected individuals among two generations of a single kindred. Longitudinal assessments of this family afforded the unique opportunity to characterize the natural history of severe periodontal manifestations associated with this disorder. Features uniformly observed among each patient included recurrent, necrotic soft tissue infections, impaired pus formation, delayed wound healing, constant granulocytosis, severe abnormalities of adhesion-dependent granulocyte functions and a profound deficiency (3%-6% of normal) of Mac-1 glycoproteins on granulocyte surfaces. Characteristic features of generalized prepubertal periodontitis including rapidly progressive alveolar bone loss affecting the primary and permanent dentitions (leading to premature tooth loss), recession, clefting and migration in association with intense gingival inflammation were uniformly observed. Biopsies of inflamed periodontal tissues in these individuals demonstrated dense infiltrates of mononuclear leukocytes but a striking absence of extravascular neutrophil granulocytes. Heterozygous family members demonstrated approximately half normal Mac-1 protein expression but no susceptibility to systemic infections and normal, adhesion-dependent leukocyte functions. Prepubescent heterozygotes demonstrated no periodontal manifestations but a 31-year-old heterozygous female exhibited clinical and radiographic features typical of postjuvenile periodontitis. The profound periodontal manifestations recognized in this clinical-pathologic model emphasize the physiologic importance of leukocyte adhesion reactions in defense of the periodontium and further suggest a possible pathologic role for Mac-1 proteins in other forms of early-onset periodontitis.
Osteoid osteoma can be easy to recognize in a classic presentation involving long bones. However, the diagnosis may be difficult when cancellous bone is involved, and surgical exploration may first lead to the diagnosis. A case is presented illustrating this problem.
The allergenicity of edible oils derived from sunflower seeds was investigated in two patients with anaphylactic sensitivity to sunflower seeds. Specific IgE-mediated hypersensitivity to sunflower seed was demonstrated by history, prick skin tests, positive passive transfer skin test, and RAST. Specific IgE directed toward sunflower oil, refined or cold pressed, could not be conclusively demonstrated. The Prausnitz-Küstner reaction with sunflower oils performed with one patient's serum was negative. Although the cold-pressed sunflower oil was found to contain a minute amount of protein, open challenge with the derivative oils resulted in no immediate or delayed reaction in the two patients studied. Sunflower oil ingestion in these patients who were highly sensitive to the parent material proved safe. Nonallergenicity of derivative products needs to be proven for each case.