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Biomedical subjects

R Sherman

Publications and source records attributed to R Sherman.

At least 37 records · Page 2Linked to original sources
PubMed1997

Quantitative evaluation of the effects of gravity and dependency on microvascular tissue transfer to the lower limb, with clinical applications.

The authors have attempted quantitatively to evaluate the effects of gravity and dependency on free-tissue transfers to the lower limb, particularly in the immediate postoperative period, using the diagnostic modalities of Doppler ultrasonography and interstitial compartment pressure measurements. Results of these quantitative evaluations promoted a change in postoperative management among patients undergoing lower-limb tissue transfer. The experience in two patient cohorts is presented.

Adult↗
PubMed1997

Salvage of the septic ankle with concomitant tibial osteomyelitis.

Five patients with concomitant distal tibia osteomyelitis and ankle sepsis with an open, draining wound were treated. All of the patients were men with an average age of 54.8 years. All of the bone infections were polymicrobial and had open draining wounds. A standardized protocol of radical soft tissue and bone debridement, soft tissue transfer, intravenous antibiotics, and delayed ankle fusion was employed. All five fusions were successful on first attempt, with an average time to fusion of 3.5 months. All patients were free of infection at an average follow-up of 27 months. We believe our aggressive treatment protocol can salvage these extremities and preclude amputation in properly selected cases.

Adult↗
PubMed1997

Soft-tissue coverage for the elbow.

Coverage of soft-tissue defects about the elbow ranges from direct wound closure to free tissue transfer. Early split thickness skin grafting is vital to preserving range of motion in burn patients. Useful regional flaps include the flexor carpi ulnaris, brachioradialis, lateral arm, and radial forearm. The latissimus dorsi is the primary distant pedicled flap with great potential for use as a functionalized transfer. Other often used free flaps include the parascapular and scapular flaps, rectus flap, and gracilis flap.

Elbow↗
PubMed1997

Torsion of the gallbladder: a case report and review of the literature.

Acute torsion of the gallbladder is a rare and poorly understood entity. Since it was first described by A.V. Wendel in 1898, approximately 300 cases have been reported in the literature. The treatment of choice remains immediate cholecystectomy, and most cases are diagnosed intraoperatively. There are typical clinical and radiological findings consistent with torsion of the gallbladder that should raise the index of suspicion for this condition preoperatively. We present a case of gallbladder torsion and discuss the pertinent literature. A re-emphasis is placed on the salient clinical features, and the availability of diagnostic tests is stressed. Given the possibility of laparoscopic cholecystectomy and the increasing incidence with which gallbladder torsion is being witnessed today, the importance of a preoperative suspicion is discussed.

Aged↗
PubMed1996

Complex translocation [7;22] identified in an epithelioid hemangioendothelioma.

We describe a malignant epithelioid hemangioendothelioma arising in the back of a 45-year-old man with pulmonary and bone marrow metastases. Light microscopic and immunohistochemical features of this tumor are presented. Karyotyping revealed several clonal abnormalities: a complex unbalanced translocation [7;22] involving multiple breakpoints (confirmed by fluorescence in situ hybridization), a Robertsonian t(14;14), and loss of the Y chromosome. Monosomy for chromosome 11 was noted in a subset of the tumor cells. To our knowledge a karyotype has not been previously reported for this unusual vascular tumor.

Bone Neoplasms↗
PubMed1996

The limited value of preoperative angiography in microsurgical reconstruction of the lower limb.

Biplanar angiography has been a prerequisite in microvascular reconstruction of the lower extremity. While defining arterial anatomy, the procedure is not without morbidity. More important, angiography does not determine the acceptability of arterial blood flow through a particular recipient vessel. The purpose of this study was to evaluate the safety of microvascular tissue transplantation for reconstruction of complex lower-limb wounds, without preoperative angiography. A consecutive series of 48 patients undergoing tissue transplantation for complex wound reconstruction during a recent 8-month period is presented. Sixty percent of patients had soft-tissue wounds classified as Gustilo IIIB preoperatively, although 89 percent of wounds ultimately arose from trauma. Preoperative and intraoperative clinical assessment of recipient vessels allowed successful reconstruction in all but one case. The only loss of a transplant arose as a result of venous outflow obstruction, a situation not to be improved by preoperative angiography. In no instance was a patient explored and reconstruction deferred due to inadequate recipient vasculature. The results of this study support microvascular tissue transplantation to lower-limb wounds without preparatory angiography in almost all circumstances. Adequate clinical parameters are presented for determining recipient pedicle status, both preoperatively and intraoperatively.

Adolescent↗
PubMed1996

Malignant clival chordoma with postoperative cutaneous metastases.

The authors report the case of a chordoma with malignant cytologic features, presenting as a mass lesion in the clival and infratemporal region at the level of the craniocervical junction in an 8-year-old female. Following gross resection of the mass, the patient subsequently developed distant subcutaneous and peritoneal metastases from the lesion. The rare histologic features, the surgical approach to the lesion, and the follow-up management of this unique case are discussed.

Case Reports↗
PubMed1996

Zone of injury: a valid concept in microvascular reconstruction of the traumatized lower limb?

Microvascular reconstruction at the lower extremity for complex composite wounds has traditionally been predicated upon performance of the microanastamosis beyond the so-called "zone of injury." Failure to do so was believed to account for increased rates of vessel thrombosis and transplant loss. Extensive vessel dissection and vein grafts were often employed in efforts to avoid the zone of injury. To further analyze the validity of this concept, we conducted a prospective evaluation of all patients undergoing microvascular reconstruction of composite lower limb wounds during a 5-month period at Los Angeles County Medical Center. There were 28 patients in this cohort. Twenty-six (93%) were judged Gustilo IIIB or worse preoperatively. Distance from the microanastamosis to the proximal bony osteotomy (zone of injury) averaged 45.7 mm. In no case was a vein graft required. All transplants healed uneventfully without any loss. A reassessment of the concept of zone of injury is urged with analysis of the quality of the recipient vessels and not their location being clinically important.

Adult↗
PubMed1995

Results of bone grafting for infected tibial nonunion.

Thirty-two patients with infected tibial nonunions were treated, including 24 men and 8 women whose ages ranged from 21 to 72 years (mean, 40 years). Thirty of 32 patients had bone defects < 3 cm. Using the Cierney-Mader classification of osteomyelitis, 11 of 32 (35%) patients were Stage 4A, and 21 of 32 (65%) patients were Stage 4B. All patients had irrigation, debridement, and stabilization using an external fixation device. Twenty-seven (84%) patients had muscle transfers. The time between initial debridement and muscle transfer ranged from 3 to 24 days (mean, 4 days). Bone grafting was performed between 6 weeks and 8 months (mean, 8 weeks) after soft tissue coverage. Patients received intravenous antibiotics for 2 to 6 weeks (mean, 6 weeks). Twenty patients received anterior grafting, 10 received posterolateral grafting, and 2 received both. Followup times ranged from 12 to 49 months (mean, 28 months). Twenty-nine of the 32 (91%) patients had tibial unions between 3 to 10 months (mean, 5.5 months) after bone grafting. The 3 failed tibias united after posterolateral grafting. Infection was controlled in all 32 patients. Autogenous cancellous bone grafting using infection control principles is an effective means to treat infected tibial nonunions.

Adult↗
PubMed1994

Two-dimensional echocardiogram in hemodynamically stable victims of penetrating precordial trauma.

UNLABELLED: Hemodynamically stable patients with penetrating precordial trauma present a diagnostic dilemma. Previous reports utilizing subxiphoid pericardial windows as the diagnostic measure demonstrated negative rates ranging from 75-82%. In an effort to decrease the high rate of negative invasive procedures, the following study was undertaken. PROTOCOL: All hemodynamically stable victims with penetrating precordial trauma were evaluated using emergent echocardiogram over a one year period at Grady Memorial Hospital. If the echocardiogram was negative for the presence of pericardial fluid, the patient was observed for 24 hours. If pericardial fluid was detected, the patient underwent a subxiphoid pericardial window. Patients requiring immediate surgery for other reasons, i.e. peritonitis, underwent a pericardial window during the procedure without preoperative echocardiogram. RESULTS: Fifty-three patients were entered into the study. The injuries sustained included 40 stab wounds, 11 gunshot wounds and 2 shotgun injuries. Two echocardiograms (8%) demonstrated > 20cc of fluid and were followed by pericardial windows. The remaining 51 patients did well without the need for pericardial window. Nine additional hemodynamically stable patients underwent pericardial windows without preoperative echocardiograms. Only one of these was positive with a cardiac injury proven at sternotomy. CONCLUSION: Echocardiogram is a sensitive noninvasive method of evaluating hemodynamically stable victims of penetrating chest wounds in proximity to the heart.

Adolescent↗
PubMed1993

Cellular responses to silicone and polyurethane prosthetic surfaces.

Prosthetic devices composed of silicone or polyurethane are commonly used in surgery. These devices elicit a soft tissue reaction which may frequently be complicated by capsule formation. Histologically the capsule comprises both cellular (fibroblasts and endothelial cells (EC)) and matrix components (predominantly collagen type I). We hypothesized that the function of the cellular elements is altered by exposure to prosthetic materials and that this alteration contributes to capsule formation. To test this hypothesis, we utilized specific in vitro assays of cell function (attachment, proliferation, matrix gel contraction), which closely mimic in vivo cellular events, in order to define the responses of EC and fibroblasts to prosthetic surfaces (foam polyurethane, flat silicone, and textured silicone). Morphologic changes were evaluated by scanning electron microscopy (SEM). Attachment of both cell types to all prosthetic surfaces was significantly decreased compared to control (HUVEC: control, 55 +/- 1; foam polyurethane, 19 +/- 4*; flat silicone, 25 +/- 3*; textured silicone, 36 +/- 1*; fibroblast: control, 93 +/- 6; foam polyurethane, 21 +/- 4*; flat silicone, 57 +/- 5*; textured silicone, 44 +/- 5* (*P < 0.05 = significant; units, percentage spread)). Fibroblast proliferation was significantly decreased on foam polyurethane (0.1 +/- 0.03*) and textured silicone (0.18 +/- 0.05*), but not on flat silicone (0.79 +/- 0.2; control = 0.96 +/- .2). In contrast, HUVEC proliferation was significantly decreased on both silicone surfaces but not on polyurethane (units, cpm/cell; control, 0.26 +/- 0.05; foam polyurethane, 0.15 +/- 0.05; flat silicone, 0.08 +/- 0.03*; textured silicone, 0.02 +/- 0.01*).(ABSTRACT TRUNCATED AT 250 WORDS)

Cell Adhesion↗
PubMed1993

The extended deep inferior epigastric pedicle flap for lower extremity reconstruction.

Large soft-tissue defects of the lower extremity can present a challenging reconstructive problem. The extended deep inferior epigastric pedicle flap is a versatile and reliable flap that can be used for the coverage of complex lower extremity soft-tissue defects as far distal as the knee. We reviewed our 5-year experience with 20 consecutive extended deep inferior epigastric pedicle flaps used to cover lower extremity defects. All wounds, including 4 soft-tissue defects of the knee, were successfully covered. Two minor complications occurred. Flap anatomy, surgical approach, and new refinements in flap design are presented. The indications for the flap and its role in ablative tumor surgery are discussed. This flap has proved to be versatile, easy to raise, and extremely hardy. The ample skin island with its large arc of rotation is well vascularized, healing well even in irradiated wounds, and the flap tolerates both postoperative pressure and radiation.

Adult↗
PubMed1993

Same admission colostomy closure (SACC). A new approach to rectal wounds: a prospective study.

OBJECTIVE: The purposes of this project were to study the healing of protected rectal wounds (RWs) using contrast enemas (CEs) and to establish the safety of same admission colostomy closure (SACC) in terms of colostomy closure (CC) and rectal wound-related outcomes, for selected patients with radiologically healed RWs. SUMMARY BACKGROUND DATA: Traditional treatment of RWs has included a diverting colostomy that is closed 2 or more months later during a readmission. METHODS: All patients admitted with a rectal injury were entered into this prospective study, treated with a diverting colostomy and presacral drainage, and managed according to a postoperative protocol that included a CE per anus to detect healing of the RW. Patients with no leaking on their first CE, no infection, and anal continence underwent SACC. RESULTS: From 1990 to 1993, 30 consecutive patients had rectal injuries, 90% of which resulted from gunshot wounds. The first CE was performed in 29 patients 5 to 10 days after injury. In this group, 21 patients did not and 8 did have leakage from their RWs. The proportions of RWs radiologically healed at 7 and 10 days after injury were 55.2% and 75%, respectively. Sixteen patients with a normal CE underwent SACC 9 to 19 days after injury (mean, 12.4 days). There were two fecal fistulas (2 of 7; 28.6%) after simple suture closure, none (0 of 9) after resection of the stoma with end-to-end anastomosis, and no RW-related complications after SACC. The mean hospitalization time was 17.4 days. CONCLUSIONS: The following conclusions were drawn: (1) CE confirmed healing of RWs in 75% of patients by 10 days after injury; (2) 60% of patients with RWs were candidates for SACC, and 53% were discharged with their colostomies closed; (3) SACC was performed without complications in 87.5% of patients with radiologically healed RWs; and (4) there were no RW-related complications after SACC.

Adolescent↗
PubMed1993

Soft-tissue coverage of the distal third of the leg and ankle.

The treatment of open fractures of the distal third of the leg and ankle region has evolved over the last decade and now focuses on debridement, skeletal stabilization, and free-tissue transfer to correct the soft-tissue deficits. Despite the application of microsurgical techniques, the management of these cases is still plagued by delayed union and nonunion, chronic, infection, and in the worst scenario, late amputation. Emphasis should now be shifted from soft-tissue cover and free-tissue transfer to the more global concept of total wound care and early return to function.

Adult↗
PubMed1993

Soft-tissue reconstruction of the foot and ankle.

Successful reconstruction of the severely injured foot and ankle remains a challenge for the surgeon. Frequently, bone and joint injuries to this area with overlying soft-tissue injuries or losses require the coordinate management by orthopedic and reconstructive specialists. Healthy, well-functioning feet are necessary to perform daily activities. Because of the dense packaging of the specialized interdependent structures of the feet, injuries to this area commonly cause significant (composite) wounds that, if not properly managed, can lead to progressive deformity and disability. Basic principles of wound management, especially those pertaining to open fracture management--wound evaluation, debridement, fracture reduction and fixation, preservation of viable tissues, prevention of infection, early soft-tissue reconstruction, and early bony reconstruction--are applicable in the management of foot and ankle wounds. The unique anatomy of the foot complicates reconstruction by limiting the availability of local tissues. Further reconstructive difficulties arise from the functional demands placed on feet and from the distal relationship of the feet to the rest of the body. Successful reconstruction of the foot is predicated on an intimate knowledge of the unique anatomy of the region, of the functional demands required of the feet, and of reconstructive methods. The simplest appropriate technique for the injured foot that is likely to produce the best outcome should be selected. Reconstructive options from the most simple to the complex include primary closure, healing by secondary intention, grafting, flaps (local and distant), and amputation. As typified by the authors' experience, reconstruction of the soft tissues of the foot and ankle frequently requires more complex methods. Seventy percent of our patients have required free-tissue transfer reconstructions, and an additional 5% have undergone other flap reconstructions.

Amputation, Surgical↗