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Biomedical subjects

Steven L Moran

Publications and source records attributed to Steven L Moran.

27 records · Page 2Linked to original sources
PubMed2005

Enhanced survival using the distally based sural artery interpolation flap.

The reverse sural artery flap is frequently used for reconstruction of the distal third of the leg, ankle, and heel. The major disadvantage of the flap is compression of the pedicle within the subcutaneous tunnel and venous congestion. Others have cited a decrease in this problem by harvesting a midline cuff of gastrocnemius muscle, including more subcutaneous tissue and using a wider-than-usual pedicle. We describe an interpolation flap technique of simply avoiding a subcutaneous tunnel and exteriorizing the pedicle with no other alterations to flap design or elevation techniques. Seven distally based reverse sural artery flaps were performed on ambulatory patients between 2001 and 2002. Venous congestion did not occur in any of the flaps. All patients were ambulatory after surgery and did not require the use of a custom shoe. We conclude that transferring the flap in 2 stages without the use of a tunnel improves the reliability of the flap and eliminates venous congestion.

Adolescent↗
PubMed2004

Free tissue transfer in patients with renal disease.

Several authors have cited renal disease as a risk factor for free flap failure. The authors performed a retrospective analysis of all patients who underwent free tissue transfer with concomitant renal disease, including acute renal failure, end-stage renal disease, chronic renal insufficiency, and functional kidney transplants, to determine what effect renal disease has on flap survival and overall reconstructive outcome. More than 1053 free flaps were examined. Renal disease was identified in 32 patients who underwent 33 free tissue transfers. Average patient age was 57 years (range, 36 to 80 years). Twelve patients (38 percent) were on chronic dialysis (end-stage renal disease), 18 patients (56 percent) had chronic renal insufficiency, and three patients (9 percent) had the diagnosis of acute renal failure at the time of surgery. Three patients in the chronic renal insufficiency group had a functioning renal transplant. Average follow-up was 16 months. Immediate postoperative complications occurred in 14 patients (42 percent of the 33 flaps). Overall perioperative mortality was 3 percent. Within the first 30 days there were two cases (6 percent) of primary flap failure; an additional four legs were lost as the result of complications related to their bypass grafts. There were no primary flap failures after 30 days; however, within the first year after surgery an additional seven limbs were lost as the result of progressive ischemia or infection, and an additional three patients died. This resulted in a 52 percent incidence of major morbidity or mortality during the first year and a 55 percent reconstructive success rate in survivors at 1 year. No significant difference was seen in postoperative morbidity or mortality when comparing the end-stage renal disease group to the chronic renal insufficiency group; however, patients with renal disease and diabetes tended to have poorer outcomes. Renal disease, especially renal disease associated with diabetes and peripheral vascular disease, can be a strong indicator of possible reconstructive failure. The surgeon and patient should be aware of the medical and surgical complications associated with this procedure at the outset.

Acute Kidney Injury↗
PubMed2004

Expression of growth factors in canine flexor tendon after laceration in vivo.

Growth factors, transforming growth factor beta (TGF-beta), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), insulin-like growth factor (IGF), basic fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF), are critical components of the cutaneous wound healing process. Little is known, however, about the expression of these growth factors in normal flexor tendon healing. In this study, we wished to examine which of these growth factors are present at 10 days following tendon injury in a canine flexor tendon repair model. Using immunohistochemical analysis, we found positive staining for all growth factors in both timing groups. TGF-beta was detected around the repair site and proximal to it. PDGF-AA, PDGF-BB and VEGF appeared in the whole tendon section following repair. EGF, IGF and bFGF were not seen in tenocytes but were present in inflammatory cells surrounding the repair site. These findings provide evidence that TGF-beta, EGF, PDGF-AA, PDGF-BB, IGF, bFGF and VEGF are all expressed at 10 days after tendon injury but by different cell types and in different locations. The time course of growth factor expression is an important element in wound healing, and a better understanding of where and when such factors are expressed may help in the development of methods to manipulate this expression, accelerate healing, and reduce adhesions.

Animals↗
PubMed2003

Biomechanics and hand trauma: what you need.

Mutilating hand trauma presents the surgeon with many reconstructive challenges. This article establishes some biomechanical guidelines to help the surgeon evaluate the hand trauma patient. Through a basic understanding of hand biomechanics, the surgeon may access more accurately what motion and function can best be salvaged. By understanding how amputation, fusion, and tendon loss impact on postoperative hand motion, the surgeon can better focus his or her reconstructive efforts to achieve the highest functional outcome for the patient.

Amputation, Traumatic↗
PubMed2003

An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients.

The thoracodorsal vessels have been the standard recipient vessels for the majority of surgeons performing free transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Recently, the internal mammary vessels have been recommended as the first-choice recipient vessels for microvascular breast reconstruction. This approach requires a shorter pedicle length, allows for central placement of flap tissue, and avoids axillary scarring. The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction. The authors performed a prospective trial examining the differences in operative and aesthetic outcomes between each recipient site. A prospective trial of 108 consecutive free-tissue transfers was conducted in 100 patients. The first 60 TRAM flap patients were randomized so that 30 flaps were anastomosed to the internal mammary vessels and 30 were anastomosed to the thoracodorsal vessels, whereas the recipient vessels for the remaining 40 patients were left to the discretion of the surgeon. Of the 40 nonrandomized patients, 10 patients underwent reconstruction using the internal mammary vessels and 30 patients underwent reconstruction using the thoracodorsal vessels. The patients' medical history and hospital course were noted. To evaluate aesthetic outcome, a group of five blinded nonmedical observers and three blinded plastic surgeons graded the reconstructions in the 60 TRAM flap patients for symmetry and overall aesthetic result on a scale of 1 to 5. Blinded practitioners administered postoperative questionnaires to patients regarding recovery time and satisfaction with the aesthetic result. Forty-three flaps were transferred to the internal mammary vessels and 65 were transferred to the thoracodorsal vessels. No significant differences existed between groups with regard to age of preoperative risk factors. Average operative time was 6 hours in each group. Average hospital stay was 5.8 days in each group. Conversion from initial recipient vessel to a secondary recipient site occurred in 12.5 percent of internal mammary reconstructions and 7 percent of thoracodorsal reconstructions. All converted internal mammary cases occurred in left-sided reconstructions and were attributable to problems with the veins. Overall, 20 percent of left-sided internal mammary reconstructions were found to have an inadequate recipient vein. Unusable thoracodorsal vessels were found only in delayed reconstructions, at a rate of 15 percent in the delayed setting. All flaps from converted procedures survived without complications. Average follow-up was 20 months, during which time there was one flap loss in the thoracodorsal group. There were no significant differences in complication rates between groups. Average aesthetic grade was 3.6 in each group. Postoperative recovery time and overall patient satisfaction were not significantly different between groups. Either recipient site can provide for a safe and acceptable result; however, surgeons should be aware of conversion rates and plan appropriately if recipient vessels appear unusable for free-tissue transfer.

Anastomosis, Surgical↗
PubMed2003

TRAM flap breast reconstruction for patients with advanced breast disease.

Transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction in patients with advanced breast cancer is controversial. Management of these patients is often complex and consists of surgical extirpation, postoperative radiation, chemotherapy, and in some cases bone marrow transplantation. Few studies have attempted to examine patient long-term survival and overall satisfaction with the surgical procedure. This study examines one center's experience with patients undergoing breast reconstruction for stage III and stage IV breast carcinoma. A retrospective review was performed of all patients undergoing TRAM reconstruction with stage III or IV breast cancer. Surviving patients and family members were contacted for follow-up. Patients were asked to grade their satisfaction with the reconstructive procedure on a 5-point scale (5 points, extremely satisfied; 1 point, extremely dissatisfied). Postoperative complications and time to return to work were also recorded. During a 10-year period (1991-2000) 21 women underwent TRAM reconstruction for advanced breast cancer. Twenty patients had stage III disease and 1 patient had stage IV disease. Mean patient age was 49 years. A total of 26 TRAM flaps were performed; 5 patients had bilateral procedures. Of the 26 TRAM flaps, 17 were immediate and 9 were delayed, and 20 were free and 6 were pedicled. Follow-up averaged 6.5 years (range, 2-10 years). Postoperative complications occurred in 7 patients and included fat necrosis (N = 3), hematoma (N = 2), cellulitis (N = 1), delayed donor site healing (N = 2), and seroma (N = 1). There were no flap losses. Patients were able to return to normal activities or work at an average of 10.6 weeks. Eleven patients developed recurrent disease. Nine patients (43%) succumbed to their disease during the follow-up period. In these patients the average interval between TRAM reconstruction and death was 3.7 years (range, 1-6.5 years). Eleven patients or surviving family members participated in the patient satisfaction survey. The average satisfaction grade was 4.6 points. All patients would repeat the TRAM reconstruction again. Patients with advanced breast cancer can be considered appropriate candidates for TRAM reconstruction. The results of this study indicate that patients with advanced breast cancer do not have an increased rate of postoperative complications, and they recover within a reasonable time from their surgical procedure despite adjuvant radiation and chemotherapy. Furthermore, the majority of patients are satisfied with their reconstructed breast and postoperative course, and would choose this reconstructive option again.

Adult↗
PubMed2002

Free-tissue transfer in patients with peripheral vascular disease: a 10-year experience.

Advances in free-tissue transfer have allowed for lower limb salvage in patients with significant peripheral vascular disease and limb-threatening soft-tissue wounds. The authors retrospectively reviewed their 10-year experience with free flaps for limb salvage in patients with peripheral vascular disease to assess postoperative complication rates and long-term functional outcome. They identified all patients undergoing free-tissue transfer with significant peripheral vascular disease and otherwise unreconstructible soft-tissue defects. Charts were reviewed for perioperative and long-term outcome. Parameters studied included perioperative morbidity and mortality, flap success, bypass graft patency, ambulatory results, and long-term limb and patient survival. Survival data were analyzed using life-table analysis, Kaplan-Meier survival analysis, and Cox testing. A total of 79 flaps were examined in 75 patients with peripheral vascular disease from July of 1990 to November of 1999. All patients would have required a major amputation had free-tissue transfer not been performed. Mean age was 60 years, average hospital stay was 32 days, and perioperative mortality was 5 percent. Within the first 30 days after operation, there were four cases of primary flap loss, and another two were lost as the result of bypass graft failure (8 percent); five of these cases resulted in amputation. There were no primary flap failures after 30 days. Follow-up ranged to 91 months (mean, 24 months). During this time, another 14 limbs were lost, most commonly because of progressive gangrene and/or infection in sites remote from the still-viable free flap. Using Kaplan-Meier survival analysis, 5-year flap survival was 77 percent, limb salvage 63 percent, and patient survival 67 percent. Sixty-six percent of patients were able to ambulate independently with the use of their reconstructed limb at least 1 year after hospital discharge, although some of these later went on to amputation. Free-tissue transfer for lower extremity reconstruction can be performed with acceptable morbidity and mortality in patients with peripheral vascular disease. Flap loss is low, and limb salvage, ambulation, and long-term survival rates in these patients are excellent.

Follow-Up Studies↗
PubMedDate not supplied

The use of vascularized grafts from the distal radius for the treatment of Preiser's disease.

PURPOSE: To examine the outcome of vascularized bone grafts (VBGs) used for the treatment of Preiser's disease. METHODS: Over a 10-year period (1993-2003) 8 pedicled VBGs were performed as the primary treatment for Preiser's disease. All patients had preoperative magnetic resonance imaging (MRI) scans that confirmed the diagnosis of avascular necrosis of the scaphoid. Bone revascularization was evaluated by examining preoperative and postoperative MRIs. All patients had a reverse-flow pedicled VBG from the distal radius. The average patient age was 40 years and the mean follow-up period was 36 months. Postoperative evaluation included range of motion, grip strength, pain evaluation, and Mayo wrist scores. RESULTS: All MRIs showed evidence of revascularization, with improvement in T2 and/or T1 signal; however, a consistent finding on MRI was incomplete revascularization of the entire proximal pole. Wrist motion averaged 55% of the unaffected side after surgery. Grip strength remained stable. Seven patients had long-term improvement in pain. The average Mayo wrist score was 68, with 1 patient rated as excellent, 1 as good, 5 as fair, and 1 as poor. There was 1 reconstructive failure that resulted in a proximal row carpectomy less than 1 year after the surgery. CONCLUSIONS: In this series VBGs led to reduced pain levels and preserved the radiocarpal wrist motion in most patients. Inability to revascularize the proximal pole of the scaphoid and ongoing wrist arthritis appear to persist despite revascularization attempts. VBGs for Preiser's disease should be limited to patients with early stage disease (Herbert stages I or II) without evidence of radiocarpal arthritis and no evidence of carpal instability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Adult↗