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PubMed1991

Local anesthesia for surgery on the foot: efficacy in the ischemic or diabetic extremity.

The efficacy, risks, and benefits of the use of local anesthesia for surgery on the foot were assessed in 75 patients who underwent 127 procedures with lower calf, ankle, metatarsal-ray, and digital blocks. There were 23 procedures on digits alone, 97 forefoot operations (transmetatarsal amputations, wound debridements, closures, osteotomies, joint resections), six ankle or hind-foot amputations, and one open ankle disarticulation. There were no complications directly related to the use of local anesthesia; specifically, no extension of preexisting infection or ischemia due to injection in the foot. There were three deaths (30-day mortality 4%). The procedures were uniformly well tolerated, even in patients with ongoing myocardial ischemia or severe metabolic disorders. Local anesthesia is a safe and effective method to perform local debridement or amputation of the foot in an ischemic or diabetic extremity.

Aged↗
PubMed1995

Infected lower extremity extra-anatomic bypass grafts: management of a serious complication in high-risk patients.

To determine optimal management and outcome of infected extra-anatomic bypass grafts (EABG), we reviewed 28 patients (19 men and 9 women; mean age 70 years) treated over a 13-year period. Mean follow-up was 42 months. There were 16 axillofemoral (AF), 10 femorofemoral (FF), and two axillopopliteal (AP) grafts. Risk factors included previous prosthetic graft infection in 13 patients, enterocutaneous fistula in two, and mycotic aortic aneurysm in one. Initial management involved complete graft excision in 12 patients, partial graft excision in 10, and nonresectional therapy in six. Failure of nonresectional therapy and partial excision in three patients each required further operative intervention with graft excision. Reconstruction in patients eventually requiring graft excision (n = 25) entailed placement of a new prosthetic AF or AP graft in eight, an autogenous FF graft in five, combined prosthetic AF and autogenous FF bypass in two, autogenous iliofemoral bypass in one, obturator bypass in one, or no reconstruction in eight. Four autogenous FF reconstructions thrombosed immediately postoperatively, and three prosthetic reconstructions became infected. The mortality rate was 18% (FF = 20%, AF = 19%, AP = 0%). The amputation rate was 25% (AP = 100%, AF = 25%, FF = 10%) and was higher without arterial reconstruction (56% vs. 12%, p = 0.02). Two patients required hemipelvectomies and one had bilateral hip disarticulation. We conclude that EABG infections can be successfully treated but carry significant morbidity and mortality. Optimal management includes EABG resection and prompt revascularization, bearing in mind the risk of early thrombosis in autogenous grafts and reinfection in prosthetic grafts.

Aged↗
PubMed1998

Circumferential forearm fasciocutaneous free flap reconstruction of forequarter amputation/chest wall resection using simultaneous extra-anatomic revascularization (SEAR).

BACKGROUND: This report describes a technique in which temporary extra-anatomic revascularization of an amputated part was used to preserve a free flap while tumor resection and chest wall reconstruction were performed. METHODS: A patient with multiple local recurrences of basosquamous carcinoma of the shoulder underwent forequarter amputation with en bloc resection of the upper chest wall. During the resection, an elbow disarticulation of the amputated limb was performed. The vascular pedicle of the amputated forearm was joined to the dorsalis pedis vessels of the foot. Following completion of tumor resection and chest wall reconstruction, the forearm was disconnected from the foot and re-anastomosed to thoracic vessels, and a circumferential fasciocutaneous free flap was then harvested and inset. RESULTS: No ischemic flap complications occurred, and the patient recovered well. Ample time was afforded for complete tumor resection with negative margins and prosthetic reconstruction of the chest wall. CONCLUSIONS: The technique of temporary, simultaneous extra-anatomic revascularization of an amputated part for later free flap harvest may be helpful in avoiding potentially long flap ischemia times in selected complex oncologic resections.

Amputation, Surgical↗
PubMed1980

Human cartilage proteoglycans isolated from normally ossifying and congenitally malformed leg bones.

Proteoglycans were extracted with 4 M guanidine HCl solution containing protease inhibitors from various zones of human epiphyseal cartilages of the normally ossifying fibula and cartilaginous rudiment of the tibia of a 12-month-old boy with congenital absence of the tibia, when the knee disarticulation was performed. All the proteoglycan preparations from the epiphyseal cartilages were separated with a sucrose density gradient centrifugation into two components: a heavy, major component and a light one. The molecular size and the proportion of isomeric chondroitin sulfates of polysaccharides of the heavy component differed from those of the light one. The relative amounts of isomeric chondroitin sulfates in the polysacharide moieties of the components also varied among these zones. The glycosaminoglycan content in the rudimentary tibia was equal to that of the epiphyseal cartilage of the fibula. However, proteoglycan preparations showed neither the normal sedimentation profile with two peaks nor the zonal differences as to the proportion of isomeric chondroitin sulfates. These results suggest that the alterations in proteoglycan metabolism might be involved in the pathogenetic mechanisms producing the congenital limb defect.

Cartilage↗
PubMed1984

Delayed antemortem diagnosis of adenocarcinoma of the cecum presenting as lower extremity gas gangrene.

The rare entity of nontraumatic metastatic gas gangrene is commonly associated with occult gastrointestinal malignancies. Normally the patient's course is fulminant, with rapid demise prior to ascertaining the correct etiology at autopsy. An unusual case is presented in that 65 days following hip disarticulation for gas gangrene the diagnosis of colonic cancer was appropriately suspected and then proven.

Adenocarcinoma↗
PubMedDate not supplied

Airway management after upper cervical spine injury: what have we learned?

PURPOSE: Survival after atlanto-axial-occipital ligamentous injury is uncommon and experience with the immediate clinical management of these patients is similarly low. There has been considerable work published recently with respect to airway management in similar patients and a review of this material was undertaken. METHODS: Medline searches were performed to seek out the English language literature using the key words and phrases: cervical spinal injury; atlanto-occipital dislocation; atlanto-occipital disarticulation; and airway management after spinal injury. The titles were culled for materials relevant particularly to upper cervical spinal injury, these were obtained and reviewed. The bibliographies of these articles were searched to ensure that the review would be complete. RELEVANT FINDINGS: The majority of cervical spinal movement occurring during direct laryngoscopy is concentrated in the upper cervical spine. The magnitude of movement during airway management rarely exceeds the physiological limits of the spine. Movement is reduced by in-line immobilization but traction forces cause clinically important distraction and should be avoided. Indirect techniques for tracheal intubation cause less cervical movement than does the direct laryngoscope. Survival after severe upper ligamentous injury is uncommon but intact survival occurs. Missed diagnosis is common and associated with a high incidence of severe secondary injury. Failure to immobilize the spine is deemed to be the most relevant factor in secondary injury. CONCLUSIONS: Patients who survive severe upper cervical ligamentous injury and present to hospital are uncommon. However, of those who do, both intact survival and survival with limited neurological sequelae do occur. Meticulous airway care with maintenance of alignment and provision of continuous cervical immobilization are an integral component of care in these patients.

Adult↗
PubMed2006

Microsatellite mapping of the genes for brittle rachis on homoeologous group 3 chromosomes in tetraploid and hexaploid wheats.

The brittle rachis character, which causes spontaneous shattering of spikelets, has an adaptive value in wild grass species. The loci Br1 and Br2 in durum wheat (Triticum durum Desf.) and Br3 in hexaploid wheat (T. aestivum L.) determine disarticulation of rachides above the junction of the rachilla with the rachis such that a fragment of rachis is attached below each spikelet. Using microsatellite markers, the loci Br1, Br2 and Br3 were mapped on the homoeologous group 3 chromosomes. The Br2 locus was located on the short arm of chromosome 3A and linked with the centromeric marker, Xgwm32, at a distance of 13.3 cM. The Br3 locus was located on the short arm of chromosome 3B and linked with the centromeric marker, Xgwm72 (at a distance of 14.2 cM). The Br1 locus was located on the short arm of chromosome 3D. The distance of Br1 from the centromeric marker Xgdm72 was 25.3 cM. Mapping the Br1, Br2 and Br3 loci of the brittle rachis suggests the homoeologous origin of these 3 loci for brittle rachides. Since the genes for brittle rachis have been retained in the gene pool of durum wheat, the more closely linked markers with the brittle rachis locus are required to select against brittle rachis genotypes and then to avoid yield loss in improved cultivars.

Chromosome Mapping↗
PubMed2004

Gastroliths in Yanornis: an indication of the earliest radical diet-switching and gizzard plasticity in the lineage leading to living birds?

Yanornis martini is an Early Cretaceous basal ornithurine bird. Its fish-eating diet was previously recognized from a discrete mass of disarticulated fish remains discovered in its abdominal region. A new complete and articulated specimen of Yanornis martini preserves abundant in-situ gastroliths such as have been associated with a herbivorous diet. We suggest that the occurrence of gastroliths in this specimen, fish remains in a second, and the lack of gastroliths in three others, is consistent with diet-switching in Yanornis martini. Incompatibility of the preserved data with explanations of the grit as an artifact of preservation or result of accidental ingestion is discussed. This discovery indicates the earliest presence of intermittent diet change (and associated gizzard plasticity) observed in extant birds seasonally and in response to changes in available food sources.

Animal Feed↗
PubMed2006

Predictive value of 99mTc-sestamibi scintigraphy for healing of extremity amputation.

PURPOSE: Although various non-invasive procedures have been proposed to determine the optimal level of amputation of limbs in patients who have vascular disease, currently there are no consistent criteria that can be applied before surgery. The purpose of this study was to determine whether (99m)Tc-sestamibi imaging can accurately predict the healing of amputation sites. METHODS: In a prospective study in 26 patients (21 men, 5 women; age range 23-94 years) presenting with ulcers or gangrene of the foot and hand, (99m)Tc-sestamibi imaging was performed preoperatively. The indications for amputation included gangrene (23 patients), electrical injury (2 patients) and trauma (1 patient) of extremities. Although the amputation levels were chosen according to clinical criteria and scintigraphic results, the final amputation level was defined by scintigraphic results. Two below-knee, one above-knee, 12 toe, 11 transmetatarsal, two phalanx, one finger and one thumb amputations and one shoulder disarticulation were performed. In four cases, the amputation defect was not suitable for coverage using a local dermal flap; rather, it was covered with free tissue transfer. Patients had clinical follow-up for 6-36 months (mean 11.69 months) to assess healing of the stump. Scan results were compared with clinical outcome to assess prediction of healing. RESULTS: There was healing in all amputations at the end of the follow-up period. When evaluated regarding preoperative (99m)Tc-sestamibi uptake pattern, there was no perfusion to the lesion site in 21 patients and perfusion to an area smaller than the extent of skin necrosis in four patients; thus, in these 25 patients, (99m)Tc-sestamibi scintigraphy suggested non-viable tissue in the extremities with clear-cut edges of perfused muscle tissue. Diffusely decreased uptake was seen below the left knee in one case. How scintigraphy changed management was analysed. The amputation levels proposed before scintigraphy were divided into two groups, "definite" (n=14) and "indefinite" (n=12), based on visual examination and Doppler findings. In nine patients in the definite group, the proposed amputation level before scintigraphy was not altered by the scintigraphic data. However, (99m)Tc-sestamibi scan enabled unnecessarily high amputation levels to be avoided in 12 patients in the indefinite group and in five patients in the definite group. Therefore, there was change in management of 65% of cases based on scintigraphic findings. CONCLUSION: Since healing of the stump was seen in all cases, outcome was correctly predicted by scintigraphy. This preliminary study supports the use of (99m)Tc-sestamibi scan in selecting the optimal amputation level consistent with subsequent stump healing.

Adult↗
PubMed2003

Discomallear and malleomandibular ligaments: anatomical study and clinical applications.

Phylogenesis, ontogenesis and anatomy show the existence of two discomallear and malleomandibular ligaments, arising from the first branchial arch and uniting the middle ear with the temporomandibular joint and to the mandible. The intra-articular discomallear ligament is the involuted tendon of the lateral pterygoid muscle on the primitive quadrato-articular joint. The malleomandibular ligament is the fibrous remnant of Meckel's cartilage. In the physiology of the temporomandibular joint, the discomallear ligament alone limits the anterior movement of the disc. Its stretching accompanies disco-condylar disunity, hyperlaxity and temporomandibular dislocation. The malleomandibular ligament, wrongly limited to its sphenomandibular part in classic anatomy, has no physiological role. However, it can be responsible for the dislocation of the ear ossicle chain after disarticulation or temporomandibular trauma. These two ligaments do not play any role in otological manifestations in dysfunction of the manducatory apparatus.

Humans↗
PubMed2000

Short-TE projection reconstruction MR microscopy in the evaluation of articular cartilage thickness.

The aim of this study was to assess the potential of projection-reconstruction (PR) MR microscopy in the accurate measurement of cartilage thickness. Short-TE PR microimages were acquired at 7.05 T on bone-cartilage cylindrical plugs excised from four regions of two disarticulated femoral heads (i. e. superior, inferior, posterior and anterior), using an NMR instrument equipped with a microimaging accessory. The PR microimages were then correlated with conventional spin-echo (SE) microimages and with histology. On PR microimages, acquired with an echo time of 3.2 ms, the cartilage signal was increased, allowing an accurate delineation of the cartilage from the tidemark/cortical bone region. As a consequence, by the PR method a more precise measurement of cartilage thickness compared with that performed by the conventional SE approach was feasible. An excellent correlation between PR microimages and histology was also obtained (r = 0.90). By the proposed method it is possible to accurately determine the cartilage thickness better than with the conventional SE sequences.

Aged↗
PubMed2002

Resection replantation of the upper limb for aggressive malignant tumors.

Stage IIB malignant tumors of the upper limb have been traditionally treated by amputation or disarticulation. There have been isolated reports on the technique of segmental resection of the tumor-bearing segment complete with the skin, and replanting the distal arm or forearm with or without neurovascular repair. The present paper describes four cases in which a wide resection margin was achieved in all by resecting the affected cylinder of the limb. Functional reconstruction was performed by appropriate tendon transfer. The main vessels and nerves were dealt with according to the findings revealed by preoperative investigations. If they had to be sacrificed, end-to-end suture was performed, but if the main nerves could be spared, it greatly enhanced the functional outcome. Local and systemic recurrences occurred in one case, and systemic recurrence occurred in another case. The other two cases remained disease-free at more than 4 years' follow-up. This operation is as radical as amputation, while the esthetic and functional results are equivalent to those of resection-arthrodesis.

Adolescent↗
PubMed1999

Mandibular neuralgia due to anatomical variations.

In our large collection of macerated human adult skulls and disarticulated skulls of young individuals we found cases with an extremely large lateral lamina of the pterygoid process. The medial wall of the infratemporal fossa was defined as its formation by the lateral lamina of the pterygoid process and the medial pterygoid muscle. The muscular part formed two-thirds and the lateral lamina one-third of this wall. In cases of a very large lateral lamina in our specimens nearly the whole medial wall was osseous. The third portion of the trigeminal nerve gives off the lingual nerve and alveolar mandibular nerve in the region of the infratemporal fossa. These two nerves generally passed between the lateral and medial pterygoid muscles to their terminal sites. In cases of extremely large lateral laminae the nerves had to make a curve in their course, following the shape of the enlarged lamina. During contraction of the pterygoid muscles both nerves can be compressed. Since the lingual nerve runs between muscular elements, tension and compression is probably avoided. In contrast, the mandibular nerve fixed between the oval and mandibular foramina cannot avoid tension and compression. The result is possible pain, especially during chewing, and may finally create a trigeminal neuralgia. Similar symptoms could be provoked by a foramen pterygospinale or ovalis canal replacing the foramen ovale.

Adolescent↗
PubMed2005

Dedifferentiated chondrosarcoma--a fatal disease.

BACKGROUND: We report on 13 patients with dedifferentiated chondrosarcomas. The mean age of the patients at diagnosis was 59.8 years. Nine patients were classified as stage IIB and four as stage III. METHODS: In 11/13 cases surgery was performed. Mostly, limb salvage with tumour resection and implantation of a megaprosthesis was done; three patients needed amputation or disarticulation. In one out of three patients with a pelvic tumour resection was followed by implantation of a pelvic replacement; the other two patients received tumour resection with autologous stabilisation of the pelvis. Surgical margins were wide in six patients, marginal in two and intralesional in three. Adjuvant chemotherapy was given to five patients. RESULTS: Recurrence was detected in 5/11 of the patients operated on: in two with wide, in one with marginal, and in two with intralesional resection. No recurrence was seen in 5/11 patients: in four after wide and in one after marginal resection. In one patient the stage was unknown. At follow-up 11 patients were dead of disease (DOD), one dead of unknown reason (DOU) and one alive with disease (AWD). The mean survival time was 9.7 months. Metastasis to different anatomical sites was evident after a period of 10 months. CONCLUSIONS: Our results resemble those reported in the literature. DDCS is rare and is the primary malignant bone tumour with the worst prognosis. Surgery is the most important procedure, although it is unclear whether a radical resection improves the long-term results. Information regarding neoadjuvant and/or adjuvant therapy with chemotherapy is very limited.

Adult↗
PubMed2004

A two-cage reconstruction versus a single mega-cage reconstruction for lumbar interbody fusion: an experimental comparison.

BACKGROUND: Interbody cages are used as an adjunct to anterior lumbar interbody fusion, but exposure and insertion of two cages can be difficult. A biomechanical study was performed to compare the stability and exposed surface for fusion obtained with interbody reconstruction using two traditional cylindrical cages (18-mm diameter) vs. a single expanded mega-cage (24-mm diameter). A single-cage technique could result in safer exposure, shorter operating time, and less cost. METHODS STUDY DESIGN: nondestructive testing of L5-S1 motion segments with cages compared the two configurations, and direct measure of the size of the fusion bed was made. PATIENT SAMPLE: 16 human cadaveric lumbar motion segments. OUTCOME MEASURES: significant differences in motion segment stiffness and cancellous surface areas were compared using a Wilcoxon rank sum test. Motion segments were biomechanically tested intact, and then tested again after insertion of two interbody cages (n=8) or a single mega-cage (n=8). Nondestructive biomechanical loading was performed consisting of: (1) compression (maximum load 900 N); (2) Flexion, extension, left and right lateral bending (maximum moment 18 Nm); and (3) left and right torsion (maximum moment 10 Nm). From the load-deformation curves obtained, stiffness values were calculated to compare the two-cage and the single mega-cage reconstructions. After testing, the specimens were disarticulated and the surface area of the endplate bed created in the cancellous bone (of both vertebrae) was measured to compare the potential vascular surface for osteogenesis with both constructs. RESULTS: The averages of the normalized values of stiffness were significantly greater for the two-cage group as compared to the mega-cage group in flexion only (1.08 vs. 0.74, p<0.05). For extension, torsion and lateral bending there was no significant difference in stiffness. In compression the two-cage group was stiffer, although not significantly (0.92 vs. 0.68, p<0.07). The average cancellous bed surface area was slightly greater for the single-cage reconstruction (1,208 mm(2) vs. 1,155 mm(2)), although this difference was not significant. CONCLUSIONS: The stiffness with a single anterior mega-cage was significantly lower in flexion compared with two standard cages. However, in all other modes of testing the constructs were statistically equivalent, although neither construct was significantly stiffer than the intact specimen. Additionally, the single mega-cage provides an equivalent cancellous bed for fusion as compared to dual cages. While this study is not sufficient to recommend human application, these results and our previous experience with the successful in vivo use of a single cage in rhesus monkeys [4] suggest that the single expanded anterior cage may be an acceptable concept although subsidence risk needs further investigation. The potential advantages of a single mega-cage (safer for the foramen, safer for the vessels, more consistent decortication and possibly cheaper) further suggest that examination should be given to this method as an approach to anterior interbody reconstruction in selected patients.

Aged↗
PubMed2003

Histological and radiological analysis of autoclaved bone 2 years after extirpation.

We examined grafted distal femoral autoclaved bone radiologically and histologically 24 months after surgery. The patient was a 16-year-old boy with osteoblastic-type osteosarcoma in the distal part of the left femur. The patient received pre- and postoperative chemotherapy and underwent limb reconstruction surgery using an autoclaved autograft. He was forced to undergo hip disarticulation because of local recurrence in the soft tissue. Radiologically and histologically, we were able to detect newly formed bone at the site of the distal junction and surrounding the autoclaved autograft, although most of the autoclaved bone remained without substitution even 24 months after implantation. The layer of newly formed bone surrounding the autoclaved autograft was so thin that it seemed to be ineffective for weight-bearing. Drilling into the autoclaved autograft appeared to promote little bone regeneration inside the autoclaved autograft. A bone scintigram showed newly formed bone around the autoclaved autograft, but the scan tended to exaggerate such bone formation beyond that actually confirmed by histological examination. We should be careful when applying autoclaved bone for weight-bearing parts.

Adolescent↗
PubMed2006

Factors affecting perioperative mortality and wound-related complications following major lower extremity amputations.

Major lower extremity amputations continue to be associated with significant morbidity and mortality, yet few recent large series have evaluated factors associated with perioperative mortality and wound complications. The purpose of this study was to examine factors affecting perioperative mortality and wound-related complications following major lower extremity amputation. A retrospective review was conducted of all adult patients who underwent nontraumatic major lower extremity amputations over a 5-year period at a single tertiary-care center in southern West Virginia. Demographic and clinical data, perioperative data, and outcomes were collected and analyzed to identify any relationship with perioperative mortality, as well as wound complications and early revisions (within 90 days) to a more proximal level. Variables were examined using chi-squared, two-tailed t-tests, and logistic regression. Three hundred eighty patients (61% male) underwent 412 major lower extremity amputations during 1999-2003. The initial level of amputation included 230 below-knee (BKA), 149 above-knee (AKA), and one hip disarticulation. Perioperative mortality was 15.5% (n = 59). From a regression model, age, albumin level, AKA, and lack of a previous coronary artery bypass graft (CABG) were independently related to mortality. Patients who did not have a previous CABG were nearly three times more likely to die than those who did (p = 0.038). Overall early wound complications were noted in 13.4% (n = 51). Four factors were independently related to experiencing a 90-day wound complication: BKA, community (rather than care facility) living, type of anesthesia, and preoperative hematocrit >30%. Major lower extremity amputation in patients with peripheral vascular disease continues to be associated with considerable perioperative morbidity and mortality. Even though the surgical procedure itself may not be challenging from a technical standpoint, underlying medical conditions put this group at high risk for perioperative death. Wound-healing problems are frequently encountered and must be minimized to facilitate early mobilization and hospital discharge.

Age Factors↗
PubMed2005

Long-term effects of acoustic trauma on electrically evoked otoacoustic emission.

Electrically evoked otoacoustic emissions (EEOAEs) are sounds measured in the ear canal when alternating current (AC) stimulation is passed into the cochlea. These sounds are attributed to the motile responses of outer hair cells (OHCs). The EEOAE has characteristic amplitude, phase, and fine structure. Multicomponent analysis of the EEOAE shows short (SDC) and long delay components (LDC) that are thought to originate from OHCs near the AC stimulating site and from OHCs at more remote locations, respectively. We measured the effects of various loud noise exposures on the EEOAE and the cochlear whole-nerve action potential (CAP) in animals chronically implanted with a scala tympani electrode. Noise exposures that produced permanent (PTS) or temporary threshold shifts (TTS) were associated with frequency-specific changes in CAP thresholds, EEOAE fine structure, and reductions in the amplitude of the LDC. A frequent observation in this study was an increase in the overall EEOAE amplitude after the noise exposure. The increase was correlated with increased SDC amplitude. The SDC was present in animals chemically treated with ototoxic drugs and mechanical damage to the cochlea. The SDC was eliminated after disarticulation of the ossicular chain. The presence of EEOAE fine structure in the postexposure response is an indicator of TTS in advance of CAP recovery. The results suggest that the EEOAE might be used to differentiate the mechanisms associated with TTS and PTS.

Action Potentials↗