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PubMed1997

Reliability of different electronic apex locators to detect root perforations in vitro.

The aim of this study was to evaluate the accuracy of the electronic apex locator Root ZX compared to the Sono Explorer Mark II Junior and Apit III in detecting root perforations. Extracted human teeth (n = 30) were perforated artificially in the middle third of the root and embedded in a box containing alginate. Detection of all perforations were carried out with K-files attached to the apex locators tested. The teeth were radiographed after each electronic measurement. The actual location of the tip of the file in relation to the external root surface and the radiographic determination of the perforations were carried out using a stereomicroscope. The mean distance of the tip of the file from the external outline of the root surface was short for all instruments and clinically acceptable (0.06-0.25 mm). There was no clinically significant difference between the morphometric measurements and the radiographic measurements. No statistical significance was found between large perforations (0.55-0.60 mm) and small perforations (0.25-0.40 mm). Under the conditions of this study, all electronic apex locators tested were acceptable clinical tools in the detection of root perforations.

Analysis of Variance↗
PubMed2001

Perforation complications of percutaneous central venous catheters in very low birthweight infants.

OBJECTIVE: To prospectively survey perforation complications of consecutively inserted percutaneous central venous catheters (PCVC) in very low birthweight (VLBW) infants over a 2 year period. METHODOLOGY AND RESULTS: Three serious perforation complications were encountered in a series of 100 consecutive PCVC. One infant (birthweight 685 g) developed pericardial effusion and fatal cardiac tamponade during the use of a polyurethane PCVC. At autopsy, the pericardial sac contained 8 mL fluid with a glucose concentration of 109 mmol/L and the catheter tip was embedded in the right ventricular wall. The second infant (birthweight 1380 g) showed pleural effusion and transient immobility of the right diaphragmatic leaf after perforation of a similar PCVC into the right pleural cavity. The third perforation, causing subcutaneous oedema, occurred in a 655 g infant who had a silastic PCVC. CONCLUSIONS: The data suggest a 3% incidence for PCVC-associated symptomatic perforation complications and a 1% incidence for fatal perforations, despite a policy of careful placement. The data also indicate that perforation complications occur regardless of the size or material of the PCVC. Proper visualization of the PCVC and vigilant attention to its location is required to prevent these rare but potentially fatal complications.

Autopsy↗
PubMed2001

Incompetent perforating veins are associated with recurrent varicose veins.

AIMS: we suspected incompetent perforating veins of having a role in the development of recurrent varicose veins in some patients. The aim was to look for an association between perforators and recurrent varicose veins. METHODS: a consecutive group of patients presenting with varicose veins were examined using colour duplex ultrasonography by an experienced vascular technologist. Pathological perforating veins were defined as those exhibiting bi-directional flow and a diameter of 4 mm or greater at the fascia. RESULTS: between September 1998 and July 1999, 204 patients were examined. Primary varicose veins were found in 198 legs (135 patients) and recurrent varicose veins in 91 legs (69 patients). In patients with primary varicose veins, 88 (44%) had incompetent perforators compared to 57 (63%) of those with recurrent varicose veins (Chi-squared, p <0.005). Also, for recurrent varicose veins, the percentage of patients with any given number of incompetent perforators was higher than for primary varicose veins. Overall, there was a higher number of incompetent perforators in those with recurrent veins compared to primary veins and this difference was significant at 95% confidence interval. CONCLUSION: patients with recurrent varicose veins have both a higher prevalence and a greater number of incompetent perforating veins than patients with primary varicose veins.

Humans↗
PubMed2000

'Spontaneous' neonatal gastric perforation: is it really spontaneous?

BACKGROUND/PURPOSE: Most historical reports have described gastric perforation in the neonatal population as "spontaneous." More recently, several variables, including prematurity and nasal ventilation, have been implicated as contributing factors. The authors sought to analyze the etiology, course, and outcome of newborns with spontaneous gastric perforation from one institution over a 16-year period. METHODS: The authors reviewed retrospectively the charts of all infants who underwent operation or had perforation of the stomach diagnosed in the newborn period. RESULTS: Among more than 84,000 live births, 7 newborns were identified with perforation of the stomach. Four had coexisting gastrointestinal lesions (2 necrotizing enterocolitis, 1 undiagnosed tracheoesophageal fistula, 1 meconium plug), and 1 received nasal continuous positive airway pressure (CPAP). In only 2 cases were no other gastrointestinal lesions or other presumed contributing factors (nasal CPAP) present, and thus, only 2 cases could be classified as "spontaneous." Mortality rate was 57%. Three of the patients were premature, all of whom died. CONCLUSIONS: Whereas in the older literature, most cases of gastric perforation were considered spontaneous, and were full term, the authors' review of 7 cases over a 16-year period leads us to question the cause as spontaneous. The authors found that prematurity and concomitant gastrointestinal lesions were associated with gastric perforation in the neonate and that few cases truly are spontaneous. The authors suggest that when gastric perforation occurs in neonates, a contributing cause should be sought.

Female↗
PubMed2002

Perforator flaps--the history of evolution.

This article reviews the recent evolution of perforator flaps. The tie between perforator flaps and skin flaps as well as perforator flaps and musculocutaneous flaps is explained. The paraumbilical perforator flap, the deep inferior epigastric artery flap (DIEP flap), the gluteal artery perforator flap (GAP flap) and various perforator flaps and perforator-based flaps are described in combination with the review of the relevant literature. As a prospect into the future, the technique of "supra-microsurgery" is presented.

Arteries↗
PubMed2002

[Individual perforator flaps of the upper extremity].

Perforator flaps allow an individual flap design on the basis of a preoperative ultrasound examination. Aim of the present study is a preliminary evaluation of results and technical pitfalls of this new technique in the use for flap coverage on the dorsum of the hand and the elbow region. Since 1999, seven individually designed pedicled perforator flaps were prepared on the upper extremity. In four cases, defects on the dorsum of the hand and in a further three defects in the elbow region were treated. In the latter cases the flaps were harvested in a mainly epifascial plane, without dissecting the perforating vessels down to their origin. Five flaps were based on perforating vessels of the interosseous arteries, a further two from the lateral collateral humeral artery. Three out of four pedicled perforator flaps used on the dorsum of the hand healed completely. One flap was lost because of venous insufficiency due to the lack of wrist immobilisation. In the elbow region, two out of three defects were successfully covered with an individual perforator flap. One flap was lost due to venous insufficiency, a further needed an additional split-skin graft with a partial flap loss. The main advantage of the presented technique remains the possibility of individual flap design. However, the donor-site defect is almost negligible since in most cases a primary closure of the donor site was possible. The main arteries remained untouched leaving the blood supply to the hand unchanged. Nevertheless, the mainly epifascial harvest of the perforating vessels in the elbow region has the disadvantage of a short pedicle together with a high degree of torsion which leads to an increased risk of flap loss due to venous insufficiency.

Adult↗
PubMed2005

Internal mammary perforators: a cadaver study.

Microsurgeons currently employ the internal mammary artery and vein as recipient vessels for microvascular reconstruction of the breast with increasing frequency. Recent reports have demonstrated that the perforating branches of the internal mammary artery and vein can also be used as recipient vessels. The purpose of the following cadaver study was to determine the location and diameter of these internal mammary perforators and whether they are suitable as recipient vessels. Ten fresh cadavers were obtained for this project. Using a micrometer under loupe magnification, bilateral measurements were taken of the perforators from the first five interspaces. The largest arterial perforator averaged 1.74 mm in diameter and the largest venous perforator averaged 1.78 mm in diameter. The largest perforators were most commonly found in the second interspace. Based on the results of this study, the internal mammary perforators appear to have suitable diameter for microvascular anastomosis and should be considered.

Aged↗
PubMed2001

Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: long-term follow-up.

PURPOSE: Subfascial division of incompetent perforating veins seems to be a successful treatment for patients with venous leg ulceration (CEAP 6). For postoperative wound complications, endoscopic techniques are more common than open subfascial division of incompetent perforating veins (Linton procedure). We investigated the long-term results of ulcer healing and recurrence rates and compared them with preoperative and postoperative duplex findings. METHODS: Patients with venous ulceration on the medial side of the lower leg were randomly allocated to endoscopic exploration or open exploration by means of the modified Linton approach. Ulcer healing and recurrence rates were documented. RESULTS: Thirty-nine patients were randomly allocated to exploration, 19 patients to open subfascial division of incompetent perforating veins (Linton group), and 20 patients to subfascial endoscopic division of incompetent perforating veins (SEPS group). During the follow-up period, four patients in the SEPS group died, all of causes other than the venous leg ulcer. Because of a squamous cell carcinoma that had developed in the venous ulcer, one patient in the SEPS group underwent a below-knee amputation. In a mean follow-up period of 50.6 months, the venous ulceration of all 18 patients in the Linton group who were available for follow-up initially healed. The recurrence rate in this group was 22% (4 patients). In the SEPS group, the mean follow-up period for 19 patients was 46.1 months, with the ulceration healing in 17 patients and a recurrence rate of 12% (2 patients). The presence of deep venous incompetence (DVI) did not influence the recurrence rates (P =.044, Fisher exact test), but it significantly influenced the development of new incompetent perforating veins (3 of 10 without DVI; 7 of 10 with DVI; P =.011, binomial test). CONCLUSION: The long-term follow-up results of the endoscopic division of perforating veins are comparable with those of the open division of perforating veins (modified Linton procedure).

Adult↗
PubMed2002

Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified?

OBJECTIVE: Twenty-five years ago, the senior author showed a 55% postoperative ulcer recurrence rate after open perforator ligation. Those data contributed to a nihilistic attitude toward incompetent perforating veins. Conversely, since the introduction of subfascial endoscopic perforator surgery (SEPS), we have undertaken ablation of superficial and perforator reflux as initial treatment in patients with ulcers (C6) or healed ulcers (C5). This report outlines our long-term results. METHODS: Between December 1994 and November 1999, SEPS was performed on 51 limbs in 45 patients with C5/C6 disease. Sixteen limbs underwent SEPS alone, and 35 had additional surgery on the greater saphenous vein (GSV), the lesser saphenous vein, or the tributary varicies. Data were collected according to the reporting standards in venous disease. Preoperative duplex scan of deep, superficial, and perforating veins was performed. Data were analyzed with Kaplan-Meier method, Mantel-Cox log-rank test, or t test. RESULTS: Of the 51 limbs that underwent SEPS, the GSV was stripped in 28. Twenty-nine were C6, and 22 were C5. Etiology was primary (Ep) in 25 limbs and secondary (Es) in 26 limbs. All limbs had duplex scan evidence of perforator incompetence (Ap), and deep insufficiency (A(D)) was seen in 39 cases (76%). Reflux predominated (P(R)). The clinical follow-up period was 0 to 82 months (median, 38 months). Venous disability scores improved from 9.8 before surgery to 4.2 at last follow-up (P <.05). Kaplan-Meier analysis showed 74% healing at 6 months. The presence of an ulcer more than 2 cm in diameter, secondary etiology, and SEPS without concomitant GSV stripping were associated (P <.05) with delayed healing. Among patients in whom ulcers healed or who were seen with healed ulcers, the 5-year ulcer recurrence rate was 13%. Lesser saphenous vein reflux was the only factor that correlated with increased ulcer recurrence. Deep system reflux as measured with duplex scan valve closure times did not correlate with the rate of ulcer healing or recurrence. CONCLUSION: Nihilism has no place in the management of venous disease in the 21st century. An aggressive approach to superficial and perforating vein reflux in this cohort of patients with C5 and C6 disease resulted in rapid ulcer healing and low 5-year recurrence rates. Prior saphenous vein stripping, large ulcers, and secondary etiology were associated with delayed healing. A less aggressive posture toward lesser saphenous vein reflux contributed to a higher recurrence rate in this subgroup of patients. These risk factors are useful in counseling patients as to their expected postoperative course; however, no combination of factors should a priori preclude surgical intervention in this group of patients.

Adult↗
PubMed1998

Etiology of pediatric perforating eye injuries in southern Turkey.

In the present study, the records of 242 children, aged 1-14 years, admitted with perforating ocular injury were reviewed retrospectively over a 5-year period. There were 175 boys and 67 girls in the study group. The patients were divided into 3 groups according to their ages. Perforating injuries occurred most frequently in the street in all groups. The second most common place of the injury was at home in the 1-9 year-olds and in the fields in the 10-14 year-olds. The cause of the perforation was a metallic substance in 32.6%, wood in 15.3%, stone in 12.0%, glass in 12.3%, pellets in 12%, and injection needles in 8.3%. Most of the perforations occurred during unsupervised play, while all perforations with glass occurred during traffic accidents. Surgery was performed in 234 patients, while 8 patients in whom spontaneous closure had already occurred during admission received only medical treatment. In 28.9% the visual acuity was undetermined, in 25.7% the visual acuity was 0.1 or more, in 22.7% the visual acuity was between 0.06 and light perception, and in 22.7% there was no light perception on final evaluation. It is emphasized that educative and legislative measures such as informing the parents, teachers and children about the causative factors and potential hazards of perforating ocular injuries and restricting the availability of dangerous items to children, should be taken into consideration in order to prevent perforating ocular injuries in children.

Accidents, Home↗
PubMed2003

Evaluation of the rate, location, and morphology of perforations in surgical gloves worn in urological operations.

Surgical perforation or intrinsic defects within the polymer membranes of surgical gloves are responsible for an increased exposure, and consequently infection risk, to HIV and HCV or other infectious diseases for the medical healthcare professional. A prospective field study was undertaken to evaluate the number and location of glove perforations, tested by the waterfill test. The morphology of these perforations was then inspected by stereo light and scanning electron microscopy. By comparing in-use defects to simulated defects created by medical instruments in unused gloves it was possible to categorize perforations caused by intrinsic defects or extrinsic mechanical stress. In six different types of surgical gloves collected from 720 urological operations the waterfill test revealed leakage rates of 6.6 percent to 12.3 percent. Further assessment of these gloves revealed intrinsic polymer material defect rates of 0.2 percent to 3.3 percent. The in-use acquired instrumental and mechanical perforation rate ranged from 4.6 percent to 12.15 percent. Perforations were mostly located at the index finger (left > right) or the thumbs. The morphology of the intrinsic defects was visualized as either incorporated membranous air bubbles or granular areas. The simulation of defects by surgical instruments in unused gloves resulted in the production of a catalog for comparison with defects seen in used gloves. This knowledge of the location and cause of these perforations highlights the need for a better avoidance strategy and/or establishment of a schedule for routine glove change by surgeons. In addition, the intrinsic polymer film quality of gloves can be improved by a lower incidence of air bubbles together with less granular sites.

Equipment Failure Analysis↗
PubMed2002

Factors that predict morbidity and mortality in patients with perforated peptic ulcers.

BACKGROUND: The demographic changes of perforated peptic ulcer disease were assessed in a well-defined population in northern Finland. The high mortality from perforated peptic ulcer underlines the importance of risk stratification, and clinical variables and three scoring systems were therefore tested for their ability to predict the probability of morbidity and mortality. METHODS: Two hundred and eighty patients admitted to a university hospital with peptic ulcer perforation during the 22-year period 1979-2000 were identified using a computer database, and their clinical data were reviewed from the database and patient records. RESULTS: The annual operation rate for ulcer perforation has varied from 2.7/100,000 in 1979 to 6.2 in 1985 and 3.6 in 2000 without any significant changes during the examination period. More operations have been performed for duodenal (157) than for gastric (123) ulcer perforations, but their incidence rates were quite similar at the beginning and the end of the period. Of the clinical variables, two or more associated illnesses, duration of symptoms for more than 24 hours, the amount of abdominal liquid, and low albumin concentration predicted morbidity, while a long duration of symptoms and the amount of abdominal liquid were independent risk factors for mortality. The MPI score correctly predicted 96% of postoperative complications and all the three scores, i.e. the Boey score, the MPI score and the ASA score, were good predictors of mortality. CONCLUSION: The incidence of peptic ulcer perforation has not changed during the 22-year period in northern Finland. All the three scores, i.e. the Boey score, the MPI score and the ASA score, predict mortality in patients with peptic ulcer perforation and are suitable for risk stratification preoperatively in the surgical ward.

Adult↗
PubMed2000

Making of a facial perforator map by thermography.

It has been confirmed that thermography is an effective method by which to locate perforators to be used for local flaps. One disadvantage of thermography is its complicated procedure. If it was possible to identify perforators quickly and easily, many operations would be dramatically simplified. The authors' objective was to develop a method of mapping surface perforators using thermography. They pressed a vinyl bag filled with ice water against a test area for 25 seconds and began photographing the area directly after icing. Almost all of the enhanced hot spots appeared for 65 seconds after icing. The number and locations of enhanced perforating vessels varied widely, which they anticipated as a result of differences among individuals, and fluctuations in the measuring environment and the performance of measuring instruments. However, the presence of many perforators is common, and these images are considered to be reliable. Based on their findings, the authors consider the facial perforator map to be accurate and useful. Application of the facial perforator map may simplify many operations and may contribute to making surgery safer and more effective.

Adult↗
PubMed2001

Anatomic basis of the gastrocnemius perforator-based flap.

The gastrocnemius muscle is rarely considered today as a musculocutaneous flap. Yet, the posterior calf skin by itself can still be used to advantage as a source of local or perhaps free flaps. Fascial perforators in this region were reexamined in an anatomic study in 10 fresh cadaveric specimens to investigate the possibility of a gastrocnemius muscle perforator-based flap. At least two substantive perforators were found in all limbs, and there was always one overlying the medial gastrocnemius muscle (overall mean, 4.0 +/- 1.8 perforators; range, 2-7 perforators). The origin of these perforators in any given specimen was most commonly as a secondary branch from the medial or lateral sural arteries alone (60%), from the median sural artery as a direct cutaneous branch alone (10%), or from either of the muscle pedicles and/or the median sural artery (30%). Thus, in 90% of limbs, the potential for elevating a gastrocnemius perforator-based flap exists without the need for any muscle sacrifice. Otherwise, a more traditional posterior calf fasciocutaneous flap was possible. Other deeper intramuscular collaterals were also identified so that sequential use of the muscle as a separate flap does not seem to be compromised.

Blood Vessels↗
PubMed2000

Nontraumatic corneal perforation.

PURPOSE: To study the predisposing conditions, treatments, and visual outcomes of nontraumatic corneal perforations. METHODS: A retrospective chart review was conducted of all nontraumatic corneal perforations seen between January 1992 and December 1998, with > or = 3 months of follow-up, at the Cornea Service Wills Eye Hospital. RESULTS: A total of 40 nontraumatic corneal perforations was analyzed. Sixty-two percent of the cases were female. At presentation, 35 of 40 eyes (87.5%) had best corrected visual acuity of 20/200 or worse. The most common diseases associated with perforations were keratoconjunctivitis sicca (12 eyes, 30%), bacterial keratitis (6 eyes, 15%), exposure keratopathy (5 eyes, 12.5%), and herpes simplex virus (HSV) keratitis (4 eyes, 10%). Visual acuity improved > or = 2 Snellen lines in 3 of 8 eyes (37.5%) treated with penetrating keratoplasty, 5 of 14 eyes (35.7%) treated with tissue adhesive, and 1 of 12 eyes (8.3%) given medical treatment. After allowing for the different levels of presenting vision, treatment modality was not significantly related to final visual outcome. CONCLUSION: Keratoconjunctivitis sicca is the most common underlying disease associated with nontraumatic corneal perforation. Corneal perforations were managed successfully using tissue adhesive, medical therapy, or penetrating keratoplasty. Treatment depended on the characteristics of the perforation and on the visual potential of the eye.

Adult↗
PubMed2004

Repair of root perforations using mineral trioxide aggregate: a long-term study.

Root perforations adversely affect the prognosis of teeth. Inadequacy of the repair materials has been a contributing factor to the poor outcome of repair procedures. Mineral trioxide aggregate (MTA) is a relatively new material that is being successfully used to repair perforations. The purpose of this study was to evaluate the success rate of root perforation repairs using MTA. A list of all of the perforation repairs completed with MTA at an endodontic residency program was obtained. Sixteen cases were included that met the criteria for this study. Pretreatment, immediate posttreatment, and at least 1 year follow-up radiographs were evaluated in a double-blind manner to determine the presence or absence of any pathologic changes adjacent to the perforation site. The results showed that all 16 cases demonstrated normal tissue architecture adjacent to the repair site at the recall visit. Teeth with existing lesions showed resolution of the lesion, and teeth without preoperative lesions continued to demonstrate absence of lesion formation at the follow-up visit. Based on the results of this study, MTA provides an effective seal of root perforations and shows promise in improving the prognosis of perforated teeth that would otherwise be compromised.

Aluminum Compounds↗
PubMed2005

Free medial sural artery perforator flap for resurfacing distal limb defects.

BACKGROUND: The need for thin flap coverage has increased, especially for contouring or covering shallow defects of distal limbs. The free medial sural artery perforator flap harvested from the medial aspect of the upper calf can be useful for this purpose. METHODS: Between January 2002 and February 2003, we used the free medial sural artery perforator flap for distal limb reconstruction in 11 clinical cases, including four hands and seven feet. This perforator flap is based on the proximal major perforator of the medial sural artery, which can be identified along the axis of the medial sural artery and usually emerges in an area between 6 and 10 cm from the popliteal crease and approximately 5 cm from the posterior midline of the leg. RESULTS: Most of the flaps were safely raised with a single perforator. One flap developed venous congestion during the postoperative course and finally underwent total necrosis. CONCLUSION: The main advantage of the medial sural artery perforator flap is that it only requires cutaneous tissue to achieve better accuracy in reconstructive site, and it preserves the medial gastrocnemius muscle and motor nerve to minimize donor-site morbidity. However, the tedious process of intramuscular retrograde dissection of the perforator and the unsightly scar of the donor region are the major concerns.

Adult↗
PubMed1992

The vasculature and clinical application of the posterior tibial perforator-based flap.

Use of the posterior tibial flap pedicled on the posterior tibial vessels has been described by several authors, but with it there is the major disadvantage of an unavoidable transection of the posterior tibial artery. To overcome this disadvantage, we anatomically studied the perforators from the posterior tibial artery and used posterior tibial perforator-based flaps clinically. Based on our anatomic study of 25 cadaveric legs, the cutaneous perforators were considered to be distributed from the distal to the proximal sides of the lower leg through the medial border of the tibia, and they were classified into three types: septocutaneous perforators mainly located in the distal third of the leg, muscle perforators located in the proximal half, and periosteal perforators in the proximal third of the leg. The average size and number of perforators was 0.8 mm and 3.1 in one leg, respectively. A considerable number were located at sites from 70 to 140 mm superior to the medial malleolus. Based on our clinical cases repaired with flaps, we consider this flap to be useful as a free flap for the repair of defects of the extremities and as an island flap for reconstruction of defects on the anteromedial aspect of the lower leg. The territory of the flap is relatively wide, being 19 x 13 cm. The long saphenous vein can be used safely as the venous drainage system in the case of free-flap transfer.

Adult↗