Free flap neovascularization: myth or reality?

The blood supply of 17 free flaps was studied several months after surgery. The aim was to see whether or not the free flaps acquired blood flow through vessels across the flap inset independently of the main vascular anastomoses. A color Doppler flowmeter was used to identify the original arterial and venous anastomoses, the vessels in the margin of the flap, and also across the flap inset. The main vascular pedicle was then manually compressed for 2 min and blood flow was again examined in the vessels at the margin of the flap. The flap vessels (post-anastomotic), the anastomoses, and the recipient vessels (pre-anastomotic) could be identified in every case. There was no evidence of anastomotic stenosis. No vessels (neo-vascularization) greater than 0.5 mm could be identified across the flap inset. Small arteries could be identified in the flap near the inset. These vessels emptied completely on manual compression of the vascular pedicle for 2 min and did not refill until the compression was released. This evidence suggests that the free flaps do not receive significant blood flow through vessels across the flap inset, and are therefore significantly dependent for vascularity on the original anastomoses even 1 year after surgery.     

Revascularisation by ingrowth of a free flap: Fact or fiction?

Revascularisation of a critically ischaemic extremity by means of a free flap occurs through the development of vascular connections at the free flap-surrounding tissue interface. Three clinical cases are presented showing that in the particular situation of free tissue reconstruction of an ischaemic limb, vascular connections develop which are able at least partially to supply the free flap after occlusion of its arterial pedicle. One other case demonstrates similar vascular connections by angiography © 1997 Wiley-Liss, Inc. MICROSURGERY 17:417–422 1996     

Whiplash syndrome. Fact or fiction?

A sprain/strain syndrome or "whiplash injury" is the most common cervical injury associated with rear-end impact motor vehicle accidents. This results in a complex injury, often associated with extensive soft tissue injury in the cervical spine. There is additional potential for long term alteration in neurologic, muscular, and skeletal function. Evaluation and treatment should follow standard orthopedic principles.     

Focal therapy for prostate cancer: Fact or fiction?

Prostate cancer is the commonest male cancer diagnosed in men in the UK, and the treatment of organ confined prostate cancer is a subject of much debate. Focal therapy for prostate cancer intends to treat the cancer within the prostate, whilst sparing the majority of the benign prostate tissue. In addition, the intention is to avoid treatment effects in the surrounding structures, the damage of which leads to the side effects commonly associated with radical whole gland therapies. This relies on accurate localization of the prostate cancer by biopsy and imaging followed by treatment using a modality capable of delivery to a focal area within the prostate. Focal therapy lies between the current extremes of radical whole gland treatment and active surveillance. There have been many articles reviewing the concept of focal therapy for organ confined prostate cancer, but with a paucity of data available for analysis. This is being addressed with an increase in the published data on focal therapy, using a number of different modalities. In this review, we address the question of whether the data currently published does in fact support the further development of the focal therapy approach, or whether it is a concept best relegated to the realms of fiction.     

Enhanced microfracture techniques in cartilage knee surgery: Fact or fiction?

The limited intrinsic healing potential of human articular cartilage is a well-known problem in orthopedic surgery. Thus a variety of surgical techniques have been developed to reduce joint pain, improve joint function and delay the onset of osteoarthritis. Microfractures as a bone marrow stimulation technique present the most common applied articular cartilage repair procedure today. Unfortunately the deficiencies of fibrocartilaginous repair tissue inevitably lead to breakdown under normal joint loading and clinical results deteriorate with time. To overcome the shortcomings of microfracture, an enhanced microfracture technique was developed with an additional collagen Ⅰ/Ⅲ membrane(Autologous, Matrix-Induced Chondrogenesis, AMIC). This article reviews the pre-clinical rationale of microfractures and AMIC, presents clinical studies and shows the advantages and disadvantages of these widely usedtechniques. PubM ed and the Cochrane database were searched to identify relevant studies. We used a comprehensive search strategy with no date or language restrictions to locate studies that examined the AMIC technique and microfracture. Search keywords included cartilage, microfracture, AMIC, knee, ChondroGide. Besides this, we included our own experiences and study authors were contacted if more and non published data were needed. Both cartilage repair techniques represent an effective and safe method of treating full-thickness chondral defects of the knee in selected cases. While results after microfracture deteriorate with time, mid-term results after AMIC seem to be enduring. Randomized studies with long-term followup are needed whether the grafted area will maintain functional improvement and structural integrity over time.     

Exacerbation of chronic inflammatory diseases by infectious agents: Fact or fiction?

Chronic inflammatory diseases caused by obesity represent critical public health concerns worldwide. In these diseases such as metabolic syndrome, diabetes and atherosclerosis, adipose tissue acts as an endocrine organ that releases large quantities of inflammatory mediators into circulation. Besides classically recognized effectors on the development of obesity and resultant conditions, infection has attracted attention as an enhancer of chronic inflammatory diseases. Infectious diseases have long been associated with obesity, metabolic syndrome, diabetes and atherosclerosis. However, the infectious hypothesis for chronic inflammatory diseases has been challenged by inconclusive clinical trials. Nevertheless, the large body of evidence accumulated over decades on the association of infectious diseases with obesity, diabetes and cardiovascular disease should not be disregarded. Instead, re-formulation of hypotheses of the mechanisms by which microbes affect obesity-associated diseases may be required with an emphasis on the early events in the progression of such diseases and the multifactorial nature of pathogen-host interactions. This review focuses on pathogens that directly promote obesity and on pathogens that cause chronic infections and thereby enhance metabolic diseases in obese patients. A new perspective on the interaction between infections and obesity-related diseases may improve management of chronic inflammatory diseases that rank high among global threats to human health.     

The “weekend warrior”: Fact or fiction for major trauma?

Background

The “weekend warrior” engages in demanding recreational sporting activities on weekends despite minimal physical activity during the week. We sought to identify the incidence and injury patterns of major trauma from recreational sporting activities on weekends versus weekdays.

Methods

We performed a retrospective cohort study using the Alberta Trauma Registry comparing all adults who were severely injured (injury severity score [ISS] ≥ 12) while engaging in physical activity on weekends versus weekdays between 1995 and 2009.

Results

Among the 351 identified patients (median ISS 18; median hospital stay 6 d; mortality 6.6%), significantly more were injured on the weekend than during the week (54.8% v. 45.2%, p = 0.016). Common mechanisms were motocross (23.6%), hiking or mountain/rock climbing (15.4%), skateboarding or rollerblading (12.3%), hockey/ice-skating (10.3%) and aircraft- (9.9%) and water-related (7.7%) activities. This distribution was similar regardless of the day of the week. Most patients were injured as a result of a ground-level (21.9%) or higher fall while hiking, mountain climbing or rock climbing (25.9%); motocross-related incidents (24.2%); or collision with a tree, person, man-made object or moving vehicle (14.0%). Injury patterns were similar across both groups (all p > 0.05): head (55.8%), spine (35.1%), chest (35.0%), extremities (31.1%), face (17.4%), abdomen (13.1%). Surgical intervention was required in 41% of patients: 15.1% required open reduction and internal fixation, 8.3% spinal fixation, 7.4% craniotomy, 5.1% facial repair and 4.3% laparotomy.

Conclusion

The weekend warrior concept may be a validated entity for major trauma.     

Fact or fiction: What do the benign prostatic hyperplasia data tell us?

Benign prostatic hyperplasia (BPH) is the most common benign neoplasm in men. Our understanding of this condition has improved greatly over the years and recent advances have changed our approach to management. At the end of the 19th century, prostatic enlargement was treated effectively by bilateral orchidectomy. Unsurprisingly, this treatment option never gained widespread popularity. Less than 10 years ago, surgery and watchful waiting were the only considered treatment options for BPH. We now have a number of medical therapies and minimally invasive treatment options available that can effectively manage lower urinary tract symptoms secondary to benign prostatic obstruction. However, with increased choice comes the increased need for clarity in selection and application of these various treatment options. In the current environment of evidence-based clinical practice, awareness and interpretation of data from the numerous studies is paramount. The lessons learned from these trials should be reflected clearly in our practice, with clinical management based on fact, not fiction. In this review, we critically assess the available data and understanding of the management of BPH.     

Whiplash: fact or fiction?

Cervical sprain/strain or whiplash injuries are a common cause of acute and chronic musculoskeletal impairments and are ubiquitous after rear-end automobile collisions. The diagnosis is largely subjective and the ideal treatment controversial. Unfortunately, the majority of compensated litigation claims are associated with whiplash-type injuries secondary to motor vehicle accidents. Fortunately, many recent advances have led to better understanding of the collision and injury biomechanics and to development of a prognostic classification system, objective diagnostic tests, an array of treatment modalities, and, most important, safer automobiles. These advances will undoubtedly lead to decreased incidence, a more accurate diagnosis, and a tailored management regimen resulting in improved outcomes and ultimately fewer legal proceedings.     

Tourniquet-induced restriction of the quadriceps muscle mechanism. Fact or fiction?

Many knee surgeons flex the knee and sometimes also extend the hip before inflating a tourniquet on the thigh. This practice stems from the belief that these manoeuvres prevent excessive strain on the quadriceps during surgery, the assumption being that movement of the muscle is restricted by an inflated tourniquet. We therefore examined, using ultrasound, the movement of the quadriceps muscle above and below the tourniquet before and after inflation. We applied a tourniquet of standard size to the thigh of five volunteers for approximately five minutes. A bubble of air was injected into the quadriceps muscle above the tourniquet and was the proximal point of reference. The musculotendinous junction was the distal point. The movement of the reference point was measured by ultrasound before and after inflation of the tourniquet. Each measurement was repeated with either the knee flexed and the hip extended, or the hip flexed and the knee extended. The mean and standard deviation were recorded. Before inflation the mean amount of passive movement was 1.1 +/- 0.13 cm proximal and 4.0 +/- 0.08 cm distal to the tourniquet, with a range of movement of the knee of 0 degrees to 137 degrees (6.7 degrees). After inflation the mean passive movement was 1.0 +/- 0.07 cm proximal and 4.0 +/- 0.08 cm distal to the tourniquet with a range of 0 degrees to 132 degrees (+/- 7.6 degrees). The ultrasound findings therefore have shown no evidence of restriction of the quadriceps muscle by an inflated tourniquet.     

Kissing spines: Fact or Fancy?

Summary In the Neurosurgical Clinic in Groningen 64 patients underwent surgery between 1975 and 1985 for a clinical and radiological syndrome described by Baastrup¹in 1933 and called in the Anglo-saxon literature: kissing spines.Because the results of the surgical treatment were disappointing we submitted these results to further analysis.