Experience with 24 cases of reconstructive anterior skull base surgery: classification and evaluation of postoperative facial appearance

This article details our experience with 24 cases of anterior skull base reconstruction after tumor resection. They were classified into four types according to the resected region. In 11 cases of type I resection, the orbital part of frontal bone and/or cribriform plate of ethmoid bone were resected. In two cases of type II resection, the orbital contents and partial orbital bone were resected with the addition of type I. In five cases of type III resection, the maxillary bone was resected with the addition of type II. In six cases of type IV resection, the zygomatic bone and/or facial skin were resected with the addition of type III. The tumor originating from intracranial region was 25% of this series and all of them belonged to type I. The tumor originating from extracranial region tumor was 75% and its resected region was more extensive. In type I and II resections, the cranial flap, radial forearm free flap, or a combination of the two was used for reconstruction. The rectus abdominis myocutaneous/muscle free flap was used for reconstruction of massive defects in type III and IV defects. Total incidence of postoperative complications was 16.7%. Donor site deformity of the cranial flap at the frontal and temporal region in types I and II resections and facial contour deformity in zygomatic region and defect of upper and/or lower palpebra in type IV resection were major problems with postoperative facial appearance. Although use of the rectus abdominis myocutaneous free flap combined with costal cartilages improved the midfacial contour, palpebral reconstruction remained an unsolved problem in reconstructive skull base surgery. The reconstructive goals in skull base surgery are not only to obtain safe and reliable skull base reconstruction but also to restore the facial appearance postoperatively.     

MRI Detection of Forearm Soft Tissue Injuries with Radial Head Fractures

Background

This study aims to evaluate the incidence of forearm soft tissue abnormalities associated with radial head fracture severity based on the Mason classification system.

Methods

Eighteen patients (age 18–45 years) were prospectively evaluated with elbow radiographs and magnetic resonance imaging (MRI) following longitudinal forearm trauma. MRI was performed within 10 days of the initial injury. Radiographs and MR images were evaluated in a blinded fashion by two musculoskeletal radiologists.

Results

Thirteen of 18 patients presented with Mason type I radial head fractures. In all patients with Mason type I fractures, the interosseous membrane (IOM) was intact. Two patients had Mason type II fractures with associated partial and compete tearing of the IOM and three patients had Mason type III fractures with complete tearing of the IOM. Edema was noted in the pronator quadratus in six of 13 type I injuries and seen in all type II and III injuries. No structural forearm soft tissue abnormalities were present in patients with Mason type I injuries. The presence of edema within the pronator quadratus correlated with distal forearm pain.

Conclusions

The severity of radial head fracture correlates with longitudinal forearm injury evidenced by the presence of IOM tearing. The findings suggest patients with Mason type II or III fractures of the radial head should undergo further evaluation of the forearm for associated soft tissue injuries. Edema within the pronator quadratus was present following forearm trauma regardless of the severity of fracture and was related to symptomatic forearm pain.     

全手皮肤脱套伤的分型和治疗

目的总结全手皮肤脱套伤的伤情特点,探讨全手皮肤脱套伤的分型标准及治疗方法。方法 1999年12月-2010年5月,收治41例全手皮肤脱套伤。男28例,女13例;年龄18～58岁,平均35岁。致伤原因:碾压伤28例,挤压伤13例。受伤至手术时间1～10 h,平均3 h。根据自定全手皮肤脱套伤分型标准:Ⅰ型11例,Ⅱ型5例,Ⅲ型4例,Ⅳ型8例,Ⅴ型13例。Ⅰ型采用吻合血管回植术;Ⅱ型采用带足背皮瓣的甲瓣、第2趾甲瓣再造术;Ⅲ型采用双足带足背皮瓣的第2趾甲瓣再造术;Ⅳ型采用吻合血管回植术;Ⅴ型采用带足背皮瓣的甲瓣再造(8例)或腹部皮瓣修复术(5例)。足背皮瓣切取范围为9 cm×6 cm～17 cm×11 cm,足背供区游离植皮修复。结果术后Ⅰ型6例发生部分手指坏死,Ⅳ型6例发生部分手指及手掌皮肤坏死;其余患者皮瓣、再造指及回植皮肤均成活。足背供区及腹部供区均顺利愈合。40例患者获随访,随访时间6个月～7年,平均14个月。采用吻合血管回植治疗者,手部皮肤颜色、质地接近正常,功能恢复佳,感觉恢复至S2～S4;采用甲瓣及趾甲瓣再造手指者,手功能基本恢复,再造指感觉恢复至S2～S3;采用腹部皮瓣者,手功能恢复欠佳,手部感觉恢复至S1～S2。结论采用自定标准对全手皮肤脱套伤程度进行分型,并指导临床治疗方案的选择,可获得较好临床疗效。     

Classifying calcaneal tendon injury according to MRI findings

Magnetic resonance imaging was performed on 28 patients with suspected calcaneal tendon injury prior to treatment. None of the patients were involved in competitive sports. All underwent clinical examination, some had had ultrasound or CT scans. We identified four types of lesions: type I, inflammatory reaction; type II, degenerative change; type III, incomplete rupture and type IV, complete rupture. Thirteen of the 28 patients underwent surgery and the diagnostic findings were verified. We recommend that type I, type II and type III lesions be managed conservatively, while type IV lesions should be operated in the young and active patient.     

Experiences with an arterialized venous flap for intraoral defect reconstruction

This clinical investigation should try out the suitability of arterialized venous forearm flaps for immediate reconstruction of intraoral defects after excision of an oral squamous cell carcinoma. In contrast to the free radial forearm flap there is no need for either sacrificing a peripheral artery or jeopardizing motor nerves. As the exact function of arterialized venous flaps is still unknown we had to take into account the possible loss of the flap. Therefore we used this flap in patients with small or medium sized defects only. All skin fat flaps were raised out of the right forearm using two different flap types. In 34 patient we used a flap with a superficial vein passing through (type I), in 5 patients we took a flap with two parallel proximal veins (type II). After the flap had been sutured into the intraoral defect, in flap type I the original distal end of the vein was anastomosed to an artery and the original proximal end to a vein. In flap type II there was no specific differentiation between the veins both. 18 (46.2%) of the flaps survived completely, 9 (23%) had superficial epithelial loss or some marginal necrosis and 12 (30.8%) became completely necrotic. Areas of partial loss developed slowly and formed stable granulation tissue. The flap donor sites were either closed primarily (n = 19) or were covered with split thickness skin graft (n = 20). There were no functional problems of the donor forearms. These results contrast with the high success rates achieved with orthodox free forearm flaps. Further research into venous flaps is essential.     

Urethral reconstruction after total penectomy for urethral cancer

A 59-year-old white man developed a ventral ulcer with irregular limits in the middle portion of the penis. The result of the pathologic analysis was compatible with invasive squamous cell urethral carcinoma. A total penectomy was performed. In these cases, the usually recommended urinary diversion is perineal urethrostomy. However, due to the specifications of the case, perineal urethrostomy could not be performed. The literature did not offer any other alternative for patients with this same condition. Therefore, a urethral reconstruction using a groin skin flap had to be performed.     

Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip

Sixty-three fingertip amputations in 50 patients were reconstructed using a homodigital neurovascular island flap technique based on a single neurovascular pedicle without further shortening of the distal phalanx. The procedure was carried out under regional anaesthesia, using a tourniquet and magnifying loupes. All of the flaps survived and achieved normal or adequate two-point discrimination without any painful scar or cold hypersensitivity. Fifteen patients had some loss of distal interphalangeal joint extension. The technique is simple and presents an excellent method for fingertip reconstruction in Allen type II, III and IV injuries.     

Free radial forearm flap with adipofascial tissue extension for reconstruction of oral cancer defect

The radial forearm flap has been one of the most popular flaps used to reconstruct defects after oral cancer ablation. However, it sometimes may not provide sufficient soft tissue to obliterate the dead space after tumor excision and lymph node dissection, which can result in deep wound infection of the neck or even orocervical fistula. The authors modified the radial forearm flap with a sheet of adipofascial tissue extension to prevent such postoperative complications. From January 1997 to December 2000, 52 patients who underwent ablative oral cancer surgery were studied. A total of 29 patients (group I) underwent reconstruction with the traditional radial forearm flap retrospectively, and 23 patients (group II) underwent reconstruction with the radial forearm flap along with a sheet of adipofascial tissue extension. The radial forearm flap was designed on the axis of the radial artery, was 8 x 4 to 12 x 10 cm in size, and was sufficient to resurface the intraoral defect. In group II, the radial forearm skin flap along with a sheet of adipofascial tissue 8 x 8 to 12 x 10 cm was used to obliterate the dead space of the oral floor and neck. The donor site of both groups was resurfaced with a split-thickness skin graft. In group II, the skin flap of the adipofascial tissue was resutured to its original site. Two flaps in group I failed because of arterial occlusion and required other skin flaps for reconstruction. Postoperative hematoma, which required surgical treatment for drainage, developed in five patients in group I. None of the patients in group II had hematoma formation. Nine patients in group I had a neck wound infection compared with only 2 patients in group II (a significant difference). The average volume of drainage and days of hospitalization were similar in both groups. The morbidity of the donor site of both groups was not significant. The advantages of this modification include 1) suitable soft tissue available for dead space obliteration to decrease the chance of postoperative hematoma; 2) the important vessels in the neck can be protected; 3) there is a decrease in neck wound infections; and 4) donor site morbidity is similar to the traditional group.     

Treatment of fractures of the ulnar coronoid process

Objective: To discuss the classification, management and outcome of fractures of the ulnar coronoid process. Methods: Retrospective analysis was carried out in 31 patients (19 men and 12 women of average age 29.8 years [range, 18–52 years]) with fractures of the ulnar coronoid process. The fractures were classified into four major groups based on the extent of injury to the ulnar coronoid process, the state of the anterior bundle of the ulnar collateral ligaments (UCL) and elbow stability. A fracture of the coronoid process less than halfway up was defined as type I (eleven cases); of the middle of the coronoid process with injury of the UCL as type II (nine cases); of the base of coronoid process with dislocation of the elbow joint, sometimes with injury of the UCL, as type III (six cases); and severe comminuted fracture of the coronoid process with elbow instability as type IV (five cases). We chose treatment according to the type of injury. Results: Follow‐up was 18–72 months (average 28.6 months). All patients achieved fracture union without inflammation, neural injuries or elbow instability. One type III and two type IV patients had traumatic osteoarthritis, and two type III and two type IV developed heterotopic ossification. There was a statistically significant difference between the ranges of movement of the two‐side joints in type IV. Conclusion: We choose conservative treatment for type I fractures unless the bone fragment affected movement of the elbow joint, in which case we chose operative treatment so that elbow stability was not affected. Type II and type III fractures with elbow instability were reduced by internal fixation and the ligament repaired or reconstructed. In type IV cases, bone reconstruction was necessary to recover elbow stability. Proper post‐operative rehabilitation can decrease the occurrence of traumatic osteoarthritis.     

Immediate internal fixation of open fractures of the diaphysis of the forearm.

Immediate (within 24 h) open reduction and internal fixation of 103 open fractures of one or both bones of the forearm was accomplished in 69 patients between 1980 and 1989. Fifty-four of the 103 patients were reevaluated 1 to 7 years postinjury (average 2.5 years) to determine the efficacy of this treatment. Forty-five (90%) of the 50 patients with Grade I, II, or IIIA injuries had satisfactory results. The four patients with Grade IIIB or IIIC injuries had unacceptable results. This study demonstrates, as have previous investigations, that immediate open reduction and internal fixation of open forearm fractures provide acceptable results in Grades I, II, and selected Grade III injuries. The subdivision of Grade III fractures into A, B, and C types provides a previously unreported statistically significant difference in the results obtained in management of these injuries. The difference in results in Grade I, II, and IIIA injuries as compared to the Grade IIIB and C injuries was statistically significant (p = 0.0004). The difference in Grade IIIA injuries as compared to Grade IIIB and C injuries was also significant (p = 0.014). Immediate open reduction and internal fixation can be recommended in Grade I, II, and IIIA open forearm fractures. Although it is unclear from this report whether the results in Grade IIIB and C fractures were due to the management protocol, the severity of the initial injury, or combined factors, immediate open reduction and plate fixation yielded poor results in these injuries.     

Mutilating corn-picker injuries of the hand

Our experience with 15 patients who had acute mutilating hand injuries from corn-picker machines is reviewed. Three injury patterns were defined. Type I involved severe injury to all digits of the hand, including the thumb; type II injuries involved amputation of all fingers, in whole or in part, but with sparing of the thumb; and type III injuries involved amputation of multiple fingers with sparing of the thumb and at least one other digit. Attempts at revascularization or at complex reconstruction of the injured digits in the period immediately after injury failed in all 15 patients. The most satisfactory results in patients with type I injuries were obtained by complex reconstructive procedures such as toe-to-hand transfer. Patients with type II injuries were best treated with construction of a mitten-type hand by various methods. Patients with type III injuries were best treated by amputation of the devascularized digits.     

Lateral-dorsal neurovascular island flaps for pulp reconstruction

Finger pulp loss is often observed in daily practice. When the lateral and dorsal surfaces of the injured digit remain intact, a neurovascular island flap can be designed and raised from that part of the finger for pulp reconstruction. Two types of homodigital lateral-dorsal neurovascular island flaps were used in 17 patients (13 type I and 4 type II) for reconstruction of traumatic pulp loss on an emergent basis. The type I flap was used for the pulp defect less than 2.5 cm in length; the type II flap was designed for extensive pulp loss. The size of the pulp defect varied from 1.7 x 1.2 cm to 3.8 x 1.7 cm. All flaps survived completely without any partial loss. The mean follow-up was 17.7 months. The mean static two-point discrimination was 5.2 mm in type I flaps and 9.3 mm in type II flaps. All patients except five had full range of motion of the interphalangeal joint. These five patients (3 type I and 2 type II) had 10 to 20 deg reduction in flexion of the distal interphalangeal joints. The homodigital lateral-dorsal neurovascular island flap offers a durable, well-vascularized, sensate skin flap for one-stage pulp reconstruction in select patients. This technique is relatively simple, allows early postoperative mobilization, and has an acceptable surgical outcome.     

儿童足踝部开放性损伤的处理

 目的 探讨儿童足踝部开放性损伤的特点、治疗方法及临床疗效。方法 回顾性分析2004年2月至2010年6月收治的35例足踝部损伤的病历资料,男22例,女13例;年龄3~14岁,平均8.4岁。交通伤28例,利器切割及机器辗绞伤7例。左18例,右17例,均为单侧;前中足5例,后足及踝部30例。其中合并骨折30例。按照Gustilo分型,Ⅰ型5例、Ⅱ型8例、Ⅲ型22例。Ⅰ型、Ⅱ型及早期收治的10例Ⅲ型病例在急诊行清创缝合或(和)骨折复位内固定术+皮瓣移植术;后期收治的12例Ⅲ型病例一期行清创、闭式负压引流术+石膏外固定或克氏针临时固定,二期行骨折复位(伴或不伴植骨)内固定+皮瓣移植术。结果 30例患儿获得随访,随访时间6~89个月,平均38.7月。2例Ⅱ型患儿术后伤口皮肤局部坏死,行植皮术愈合;10例Ⅲ型患儿一期行急诊手术,手术次数2~6次,平均3.6次;创面愈合时间3~15周,平均8.3周。1例出现慢性骨髓炎,窦道残留,经多次病灶清除植骨后痊愈; 2例足踝及小腿外侧肌肉坏死行皮瓣移植,术后3年因瘢痕组织挛缩出现足踝部内翻畸形,行外固定架矫形后正常行走。12例行分期治疗的Ⅲ型患儿皮瓣均存活,色泽及弹性良好,愈合时间3~8周,平均6.8周。伴发足踝部骨折者骨折愈合良好。按Maryland标准评分[1],优17 足、良9足、中3例、差1例,优良率为86.7%。结论 儿童足踝部创伤以车祸伤为多见;按损伤程度分级分期治疗可取得较好临床疗效。     

Proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures

The purpose of this study was to evaluate the efficacy and safety of the proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures. A prospective study was performed in 41 patients with femoral neck fractures treated with a proximal femoral locking plate with cannulated screws between January 2005 and December 2008. Twenty-five men and 16 women had a mean age of 47 years (range, 21-65 years). The time from injury to surgery ranged from 2 hours to 7 days. Three patients had a Garden type I fracture, 9 a type II, 18 a type III and 11 a type IV. Operative time, intraoperative blood loss, fracture healing time, Harris Hip Score for hip function, and complications were recorded to evaluate treatment effects.Mean operative time was 63.6 minutes (range, 40-90 minutes), with mean intraoperative blood loss of 84.2 mL (range, 50-200 mL). Mean time to union was 15.5 weeks (range, 12-36 weeks). Two patients (Garden type III and type IV) did not achieve union, and 4 patients (1 Garden type III and 3 type IV) had avascular necrosis of the femoral head. In patients with nonunion, 1 (Garden type III) underwent intertrochanteric osteotomy, and the other underwent total hip replacement (THR). In patients with avascular necrosis, 2 required THR and the others (1 Garden type III) required no further surgery. Twenty-six (63%) patients had excellent results, 8 (20%) had good results, 3 (7%) had moderate results, and 4 (10%) had poor results. These findings suggest that the proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures is effective and results in fewer complications, especially for Garden type I, II, and III fractures.     

Urethra reconstruction following resection of penile leiomyosarcoma

Leiomyosarcoma is a rare tumor, particularly in genital area. We present a case of penile lyomyosarcoma. Surgical treatment involved subcutaneous penectomy, preserving a sensate skin envelope, bilateral groin dissection and perineal urethrostomy. Reconstruction of the urethra and soft tissue was carried out using a free radial forearm flap. We believe that subcutaneous penectomy should be considered as a treatment option in selected cases of penile tumor as this facilitates urethral reconstruction.     

指尖横形离断伤的分型及修复方法探讨

目的 探讨指尖横形离断伤新的分型和修复方法.方法 2000年3月-2006年10月,收治20例指尖横形离断伤.男13例13指,女7例7指;年龄17～47岁.挤压伤9例,切割伤5例,电锯伤6例.指尖横形离断伤分为4型:Ⅰ型为甲床远1/3平面,Ⅱ型为甲床中段平面,Ⅲ型为甲床近1/3平面,Ⅳ型为甲根平面.Ⅰ型中示指2例,小指1例:Ⅱ型中拇指2例,示指、中指各3例:Ⅲ型中示指3例,环指、小指各1例;Ⅳ型中拇指2例,中指、小指各1例.缺损范围1.2cm×1.2cm～1.5 cm × 1.2 cm.伤后至手术时间3～10 h.其中Ⅰ、Ⅱ型应用带血管神经束顺行岛状皮瓣,并行改良甲床扩大术;Ⅲ、Ⅳ型应用带血管神经束顺行岛状皮瓣与甲床回植,行改良甲床扩大术.术中皮瓣切取范围1.5 cm×1.2 cm～2.0cm×1.4 cm.结果 术后皮瓣及甲床均成活,切口Ⅰ期愈合.供区植皮均成活,创面1期愈合.患者均获随访,随访时间2～6个月,平均4个月.皮瓣外形饱满、质软,肤色和皮温均正常,两点辨别觉4.5～6.5 mm.Ⅰ、Ⅱ型患指指甲较术前延长3～4 mm;Ⅲ、Ⅳ型患指指甲较术前延长8～10 mm.1例术后6个月出现钩甲畸形,未作处理.指甲光滑、无压痛,甲床平整无甲棘:患指各关节活动无影响.结论 对指尖离断伤损伤平面进行分型后采用不同的修复方法,有利于最大程度恢复指尖功能和外形.     

Thoughts on the management of amputation and amputation-like injuries in the upper extremities

Summary Between 1982 and 1993, 65 amputation and amputation-like injuries in the upper arm (n = 18), proximal and middle forearm (n = 32) and distal forearm and wrist level (n = 15) were treated in our institution. The overall survival rate in our series was 92.3 % (60/65). In 3 of 65 cases early secondary amputation because of vascular failure was necessary. There was one reamputation because of deep infection with beginning sepsis. Severe systemic disturbances were seen in one patient, requiring early reamputation. Twenty-five patients with a follow-up of more than 2 years were reviewed in a retrospective clinical study and evaluated according to the Chen classification. Of 8 patients with upper-arm involvement, 2 had a grade II result, 4 a grade III and 2 a grade IV result. There were 1 grade I, 2 grade II, 2 grade III and 5 grade IV results in the proximal forearm group. In the distal forearm group 2 patients each showed a grade I, II and III result and 1 a grade IV. Taking grades I and II results together, a “functional extremity” could be reconstructed at the upper arm level in 25 %, proximal forearm 30 %, and the distal forearm in 58 %. The main advantage of replantation/revascularization of the upper limb is the possibility of restoring some sensitivity to the hand in addition to partial motor recovery, which always provides twice as much individual motor function as is offered by any type of prosthesis currently available. The higher cost and number of operations needed, as well as the longer postoperative care and longer disability time after replantation/revascularization are nevertheless justified by the significant increase in quality of life.      

Initial Resection of Potentially Viable Tissue is not Optimal Treatment for Grades II–IV Pancreatic Injuries

Purpose  This study was designed to ascertain the optimal therapy and diagnostics for children with pancreatic injury. Methods  From January 1, 2001 to January 1, 2007, all children (newborn to 17 years) who presented to this Level I trauma center with demonstrated pancreatic injury were prospectively entered into the TRACS IV system and reviewed for injury type, diagnostics, therapy, demographics, and outcome. Results  Fourteen children sustained grade II or higher pancreatic injury during this period. CT scan was performed for diagnosis in all cases. There were 11 boys and 3 girls, and mean age was 6.9 (range, 2–16) years. There were five grade II injuries, four grade III injuries, four grade IV injuries, and one grade V injury. All grade II injuries were treated successfully nonoperatively with observation. The nine grade III–IV injuries all underwent operative external drainage without pancreatectomy or stent placement. The single grade V injury died of multiple associated injuries after operative intervention. No pseudocysts developed in these children. All children have normal pancreatic function, and all except one have normal anatomy on follow-up scans. Early exploration and drainage directly reduces length of stay. Conclusion  Grade II pancreatic injuries do not require routine surgical exploration in children. Grade III and IV injuries in this series were treated with expeditious drainage of the pancreatic bed and did not require routine pancreatectomy or endoscopic stint placement as some have recommended. Early drainage shortens hospital stay, and outcomes from this therapy are excellent. Pancreatic resection of exocrine defunctionalized segments of pancreas may be performed safely electively after acute injury if necessary, but anecdotal information from this series indicates that too may not be necessary. Grade V injuries often are accompanied by multiple other organ injuries and are associated with a significant mortality rate. A multi-institutional investigation is warranted to reassess optimal therapy for pancreatic injury in children. An erratum to this article can be found at     

Splenorrhaphy. The alternative.

From 1980 to 1989, 240 adult patients underwent splenorrhaphy at one urban trauma center. This represents 43.4% of all splenic injuries seen during this time interval. Splenic injuries were graded I to V, and splenorrhaphy was attempted except when the spleen was shattered or when multiple injuries with associated hypotension were present. Penetrating wounds, blunt trauma, or iatrogenic/unknown etiologies were present in 54.2%, 41.6%, and 4.2% of patients, respectively. Grade I or II injuries were present in 51.7% of patients, grade III in 34.6%, grade IV or V in 9.6%, and unknown grade in 4.1%. The technique of splenorrhaphy was simple suture (usually chromic) with or without the addition of topical hemostatic agents in 200 patients (83.3%), topical agents alone in 12 (5%), unknown type of repair in 12 (5%), compression, cautery, or nonbleeding injury in 9 (3.8%), and partial or hemisplenectomy in 7 (2.9%). Postoperative rebleeding occurred in three patients (1.3%) with grade II, III, and IV injuries, respectively, and led to splenectomy at reoperation. In another patient who had a hemisplenectomy performed for a grade IV injury, subphrenic abscesses and septic shock led to the death of the patient. Splenorrhaphy can be safely performed in properly selected adult patients after a variety of injuries. The risk of rebleeding is practically nil when the spleen is fully mobilized and visualized during repair.