“Emergency” definitive reconstruction of a necrotising fasciitis thigh debridement defect with a pedicled TRAM flap

INTRODUCTIONNecrotising fasciitis (NF) is a rare, severe, rapidly progressing and life-threatening synergistic infection primarily affecting the superficial fascia. A novel method of definitive and aesthetic reconstruction of NF thigh defects by using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap without recourse to temporising skin grafts is presented.PRESENTATION OF CASEA 30-year-old parous woman presented in extremis with fulminant NF of her left anteromedial thigh. Following emergency radical debridement and intensive care stabilisation she was reconstructed 48 h later in a single stage with a pedicled TRAM flap islanded on the ipsilateral deep inferior epigastric vessels. There was excellent contour restoration of her thigh and coverage of the exposed femoral vessels.DISCUSSIONPedicled flaps based on the rectus abdominis muscle provide a large, readily available reconstructive option for correction of substantial regional defects as herein illustrated. They are robust when based on dominant inferior vascular pedicle with a long reach and wide arc of rotation when designed transversely (as a TRAM flap).CONCLUSIONThis case also illustrates that definitive flap reconstruction of NF can be successfully undertaken in the emergent setting, thereby negating the need for large areas of skin grafting which can lead to contractures with consequent functional impairment and suboptimal aesthetic results.     

Reconstruction of a large pelvic defect by transfer of a quadruplet combination of pedicled flaps from the medial thigh using bilateral muscular gracilis flaps and bilateral vertical posteromedial thigh (vPMT) propeller flaps—A case report

The reconstruction of defects of the perianal area and vagina places a high demand on a reconstructive surgeon. Different reconstructive methods include a skin graft, a local skin flap, a musculocutaneous flap, and a pedicled perforator flap. Here, we report the case of a 59-year-old female patient with a pelvic defect, who underwent reconstruction with a quadruplet combination of pedicled flaps from the medial thigh, due to an extensive resection of a recurrence of a squamous cell carcinoma of the anus, vulva, and partially the colon. The surgical oncologist performed a rectum amputation, a partial colectomy, a complete hysterectomy, and a resection of the dorso-lateral vaginal vault in order to achieve tumor-free margins. The resulting defect measured 14 × 11 cm² with 8 cm of deep space. The defect was covered and reconstructed by employing a bilateral pedicled gracilis muscle flap rotated about 120° and advanced to fill up the residual spare space in the deep and a bilateral vertical posteromedial thigh (vPMT) using a propeller flap measuring 27 × 10 cm² rotated 180° in order to reconstruct the vagina and the perianal area. All flaps survived without major post-operative complications. The donor site morbidity was minimal. The range of motion was not limited over both hip and knee joints. Patient had no problem with urination. Sexual intercourse was not highly considered due to patient's old age. The follow-up at 6 months showed acceptable cosmetic results with a satisfying contour of the coverage and reconstructed area. The combination of pedicled gracilis muscle flap and vPMT propeller flap may represent a valuable option in such a defect where deep space obliteration and reconstruction of the vagina with perianal contouring are needed.     

Reconstruction of finger pulp defect with reversed fasciocutaneous island flap from same finger

Objective:To investigate the clinical curative effect of reconstruction of finger pulp defect by anastomosis of reversed fasciocutaneous island flap with dorsal branch of the digital nerve of the same finger. Methods: The restoration of finger pulp defect with fasciocutaneous island flap from the same finger was conducted in 25 cases (30 fingers) from January 2002 to June 2003. Nine patients (11 fingers) whose flaps with dorsal branch of the digital nerve anastomosed with the digital inherent nerve around the surface of the wound were Group A and the others were Group B. The follow-up was carried out at 3 and 9 months after the operation to observe the shape of finger pulp and the sense restoration between two groups. Results: All flaps of 25 cases (30 fingers) survived. Three months after operation, the patients had fully grown finger pulps and recovered the superficial sensation and tactile sense of finger pulps. The two point discrimination on average was 5. 00 mm±0. 23 mm in Group A and 6.00 mm±0.30 mm in Group B. The difference between two groups was highly significant. Nine months later, their senses of finger pulps between two groups were recovered basically. Conclusions: The reversed fasciocutaneous island flap from the same finger is the first choice to reconstruct the finger pulp defect, and the anastomosis of dorsal branch of the digital nerve shall be determined according to the specific condition.     

Morton’s neuroma neuro-osteodesis through a plantar approach

Background

Morton’s neuroma is an entrapment neuropathy. Several surgical techniques were proposed for the management of this painful condition and to potentially limit the stump neuroma formation with variable results including attempts to seal the end of the nerve with cryogenic freezing, cauterization, electrocoagulation, carbon dioxide laser, chemical sclerosis, mechanical crush or ligation, fascial capping, and synthetic capping with methyl methacrylate, cellophane, collodion, silicone, glass, tin, tantalum, and silver and gold foils.

Patients & Methods

 In this study, 18 patients with Morton’s metatarsalgia were treated using a plantar approach, and neuro-osteodesis that entails burring the nerve into adjacent bone.

Results

All patients had satisfactory results except one case that necessitated a second surgery. Twelve patients were completely satisfied and five were satisfied with minor reservations.

Conclusions

Based on the results provided by this prospective study, we believe that neuro-osteodesis through a plantar approach is expected to be a satisfactory measure for the management of this painful foot condition.     

Reconstruction of an abdominal wall defect with biologic mesh after resection of a desmoid tumor in a patient with a Gardner’s syndrome

Introduction: Desmoid tumors are rare proliferative and invasive benign lesions. They can be sporadic, but in most instances, desmoid tumors develop in the context of Gardner’s syndrome with principal localization in the abdominal cavity and abdominal wall.

Case-report: We report the case of a 24-year-old female presenting Gardner’s syndrome with a symptomatic abdominal wall desmoid tumor. Lack of response to medical treatment led to surgical management consisting in a complete resection and parietal reconstruction with a biologic mesh. Postoperative course was uneventful and there was no evidence of recurrence at 12 months of follow-up.

Discussion: Conventional treatment of abdominal wall desmoid tumors consists in a wide and radical resection. However, complete resection is not always feasible because of difficulty to differentiate the desmoid tumor from adjacent tissues. The surgical approach may require different techniques to repair the parietal defect including prosthetic material such as synthetic or biologic meshes. Biological mesh is an ideal alternative to synthetic graft, mainly in case of infection.

Conclusion: We have encountered a case of a symptomatic growing desmoid tumor of the abdominal wall in a young patient with Gardner’s syndrome, successfully treated by complete resection and reconstruction with a biologic mesh to correct the parietal defect.     

Anaesthetic management of a child with Bartter’s syndrome

We report the anaesthetic management of an eight-year-old asthmatic boy with Bartter’s syndrome who had bilateral orchidopexy with caudal epidural analgesia. Bartter’s syndrome is a rare congenital disorder characterized by hypokalaemic hypochloraemic metabolic alkalosis, hyperaldosteronism, hyperreninaemia and hyperplasia of the juxtaglomerular apparatus of the kidneys. Characteristically, although these patients are normotensive they may be hypovolaemic. They may have unstable baroreceptor responses and show marked resistance to vasopressors. Hence, fluid, acid-base and electrolyte imbalances along with haemodynamic instability pose particular problems in their anaesthetic management. Previous case reports have described the management of these patients with general anaesthesia, our patient had his orchidopexy with caudal epidural analgesia using plain bupivacaine 0.5%. The patient was haemodynamically stable throughout surgery and was comfortable with caudal analgesia as the sole anaesthetic. Hypovalaemia, acid-base status and electrolyte imbalance were treated before instituting caudal epidural analgesia. We present this case report which describes the anaesthetic considerations in the light of the pathophysiology of Bartter’s syndrome.     

Superficial circumflex iliac artery perforator flap in a case of Fournier’s gangrene

Fournier’s gangrene (FG) is a rare and acute form of necrotizing fasciitis involving the perineal region and genitalia with occasional extension up to the abdominal wall. The etiology of the FG is only partially understood, but in the majority of cases, aerobic and anaerobic bacteria are involved. FG is characterized by mortality rate ranging from 15 to 20 %, and for this reason, the disease must be treated aggressively. The key of management, after the emergency debridement of necrotic tissue, is a functional and esthetic reconstruction. We reported a case of FG in which the wide scrotal skin and fascia loss was managed with a propeller superficial artery perforator flap. Level of Evidence: Level V, therapeutic study.     

Reconstruction and anticipatory Langenskiöld procedure in traumatic defect of tibial medial malleolus with type 6 physeal fracture

Traumatic osteoarticular or ligament defect of the tibial medial malleolus is a rare entity in children. Associated lesions may include soft tissue and joint defect, subsequent instability of the ankle, and growth arrest. We report here, the case of an 11-year-old boy, a victim of a severe trauma to the ankle, managed by an original technique. It combined a reconstruction by a composite iliac crest and gluteal fascia graft, an anticipatory Langenskiold procedure, and a serratus anterior muscle flap. This original technique proved to be a suitable alternative in this type of trauma.     

Hypokalemic rhabdomyolysis in a child with Gitelman’s syndrome

We report here the first published case of a pediatric patient with Gitelman’s syndrome (GS) in whom hypokalemia-associated rhabdomyolysis developed. A 13-year-old girl was admitted with weakness of the extremities, walking difficulty and calf pain. Laboratory data showed a serum potassium level of 2.1 mmol/l and a serum creatinine phosphokinase level of 1,248 IU/l plus myoglobinemia. The presence of normomagnesemia was the basis for a genetic analysis of the thiazide-sensitive sodium chloride cotransporter gene, which revealed compound heterozygous mutations in this gene. Prompt fluid expansion and potassium supplementation led to regression of the muscle symptoms. Hypokalemia can be a rare cause of rhabdomyolysis in patients with GS, even in childhood. We emphasize that genetic analysis is advisable to determine whether the suspicion of GS is warranted.     

Herniation through both Winslow’s foramen and a lesser omental defect: Report of a case

(Received for publication on May 6, 1999; accepted on Jan. 7, 2000)     

Normovolemic hemodilution using hydroxyethyl starch 130/0.4 (Voluven) in a Jehovah’s Witness child requiring cardiopulmonary bypass for ventricular septal defect repair

Surgical repair of congenital heart disease during cardiopulmonary bypass is common, and performing these complicated procedures in the absence of blood transfusions is especially challenging. A case of a Jehovah’s Witness child who underwent surgical repair of a ventricular septal defect utilizing a new tetrastarch for autologous normovolemic hemodilution is reported. A successful operative repair was achieved without the need for non-autologous blood transfusion.     

Collagenase treatment of Dupuytren’s contracture using a modified injection method

Background and purpose — Treatment of Dupuytren’s contracture (DC) with collagenase Clostridium histolyticum (CCH) consists of injection followed by finger manipulation. We used a modified method, injecting a higher dose than recommended on the label into several parts of the cord, which allows treatment of multiple joint contractures in 1 session and may increase efficacy. We studied the occurrence of skin tears and short-term outcome with this procedure.

Patients and methods — We studied 164 consecutive hands with DC, palpable cord, and extension deficit of ≥ 20º in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint (mean patient age 70 years, 82% men). A hand surgeon injected all the content of 1 CCH vial (approximately 0.80 mg) into multiple spots in the cord and performed finger extension under local anesthesia after 1 or 2 days. A nurse recorded skin tears on a diagram and conducted a standard telephone follow-up within 4 weeks. A hand therapist measured joint contracture before injection and at a median of 23 (IQR: 7–34) days after finger extension.

Results — A skin tear occurred in 66 hands (40%). The largest diameter of the tear was ≤ 5 mm in 30 hands and > 10 mm in 14 hands. Hands with skin tear had greater mean pretreatment MCP extension deficit than those without tear: 59º (SD 26) as opposed to 32º (SD 23). Skin tear occurred in 21 of 24 hands with MCP contracture of ≥ 75º. All tears healed with open-wound treatment. No infections occurred. Mean improvement in total (MCP + PIP) extension deficit was 55º (SD 28).

Interpretation — Skin tears occurred in 40% of hands treated with collagenase injections, but only a fifth of them were larger than 1 cm. Tears were more likely in hands with severe MCP joint contracture. All tears healed without complications. Short-term contracture reduction was good.     

Hypokalemic rhabdomyolysis in a child with Bartter’s syndrome

Hypokalemia represents a rare cause of rhabdomyolysis. Some reports have described a few adult patients affected by Bartters syndrome and Gitelmans syndrome with rhabdomyolysis due to severe hypokalemia. We report the first pediatric patient with Bartters syndrome in whom rhabdomyolysis developed when her plasma potassium level was less than 2 mEq/l. Prompt intravenous fluid and potassium prevented tubular damage and acute renal failure. We recommend determining serum creatine phosphokinase in all patients affected by Bartters syndrome and profound hypokalemia.     

Brodie’s abscess following percutaneous fixation of distal radius fracture in a child

We report the case of a Brodie’s abscess presenting five and a half years following closed reduction and percutaneous pinning of a distal radius fracture. The index surgery was complicated by a pin site infection that was treated successfully with antibiotics. The patient represented with forearm pain years later, and radiological investigations revealed a Brodie’s abscess in the distal radius at the site of the previous Kirschner wires. The Brodie’s abscess was managed through surgical curettage and antibiotics. Staphylococcus aureus and diphtheroid organisms were cultured from the intraoperative specimens. A Brodie’s abscess is a form of localised subacute osteomyelitis, which usually occurs in the metaphysis of long bones and can mimic malignancy. Previous trauma or surgery has been implicated as predisposing factors. We have only identified one previously reported case of Brodie’s abscess following percutaneous pinning. Ours is the first reported case in an adolescent. The aim of this paper is to raise awareness of this rare complication and review the current literature.     

Case Report: Reconstruction of a 16-cm Diaphyseal Defect after Ewing’s Resection in a Child

Numerous options exist for intercalary segmental reconstruction after bone tumor resection. We present the extension of a recently developed surgical two-stage technique that involves insertion of a cement spacer, induction of a membrane, and reconstruction of the defect with cancellous and cortical bone autograft in a 12-year-old child. The boy was referred to our center for treatment of a right femoral diaphyseal Ewing’s sarcoma. The first stage involved resection of the tumor and reconstruction with a locked intramedullary nail and a polymethylmethacrylate cement spacer. Seven months after the initial procedure during which adjuvant chemotherapy was given, the second-stage procedure was performed. The cement was removed and cancellous and cortical bone autograft was grafted in the membrane created around the cement spacer. Touchdown weightbearing was allowed immediately, partial weightbearing was resumed 6 weeks after the operation, and full weightbearing was allowed 4 months later. Successive plain radiographs showed rapid integration of the autograft to the host bone with bone union and cortical reconstitution. The principle of the induced membrane reconstruction seems applicable to intercalary segmental reconstruction after bone tumor resection in children. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution has approved the reporting of this case report, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.