Cotrel-Dubousset instrumentation in neurofibromatosis spinal problems

Cotrel-Dubousset (CD) instrumentation has been employed in 12 patients with neurofibromatosis with spinal deformity (ten regular scoliosis, one dysplastic kyphoscoliosis, and one multilevel laminectomy). The follow-up period averaged 33 months. In regular scoliosis frontal correction averaged 69%, axial derotation averaged 33%, and sagittal normalcy was produced without immobilization and without pseudoarthrosis. Successful arthrodesis was obtained in a dysplastic patient after initial failure via anterior concave struts and posterior CD instrumentation with immobilization. Stabilization and fusion of one patient with multiple-level thoracic laminectomy was achieved without immobilization. CD instrumentation is effective in the surgical management of neurofibromatous spinal abnormalities.     

Cotrel-Dubousset pedicle screw system for various spinal disorders. Merits and problems.

Eighty-five consecutive patients with various spinal disorders who underwent surgery using the Cotrel-Dubousset pedicle screw system at Kantoh Rosai Hospital between August 1986 and November 1989 were studied. The group included 52 men and 33 women, ranging in age from 19 to 76 years, with an average age of 53 years. The postoperative follow-up period was from 15 to 54 months, with an average of 33 months. The diagnoses were lumbar degenerative disorders in 69 cases (spondylolisthesis in 32, lumbar degenerative spinal canal stenosis without spondylolisthesis in 21, and "unstable lumbar spine" in 16), spinal trauma in 9, spinal deformities in 5 (scoliosis in 3 and kyphosis in 2), and tumor in 2 (1 spinal cord tumor and 1 vertebral tumor). The Cotrel-Dubousset pedicle screw system proved not only to be useful in fixing an unstable spine from the lower thoracic vertebra to the sacrum, as is the case with the other pedicle screw systems, but also to have great advantages for use in various spinal disorders, including reduction of slipped vertebra, correction of spinal deformity combined with a hook system, and for anterior spinal instrumentation. Postoperative clinical results were good in most of the cases, but pseudarthrosis considerably affected the results in a few cases. Therefore, great care must be taken, both strategically and technically, to prevent pseudarthrosis.     

Early experience with crimped bovine pericardial conduit for arterial reconstruction.

A bovine pericardial conduit was developed in the laboratory incorporating the principle of crimping used for synthetic vascular prostheses. The pericardium was processed in glutaraldehyde and the tube was crimped by a technique which preserves the integrity of collagen fibres. This vascular substitute presents a non-thrombogenic and non-porous inner surface which does not require preclotting and does not leak. The material is very soft, easy to handle and suture, coapts nicely to suture lines resulting in a hemostatic anastomosis. The crimping design provides longitudinal elasticity and resistance to collapsing, retains its shape with bending and avoids kinking. Crimping provides a circular tube which makes the construction of the anastomosis easier. Experimental studies in dogs demonstrated absence of thromboembolism with the conduit implanted in the abdominal aorta. Fibrin accumulation was not noted in the convexities of the crimps. This conduit was designed for aortic and pulmonary reconstruction and available in different sizes with or without a biological valve. Initial clinical experience included its use in 10 patients with aortic dissections or aortic aneurysms from August 1989 to March 1990. A reconstruction of the abdominal aorta was performed in 2 patients, the descending thoracic aorta in 2, the ascending aorta in 2 and the ascending aorta including the aortic valve and reimplantation of coronary arteries in 4. For the latter 4, composite crimped pericardial tubes containing a porcine bioprosthesis were used. An additional patient with a single ventricle underwent a Fontan type operation also employing a valved crimped pericardial conduit.(ABSTRACT TRUNCATED AT 250 WORDS)     

Early experience with the crescent expander in immediate and delayed breast reconstruction.

Traditional breast expanders have known drawbacks, such as undesirable fullness at the upper pole, inadequate expansion of the residual breast tissue, and poor ptosis of the reconstructed breast. Crescent-shaped expanders are thought to improve the result in that expansion is concentrated at the basal breast pole. The aim of this prospective pilot study was to evaluate our results with the crescent-shaped expander in immediate and delayed breast reconstructions. Twenty-five patients, median age 51 (27-75) years, underwent 28 operations. The median follow-up time was 8 (4-15) months. Four patients developed complications including superficial infections, capsular contractions (Baker III-IV), and fullness of the upper pole. Three of these patients had been given irradiation. Breast reconstructions with the crescent-shaped expander allowed expansion of the lower pole and led to an anatomical breast shape. Patients' satisfaction during expansion was good. Our data indicate a correlation between complications and radiotherapy.     

Early experience with mitral valve reconstruction for mitral insufficiency

Mitral valve repair for mitral regurgitation has been reported to have more favorable early and late results than mitral valve replacement. From July 1985 through July 1990, 63 patients have undergone valve repair at Good Samaritan Hospital. Twenty-two men and 41 women whose ages ranged from 34 to 81 years (mean 67.9 years) were treated. Twenty-eight patients were in New York Heart Association functional class III or IV. Twelve (19%) had undergone prior cardiac surgery. Isolated valve repair was performed in 18 patients. Valve repair was combined with coronary artery bypass grafting, other valve procedures, or aneurysm resection in the remainder (71%). Two patients (3%) died while in the hospital, and four deaths (one valve-related) occurred after discharge. Leaflet resection for ruptured chordae was done in 24 patients (38%), chordal shortening in 5 patients (8%), and leaflet transposition in 2 patients. Rigid ring annuloplasty (Carpentier) was performed in 62 patients. Eight patients required mitral valve replacement at the same operation because of unsatisfactory valve repair. Results of valve repair evaluated by echocardiography at discharge show that 48 patients (88%) are free of significant regurgitation. Follow-up to date reveals that all surviving patients who underwent valve repair have clinically improved and are stable. Four of five patients with moderate mitral regurgitation are currently asymptomatic. There have been two valve-related late failures requiring reoperation. Based on this early experience, we conclude that valve repair compared with mitral valve replacement has a low operative mortality with good early results. Continued efforts to preserve native mitral valve function in the presence of mitral regurgitation appear justified.     

Biplanar flap reconstruction for pressure ulcers: experience in patients with immobility from chronic spinal cord injuries

BackgroundSurgical therapy for advanced-stage pressure ulcers recalcitrant to healing is a widely accepted practice. The present study examined the incidence of wound recurrence after reconstruction with fasciocutaneous versus combined (biplanar) muscle and fasciocutaneous flaps.MethodsA retrospective review identified 90 nonambulatory patients with spinal cord injury who underwent reconstruction for persistent decubitus ulcers from 2002 to 2008. Electronic medical records were surveyed for patient comorbidities and postoperative complications. Statistical methods included the Fisher exact test and the Mann–Whitney U test with a 2-sided P value of less than .05.ResultsAmong 90 patients reviewed, 33% (n = 30) received fasciocutaneous flaps and 66% (n = 60) underwent biplanar reconstruction. Comorbidities were the same between cohorts with the exception of a greater prevalence of diabetes in the biplanar group (27% vs 50%; P < .05). The incidence of recurrence for biplanar flaps (25%) was significantly lower than for fasciocutaneous reconstruction (53%; P < .01).ConclusionsBiplanar flap reconstruction should be considered for chronically immobilized patients at high risk for recurrent decubitus ulceration.     

Breast reconstruction after mastectomy. The Cape Town experience

As methods have advanced, trends in breast reconstruction after mastectomy have changed considerably with more emphasis being placed on reconstruction by means of tissue expansion. Indications for using the various methods available are discussed and their advantages and disadvantages enumerated. By May 1987, 95 breasts in 88 patients had been reconstructed at Groote Schuur Hospital with few complications. The challenge remains one of improving the appearance of reconstructed breasts.     

Early experience with the deep inferior epigastric perforator flap in breast reconstruction

The free transverse rectus abdominis myocutaneous (TRAM) flap has earned a prominent place in the armamentarium of the clinician performing breast reconstructive surgery. There is, however, significant morbidity associated with this flap. With the advent of the deep inferior epigastric artery perforator (DIEP) flap many of these disadvantages may be overcome. Early experience with this promising technique is presented.Presented at the Seventh Annual Meeting of the European Association of Plastic Surgeons (EURAPS), May 16-18, 1996, Innsbruck, Austria     

Early experience in reconstruction of long ureteral strictures with allogenic amniotic membrane

Objective:   To present our experience with the application of human amniotic membrane for the reconstruction of extensive ureteral wall defects.
Methods:   Between 2003 and 2006, 11 patients underwent reconstructive surgery of the ureter. A human amniotic membrane allograft was used to supplement ureteral wall defects. Indications for the procedure included ureteral strictures of a 5.5 cm average (range, 3–8 cm) localized in different parts of the ureter: upper (5), middle (5) and lower (3). The etiology of ureteral loss was: postinflammatory after a complicated stone disease (5), iatrogenic (4) and idiopathic (2). Diagnosis of ureteral stricture was based on antegrade pyelography and excretory urography. Two patients had synchronous treatment for upper and middle ureteral stenosis. Treatment efficacy was assessed by excretory urography and ultrasound.
Results:   The mean hospitalization time was 11.9 days, mean operation time 128 min and with an average follow up of 25.2 months. Complications included: stricture recurrence (1) and symptomatic urinary tract infections (2). Excretory urography showed lack of obstruction and normal width of ureters. In one patient, residual hydronephrosis was present on ultrasound.
Conclusions:   The described method seems to be a promising tool in the reconstruction of extensive ureteral strictures.     

Early experience with in situ saphenous vein bypass for distal arterial reconstruction

During a 36-month period 74 patients underwent infrainguinal in situ saphenous vein bypass to the popliteal or tibial vessels. The first 54 operations were performed with standard valvulotomes and valve-cutting scissors, while in the last 20 operations a new intraluminal valve-cutting device was used to incise the valves. Ninety-four percent of bypasses were performed for limb salvage, 80% of all operations were done to the tibial vessels, and 31% of bypasses were done to the ankle vessels. The operation was attempted in 81 patients and completed in 74 patients, for a vein utilization rate of 91%. Fifty-five percent of all veins had a distal diameter of less than 4 mm (average 3.6 mm). The patency rates were 92% at 3 months and 90% at 12 and 36 months for all grafts. There were six failed grafts, all within the first 6 months, and eight diabetic patients required reoperation, two for missed valve leaflets, and three needed revision of the distal anastomosis; however, all these grafts were patent at the time of reexploration. There were four perioperative deaths and two patients had nonfatal postoperative myocardial infarctions. This study demonstrates that in situ saphenous vein grafting provides for a high vein utilization rate and suggests that the technique provides for higher graft patency and limb salvage rates than do more traditional types of procedures.     

Early experience with the crescent expander in immediate and delayed breast reconstruction

Traditional breast expanders have known drawbacks, such as undesirable fullness at the upper pole, inadequate expansion of the residual breast tissue, and poor ptosis of the reconstructed breast. Crescent-shaped expanders are thought to improve the result in that expansion is concentrated at the basal breast pole. The aim of this prospective pilot study was to evaluate our results with the crescent-shaped expander in immediate and delayed breast reconstructions. Twenty-five patients, median age 51 (27–75) years, underwent 28 operations. The median follow-up time was 8 (4–15) months. Four patients developed complications including superficial infections, capsular contractions (Baker III–IV), and fullness of the upper pole. Three of these patients had been given irradiation. Breast reconstructions with the crescent-shaped expander allowed expansion of the lower pole and led to an anatomical breast shape. Patients’ satisfaction during expansion was good. Our data indicate a correlation between complications and radiotherapy.     

Early experience and results with the periacetabular osteotomy. The Mayo Clinic experience.

The purpose of the present study was to review the early results of periacetabular osteotomy in the initial group of patients undergoing this procedure at the authors' institution. The first 21 hips in 19 patients with greater than 2 years followup, which represents the learning curve with this operation, were reviewed retrospectively. There were 14 females and five males with an average age of 21 years (range, 17-43 years). Intertrochanteric osteotomy was performed simultaneously on four patients with coxa valga and inadequate correction with periacetabular osteotomy alone. At an average of 38 months of followup (range, 24-52 months), the Mayo hip scores improved from an average of 46 points (range, 34-58 points) to an average of 68 points (range, 42-80 points). Hip range of motion declined slightly in all three arcs of motion. The lateral center edge angle of Wiberg improved from an average of 2 degrees to an average of 24 degrees. The loading zone angle (T?nnis) improved from an average of 24 degrees to an average of 11 degrees. The anterior center edge angle of Lequesne improved from an average of -6 degrees to an average of 38 degrees. Complications included two peroneal palsies, both of which resolved completely; three ischial fractures that healed uneventfully; three asymptomatic pubic nonunions; and asymptomatic heterotopic ossification in five patients. One patient underwent subsequent total hip arthroplasty for progressive arthritis and pain. Another patient required intertrochanteric osteotomy at a later date. The early results in this initial group of patients treated with periacetabular osteotomy show reliable radiographic correction of deformity and improved function with an acceptable complication rate. Patients should be counseled carefully about possible loss of motion postoperatively. Additional study is necessary to assess the long term results of this procedure.     

Two-stage flexor-tendon reconstruction. Ten-year experience

One hundred and fifty fingers in 136 patients were treated by a two-stage flexor-tendon reconstruction and followed for an average of 2.4 years. A salvage procedure such as this was needed for most of these fingers since 81 per cent of the injuries were in Zone 2 and 45 per cent were Grade 5 in severity. Before reconstruction, the mean total active motion (all joints combined) for each finger was 102 degrees and the mean grip strength was 20 per cent of normal. At final follow-up, the mean total active motion of these fingers was 176 degrees and the mean grip strength was 79 per cent of normal. Three months after tendon-grafting, the results had reached a plateau, and no significant change occurred thereafter. Complications were a flexion contracture of varying degree in 41 per cent of the fingers, especially when a contracture was present preoperatively (40 per cent); rupture of the tendon graft in 14 per cent; and infection in 4 per cent. This review reaffirmed the usefulness of two-stage flexor-tendon reconstruction as a salvage procedure to restore function of flexor tendons.     

Our experience with pharyngoesophageal reconstruction.

Our experience with 11 cases of cervical esophageal reconstruction following excision of the hypopharynx and conservative neck dissection is reported. For the reconstructive procedure, we utilized a full-thickness skin graft from the penis according to Kaplan and Markowicz in 2 cases and a deltopectoral flap according to Bakamjian in 9. Critical evaluation of the clinical follow-up has led us to prefer the second method. It seems, in fact, to be the solution of choice in this kind of surgery, for the deltopectoral flap offers a generous source of viable skin due to its good blood supply.     

Cotrel-Dubousset instrumentation in adults. A preliminary report

In an attempt to assess the value of the Cotrel-Dubousset (CD) system for adult spinal disorders, the first 50 adult cases performed at Johns Hopkins were reviewed. Treatment of adult scoliosis with the CD system yielded results comparable to standard techniques. Curve correction was directly proportional to the preoperative flexibility with no loss of correction in any case. All patients went on to a solid arthrodesis, with only three patients requiring the use of postoperative orthoses. Operative time was initially prolonged during the phase of acquiring expertise with the system; however, blood loss and hospitalization were comparable. In both the scoliosis and kyphosis groups instrumentation and fusion incorporated the same number of levels as would have been required for conventional instrumentation systems. In the spondylolisthesis, tumor and trauma groups a total of 88 transpedicle screws was used in 18 patients without neurologic complications. Pedicle screws provided a fixation alternative in cases requiring laminectomies. In the 25 cases with tumors, spondylolisthesis, and trauma, CD instrumentation reduced the number of vertebral levels required for fixation. Compared to Harrington or Luque systems, the average number of motion segments spared per patient was 1.3 in the spondylolisthesis group, 2 in the tumor group and 2.1 in the trauma group. This study suggests that the CD system, although initially developed for idiopathic adolescent scoliosis, is versatile and can be safely and effectively applied to a variety of adult spinal conditions. In cases of spinal pathology due to neoplasm, spondylolisthesis, and trauma, CD instrumentation with the option of transpedicle fixation appeared to offer significant advantages over conventional methods, and an average of 1.6 lumbar motion segments could be preserved per case.     

Extended latissimus dorsi musculocutaneous flap for breast reconstruction: experience in Oriental patients.

Unilateral breast reconstruction with an extended latissimus dorsi musculocutaneous flap was carried out for 12 women in the National Cheng Kung University Hospital. Eleven patients acquired a good or fair result cosmetically. We analysed the net weight of the flap as well as various anthropometric data to see what effect they have on the final aesthetic outcome. The weight of the flap ranged from 180 to 610 g, and the resected specimen weighed from 160 to 635 g. The flap weight was equivalent to 61%-113% of the specimen weight. A satisfactory result could be achieved when the bulk of the flap attained 70% of the mass resected. We also observed that the aesthetic quality is better when the breast is less ptotic. All of the muscle transfers survived completely without any flap loss. The only complications included one minor wound edge slough and another modest seroma formation at the donor site. This reconstructive method is a viable option for young women with small or medium-sized breasts who anticipate pregnancy in the future. It is especially advisable in Oriental society, since the breast size of the patients is generally smaller and the donor scar is hidden, given the hypertrophic tendency of the lower abdominal scar in Asian people undergoing TRAM flap reconstruction.