Latissimus dorsi flap coverage of soft tissue defect following below-knee amputation: emphasis on flap design and recipient vessels

High-energy trauma to the lower extremity often results in amputation of the limb. For maximal preservation of limb length during amputation, free tissue transfer is often necessary. In this study, we report our experience of stump coverage using latissimus dorsi musculocutaneous flaps with an emphasis on flap design and recipient vessels. Between January 2005 and September 2010, twelve patients with severe traumatic injuries to the lower leg underwent below-knee amputations with stump coverage using latissimus dorsi free flaps. The primary and secondary cases were approached differently regarding the flap design and recipient vessels. All flaps survived completely. There were 8 primary cases and 4 secondary cases. In the primary cases, the anterior tibial artery was used as the recipient vessel in 6 cases, and in 2 cases, the descending geniculate artery was used. In the secondary cases, the descending geniculate artery was used in all cases. There were two cases of ulceration on the grafted non-weight-bearing site, but after the usage of collagen–elastin artificial dermis, no ulcerations were seen. The latissimus dorsi musculocutaneous flap is the most feasible option for coverage of amputation stumps. In flap design, the width of the skin paddle must match the anteroposterior diameter of the defect at the stump. The latissimus dorsi muscle must sufficiently wrap the bony stump for padding. We recommend using the anterior tibial artery as a recipient vessel in primary cases, and the descending geniculate artery in secondary cases.     

The predisposing factors for the heterotopic ossification after cervical artificial disc replacement

Background contextHeterotopic ossification (HO) is defined as a formation of bone outside the skeletal system. The reported HO occurrence rate in cervical artificial disc replacement (ADR) is unexpectedly high and is known to vary. However, the predisposing factors for HO in cervical ADR have not yet been elucidated.PurposeInvestigation of the predisposing factors of HO in cervical arthroplasty and the relationship between degeneration of the cervical spine and HO occurrence.Study designRetrospective study to discover predisposing factors of HO in cervical arthroplasty.Patient sampleA total of 170 patients who underwent cervical ADR were enrolled including full follow-up clinical and radiologic data.Outcome measuresRadiologic outcomes were assessed by identification of HOs according to McAfee's classifications.MethodsThis study enrolled a total of 170 patients who underwent cervical ADR. Pre-existing degenerative change included anterior or posterior osteophytes, ossification of the anterior longitudinal ligament, posterior longitudinal ligament, or ligamentum nuchae. The relationships between basic patient data, pre-existing degenerative change, and HO were investigated using linear logistic regression analysis.ResultsAmong all 170 patients, HO was found in 69 patients (40.6%). Among the postulated predisposing factors, only male gender and artificial disc device type were shown to be statistically significant. Unexpectedly, preoperative degenerative changes in the cervical spine exerted no significant influence on the occurrence of HOs. The odds ratio of male gender compared with female gender was 2.117. With regard to device type, the odds ratios of Mobi-C (LDR medical, Troyes, France) and ProDisc-C (Synthes, Inc., West Chester, PA, USA) were 5.262 and 7.449, respectively, compared with the Bryan disc.ConclusionsDefinite differences in occurrence rate according to the gender of patients and the prosthesis type were identified in this study. Moreover, factors indefinably expected to influence HO in the past were not shown to be risk factors thereof, the results of which may be meaningful to future studies.     

Initial experiences with RoSS surgical simulator in residency training: a validity and model analysis

Robotic surgery is an important new tool in many surgical procedures, and training curriculums must adapt to this new technology. Robotic surgical simulators have been developed as a means of providing training without the inherent risks of actual surgery. The purpose of this study is to evaluate the construct validity of the RoSS surgical simulator by correlating simulator performance with amount of time in training and to create a performance model in which time in training is a parameter. A total of eight residents with varying amounts of training were given access to the RoSS surgical simulator and were evaluated on performance of a simulated surgical task. This data was then used to create Akaike information criteria to compare goodness of fit. Participants were also given a questionnaire as to their experience with the simulator and their feelings about the use of simulators in training. Training time and performance within the simulator were shown to have a linear relationship. Correlations were high, with R ² values of 0.95, 0.94, and 0.86 for each of the three performance metrics. Likelihood ratios were similarly high at 4.25 × 10⁹, 10,950, and 362. Participant opinion showed that residents feel that robotic training is an important part of their education and that the simulator is an effective supplement. The RoSS surgical simulator accurately corresponds to training level and is a valid evaluation tool of training experience. These findings are encouraging for the use of robotic simulators in surgical training.     

Hepatic paraganglioma and multifocal gastrointestinal stromal tumor in a female: Incomplete Carney triad

The Carney triad (CT) describes the coexistence of multiple neoplasms including gastrointestinal stromal tumors (GISTs), extra-adrenal paraganglioma and pulmonary chondroma. At least two neoplastic tumors are required for diagnosis. In most cases, however, CT is incomplete. We report a case of an incomplete CT in a 34-year-old woman with a multifocal GIST and non-functional paraganglioma of the liver. Preoperative evaluation with a gastrofiberscope and abdominal computed tomography revealed multiple gastric tumors resembling GISTs and a single liver lesion which was assumed to have metastasized from the gastric tumors. The patient underwent total gastrectomy and partial hepatectomy. Histologic findings confirmed multiple gastric GISTs and paraganglioma of the liver. We report a case of a patient with incomplete expression of CT.