Closure of the donor site of the free radial forearm flap: a comparison of full-thickness graft and split-thickness skin graft

INTRODUCTION: Donor-site complications of free radial forearm flaps (FRFF) after closure with a split-thickness skin graft (STSG) have been reported repeatedly. Different types of closure of the donor site have been advocated to reduce donor-site complications. In our practice, a V-Y closure with a local full-thickness skin graft (FTG) is performed generally. PURPOSE: A retrospective follow-up study was performed comparing subjective and objective outcomes of FTG versus STSG closure. FRFF donor site closure in 34 head and neck cancer patients (15 STSG, 19 FTG) was studied. RESULTS: Both methods of closure showed good function, sensibility, and esthetic outcome. No statistical differences between the 2 methods could be shown. CONCLUSION: V-Y local donor site closure is a good technique which prevents an additional donor site scar and discomfort when performing an STSG closure.     

Quantitative assessment of fatty degeneration in rotator cuff muscles determined with computed tomography

OBJECTIVES: Reliable assessment of fatty degeneration of rotator cuff muscles is desirable to predict the outcome of shoulder surgery. Currently used qualitative assessments are limited by relatively high inter- and intraobserver variability. It was hypothesized that a quantitative measurement of muscle density using computed tomography (CT) was more reliable and reproducible. MATERIALS AND METHODS: Thirty shoulders from patients with rheumatoid arthritis were analyzed using parasagittal multiplanar reconstructions acquired from a 16-slice CT scanner. Three observers visually rated the severity of fatty degeneration and independently outlined the rotator cuff muscles, after which the mean density was calculated. Inter- and intraobserver agreement on both measurements was expressed by the interclass correlation coefficient (ICC) and the standard deviation of the differences (SDD) between the measurements. RESULTS: A strong correlation was found between the quantitative measure and the visual rating (R2 = 0.94; P < 0.0001). The SDD in muscle density did not exceed 2.3 Hounsfield units, and the mean rotator cuff ICC (0.98) was substantially greater than that of the visual rating (0.63). CONCLUSIONS: This study describes a reproducible method to quantify fatty degeneration of the rotator cuff muscles in CT images, with a higher interobserver agreement than the visual score, and may prove a reliable tool to evaluate the quality of the rotator cuff muscles.     

Undiagnosed obstructive sleep apnea syndrome in children with syndromal craniofacial synostosis

Children with syndromal craniofacial synostosis have a high risk for obstructive sleep apnea syndrome. Early diagnosis and treatment can relieve symptoms and morbidity. Little is known about the development and natural history of obstructive sleep apnea syndrome through life. The aim of this study was to investigate our experience of clinical history and treatment modalities concerning obstructive sleep apnea syndrome from birth until the current age in children with syndromal craniofacial synostosis. Children with one of the three syndromal craniofacial synostoses (Apert, Crouzon, or Pfeiffer) born between 1984 and 2001 were evaluated. The medical history and symptoms of obstructive sleep apnea syndrome were assessed by retrospective analysis of the medical records. The present and past complaints were explored by means of a questionnaire. Retrospective analysis of the medical records showed a suspicion for obstructive sleep apnea syndrome in 26% of the children compared with 53% in the questionnaire. The severity and presentation of obstructive sleep apnea syndrome were not related to the age of the child. Obstructive sleep apnea syndrome symptoms occurred in almost half of the children during colds. Several symptoms were significantly more common in children with a high suspicion for obstructive sleep apnea syndrome. Treatment modalities consisted of adenotonsillectomies, continuous positive airway pressure, and Le Fort III surgery. Use of a standard questionnaire showed that the suspicion for obstructive sleep apnea syndrome in children with syndromal craniofacial synostosis is much higher than reported in the medical records. Regular screening for obstructive sleep apnea syndrome with a standard questionnaire could be of additional value for the detection of obstructive sleep apnea syndrome in children with syndromal craniofacial synostosis.     

Postnatal onset of craniosynostosis in a case of Saethre-Chotzen syndrome

Saethre-Chotzen syndrome is a craniosynostosis syndrome characterized by facial and limb abnormalities. It is caused by mutations in the TWIST gene on chromosome 7p21. To date, more than 80 different mutations in TWIST have been reported in the literature.Recently, large deletions of chromosome 7p, encompassing the TWIST locus, have been detected in patients with clinical features of Saethre-Chotzen syndrome. Strikingly, all these patients were severely mentally retarded, which is otherwise a rare finding in Saethre-Chotzen syndrome. The authors report a patient with a large TWIST/7p deletion but with normal development. Furthermore, craniosynostosis was not present at birth or at the age of 4 months. However, skull radiographs taken at the age of 14 months showed stenosis of both coronal sutures, as well as of part of the sagittal suture. Reports on postnatal onset of craniosynostosis have been made in Crouzon syndrome but, to the authors' knowledge, never in Saethre-Chotzen syndrome.     

Preferred mesh-based inguinal hernia repair in a teaching setting: results of a randomized study

HYPOTHESIS: Surgeons' preferences for any of 3 methods of inguinal hernia repair are comparable in terms of operating time, incision length, perceived difficulty, and surgeon's satisfaction. DESIGN: Randomized patient-blinded study. SETTING: Teaching hospital. PATIENTS: A total of 334 patients randomized to receive 1 of the 3 repairs. INTERVENTIONS: Patients underwent hernia repair with the Prolene Hernia System, mesh plug repair, or Lichtenstein technique. MAIN OUTCOME MEASURES: Operating variables, surgeon's rating of satisfaction and difficulty, grade and experience of the operating team, and complications. RESULTS: The Lichtenstein technique took significantly the longest operating time (52 minutes vs 41 or 42 minutes; P<.001). The mesh plug repair scored the best results in difficulty and satisfaction. Overall, surgeons having performed more than 5 procedures rated the repairs less difficult and with significantly more satisfaction (P<.001 and P = .001, respectively). The complication rate did not differ between the treatment groups. None of the operative findings was correlated to the outcome, except for adverse correlation with the body mass index. CONCLUSION: From a surgeon's point of view, the mesh plug repair is superior to the Lichtenstein technique and the Prolene Hernia System in terms of operating time, incision length, perceived difficulty, and surgeon's satisfaction.     

Aortic aneurysm repair is associated with a lower inflammatory response compared with surgery for inflammatory bowel disease

BACKGROUND: Since the plasma cytokine profile reflects the body's inflammatory response to injury, this study was designed to prospectively observe the plasma cytokine levels in response to the degree of different sorts of abdominal surgical trauma. METHODS: Plasma levels of TNF-alpha, type I TNF receptor (p55), type II TNF receptor (p75), IL-6, IL-8, IL-10, phospholipase A(2) (PLA(2)), and haptoglobin were measured peri-operatively in patients undergoing bowel resection for inflammatory bowel disease or diverticulitis (IBD) (n = 9), elective repair of abdominal aortic aneurysm (AAA) (n = 9), or laparoscopic cholecystectomy (lap chole) (n = 9). RESULTS: The IBD patients showed a significant (p < 0.05) post-operative elevation in plasma IL-6, p55, p75, and PLA(2) levels, but no significant change in TNF-alpha, IL-8, IL-10 or haptoglobin levels. The AAA patients had a significant post-operative rise in IL-10 levels and a significant decrease in plasma haptoglobin levels, but no significant change of TNF-alpha, IL-6, IL-8, p55, p75, or PLA(2) concentrations. The lap chole patients demonstrated no significant change in any of these parameters. CONCLUSION: These data show that IL-6, IL-10, p55, and p75 are markers to measure the degree of inflammatory stress associated with abdominal operative procedures and demonstrate the relative lack of a cytokine response to laparoscopic cholecystectomy.     

Treatment of the triphalangeal thumb

Triphalangeal thumb is a thumb with 3 phalanges and has an estimated incidence of 1 in 25,000 live births. Clinical presentation of triphalangeal thumb can vary considerably. Most strikingly is the long finger-like thumb with clinodactyly, in the same plane as the fingers and may or may not present with an extra thumb. Anatomically, the extra phalanx can have different shapes, from wedge to rectangular. Furthermore, the involved joints, ligaments, muscles, and tendons of the first ray, from distal interphalangeal joint to radiocarpal joint, can be hypoplastic, malformed, or absent with varying degrees of stiffness or instability. Also, the first web can be insufficient, and radial polydactyly as well as other hand deformities can be present. The aim of surgical treatment is to try to reconstruct or correct the anatomic difference and at the same time provide a more acceptable appearance. In our series, depending on the malformation, operations varied from removal of the delta phalanx with ligament reconstruction to multiple osteotomies and rebalancing as well as pollicization. Complications are mostly related to structures that have not been reconstructed or corrected during operation. Results in these often complex cases can be rewarding if the surgeon has sufficient knowledge of the underlying anatomic differences.     

The effect of fluoropyrimidines with or without thymidine phosphorylase inhibitor on the expression of thymidine phosphorylase

Thymidine phosphorylase (platelet-derived-endothelial-cell-growth-factor) catalyzes the reversible phosphorolysis of thymidine to thymine and 2-deoxyribose-1-phosphate, activates 5'-deoxy-5-fluorouridine (5'DFUR) and inactivates trifluorothymidine (TFT). The effect of 5'DFUR and TFT with or without a specific thymidine phosphorylase inhibitor (TPI) on thymidine phosphorylase mRNA, protein expression and activity was studied, in three human colon cancer cell lines, WiDR, HT29 and Lovo exposed for 72 h at IC50 concentrations. In Lovo cells TFT plus TPI only increased thymidine phosphorylase-protein expression 1.7-fold; 5'DFUR and TFT treatment increased thymidine phosphorylase mRNA levels 5- and 1.4-fold, respectively. In WiDR cells, 5'DFUR plus TPI significantly decreased thymidine phosphorylase-protein. TFT and TFT plus TPI increased thymidine phosphorylase-protein 2- and 3-fold, respectively. TPI and 5'DFUR decreased thymidine phosphorylase-mRNA levels significantly. In HT29 cells, 5'DFUR and 5'DFUR plus TPI decreased both thymidine phosphorylase-protein and thymidine phosphorylase-mRNA. In all cell lines 5'DFUR and TFT did not affect thymidine phosphorylase activity, but treatment with TPI (alone or in combination) eliminated thymidine phosphorylase activity. This demonstrated that regulation is drug and cell line dependent.