Flap Monitoring Using Transcutaneous Oxygen or Carbon Dioxide Measurements

Free tissue transfer is a cornerstone of complex reconstruction. In many cases, it represents the last option available for a patient and their reconstruction. At high-volume centers, the risk of free flap failure is low but its occurrence can be devastating. Currently, the mainstay for flap monitoring is the clinical examination. Though reliable when performed by experienced clinicians, the flap exam is largely subjective, is performed discontinuously, and often results in significant time delay between detection of flap compromise and intervention. Among emerging flap monitoring technologies, the most promising appear to be those that rely on noninvasive transcutaneous oxygen and carbon dioxide measurements, which provide information regarding flap perfusion. In this article, we review and summarize the literature on various techniques but primarily emphasizing those technologies that rely on transcutaneous gas measurements. We also define characteristics for the ideal flap monitoring tool and discuss critical barriers, predominantly cost, preventing more widespread utilization of adjunct monitoring technologies, and their implications.     

Occlusion of the Profunda Femoris Artery in Competitive Cyclists

Symptomatic lower limb ischaemia in endurance athletes and competitive cyclists is usually due to iliac artery compression syndrome. We report the cases of two competitive cyclists who presented with thigh claudication, with no previous cardiovascular or thrombo-embolic risk factors. They both had normal conventional and sports exercise tests. Further investigations revealed flush occlusion of the profunda femoris artery, believed to be due to dissection. Both patients improved with graduated exercise. We recommend contrast-enhanced MRA as the investigation of choice for this previously unreported condition.     

The use of outcome measures relating to the knee

Accurate outcomes assessment is one of the fundamental aspects of any reliable research. There are a vast number of outcome instruments currently available in orthopaedics. This plethora and diversity can lead to frustration when it comes to choosing the appropriate option. In this article we address the essential properties an outcome measure must possess, aiming to allow an informed selection of the most suitable instrument. We describe and illustrate key psychometric properties that are to be assessed when judging suitability of an instrument, such as validity, reliability and responsiveness. We also review some of the most commonly used and recommended outcome measures available in regard to different knee pathologies. With no intention of recommending a specific option, we briefly outline advances and shortcomings of named instruments.     

Association of benign recurrent vertigo and migraine in 208 patients

The aim of this study was to determine the association of benign recurrent vertigo (BRV) and migraine, using standardized questionnaire-based interview of 208 patients with BRV recruited through a University Neurotology clinic. Of 208 patients with BRV, 180 (87%) met the International Classification of Headache Disorders 2004 criteria for migraine: 112 migraine with aura (62%) and 68 without aura (38%). Twenty-eight (13%) did not meet criteria for migraine. Among patients with migraine, 70% experienced headache, one or more auras, photophobia, or auditory symptoms with some or all of their vertigo attacks, meeting the criteria for definite migrainous vertigo. Thirty per cent never experienced migraine symptoms concurrent with vertigo attacks. These met criteria for probable migrainous vertigo. Among patients without migraine, 21% experienced either photophobia or auditory symptoms with some or all of their vertigo attacks; 79% experienced only isolated vertigo. The age of onset and duration of vertigo attacks did not differ significantly between patients with (34 ± 1.2 years) and patients without migraine (31 ± 3.0 years). In patients with migraine, the age of onset of migraine headache preceded the onset of vertigo attacks by an average of 14 years and aura preceded vertigo by 8 years. The most frequent duration of vertigo attacks was between 1 h and 1 day. Benign recurrent vertigo is highly associated with migraine, but a high proportion of patients with BRV and migraine never have migraine symptoms during their vertigo attacks. Other features such as age of onset and duration of vertigo are similar between patients with or without migraine.     

Are pain and function better measures of outcome than revision rates after TKR in the younger patient?

Revision is the gold standard outcome measurement for survival analyses of orthopaedic implants but reliance on revision as an endpoint has been recently questioned. This study, that assesses long-term outcome in a specific group of patients who had undergone total knee replacement (TKR) for osteoarthritis, highlights the main problems facing modern survival analyses. Minimum 12-year survival and outcome data were reviewed for a series of sixty patients under the age of 60 years (mean age 55.4 years) who underwent total knee replacement (TKR) for osteoarthritis. The patients are a subgroup from a larger consecutive series of 1429 patients who underwent TKR between 1987 and 1993 at a single institution. Whilst the main study aim was to compare outcome of TKR using different endpoints, the outcome of TKR in this younger subpopulation could also be investigated.With revision as the primary endpoint the survival for TKR was 82.2% (95% CI 17.3). The mean OKS at follow-up (mean 15.7 years) was 30.9. However, many of the 82% of patients who did not undergo revision had a less than satisfactory outcome. 41% of these patients reported modest or severe pain (using the OKS) at final follow-up. A combined endpoint including revision, poor function and significant pain drastically reduced the survival rate for the operation. Survival based on revision alone provides an acceptable but inaccurate impression of outcome in younger TKR patients (under 60 years). A true representation of the success of TKR should include pain and function as endpoints.     

Early bone marrow transplantation in an infant with Wiskott-Aldrich syndrome.

The Wiskott-Aldrich Syndrome (WAS) is a rare X-linked immunohematological disorder characterized by eczema, profound thrombocytopenia, and progressive immunodeficiency. Severe hemorrhage, overwhelming sepsis, or lymphoreticular malignancy usually cause death in childhood. Recently, bone marrow transplantation (BMT) has been curative in some well-established cases, but there is no general agreement about the place of BMT in infants with WAS before the development of significant immunological abnormalities. We describe the successful use of early histocompatible BMT in a 10-month-old infant in whom WAS was diagnosed on the basis of eczema, thrombocytopenia, small platelets, and raised serum immunoglobulin A (Ig) and IgE, but before the development of immunodeficiency as evidenced clinically by recurrent infections, or immunologically by low serum IgM or consistently abnormal lymphocyte responses to mitogens. After an unstable period for several weeks posttransplantation when he developed marked hepatomegaly and severe interstitial pneumonitis, he made a good recovery. His eczema and thrombocytopenia resolved and he has shown no clinical or laboratory evidence of immunodeficiency. It is now over 2 years since his BMT. Because of the poor prognosis of WAS, where a histocompatible donor is available, BMT at the earliest opportunity, despite the inherent risks of such a procedure, may be the best option for an infant with WAS.     

Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion

In a group of 55 women with chronic pain due to pelvic congestion measurement by ultrasound revealed they had a larger uterus and thicker endometrium as compared with a group of normal women matched for age, parity and the presence of polycystic ovaries found on ultrasound scanning. Many women with pelvic congestion (56%) were found on ultrasound to have cystic changes in their ovaries which ranged from a classic polycystic pattern to the appearance of clusters of 4-6 cysts in bilaterally enlarged ovaries. It is suggested that uterine enlargement and thickening of the endometrium are caused by oestrogen, either from the effects on the target organs of an increased concentration or of hypersensitivity to oestrogen.