Modified Z-plasty repair of webbed neck deformity seen in Turner and Klippel-Feil syndrome.

OBJECTIVE: Webbed neck deformity exists in many syndromes including Turner's or Klippel-Feil syndrome. Multiple problems are encountered with existing techniques to correct a webbed neck deformity. In Turner's syndrome, a subcutaneous band of thickened fascia and a low neck hairline present a challenge to the surgeon when designing a repair. The authors propose the following new technique that addresses both issues. MATERIAL AND METHODS: Five patients with webbed neck underwent this new procedure. A Z-plasty is performed with the midline arm down the length of the web. The subcutaneous fibrous band is excised, the shortened trapezius is released, and the hair-bearing flap is excised. The anterior flap is rotated and advanced to join its mate flap from the contralateral neck at the posterior midline. A resultant dog-ear near the acromion is corrected with an additional Z-plasty. RESULTS: In all five patients, the functional and aesthetic results were very satisfactory to both patient and surgeon. An 11-year follow-up is presented with excellent correction of the webbing. Both limited range of motion and the cosmetic deformity are addressed by this technique. CONCLUSION: The results obtained by using the simplified modified Z-plasty technique for repair of webbed neck deformity are very satisfactory. We propose the use of this technique for correction of webbed neck deformities whenever the posterior surface of the neck web contains a significant amount of hair.     

Methodology for the determination of dinitroaniline herbicides in tissue and excreta

A method is presented for the analysis of trace amounts of dinitroaniline herbicides in tissue and excreta. The method employs extraction of the tissue or excreta with organic solvent, clean up by liquid/liquid partitioning or silica gel chromatography, and ultimate analysis by gas chromatography using electron capture detection. Recoveries of greater than 80% were noted over the range of concentration 0.1 to 1.0 microgram/g.     

Mechanical performance of sutures in surgery.

In this study, we have compared the recommended configuration of a knot with specified sutures as ascertained by mechanical performance tests to that employed by a group of board-certified surgeons. Agreement between the surgeon and the results of the test was encountered in only one fourth of the instances. In another one fourth of the cases the surgeon overestimated the number of throws required for a knot to reach knot break. This additional suture material further handicaps the host's defenses, thereby inviting infection. Surgeons employed knots that untied without reaching knot break in the remaining half of the cases. The holding power of many of the knots that untied was substantially less than that of knots reaching knot break. On the basis of the study, it is recommended that results of the mechanical performance tests be made readily available to the surgeon so that his patient can receive maximal benefits from the knotted suture with the least damage to the host's defenses.     

Rapid antibiotic disk sensitivities of burn eschar and infected wounds.

This study was undertaken to develop a more rapid antibiotic sensitivity test of the pathogens in soft tissue infections and burn wound eschar. The proposed rapid antibiotic sensitivity test was performed directly on the clinical specimen rather than on single strains of bacteria isolated from the tissue. By performing the antibiotic sensitivity tests directly on the tissue sample, the physician obtains the test results within seven hours after receiving the specimen rather than 38 to 52 hours later, the time delay encountered with the conventional technique. The modification used did not alter most of the standards advised by the Food and Drug Administration (3), since there was no inclusive change in medium, agar depth or antibiotic sensitivity disk. The changes in the Kirby-Bauer (1) test necessitated by using the clinical specimen did not alter significantly the interpretation of the antibiotic susceptibility. If clinically significant numbers of bacteria, 10(6)-10(9), were present, variations in the inoculum size did not appreciably change the results of the antibiotic susceptibility tests. If the incubation requirement for the standard Kirby-Bauer (1) antibiotic susceptibility test was reduced to seven hours, it also did not significantly limit the accuracy of the test. As expected, the variable most difficult to standardize was the heterogeneous inoculum containing large numbers, 10(7), of different organisms. A zone of inhibition interpreted as sensitive with one organism was occasionally masked by the presence of the confluent growth of an organism in which the zone of inhibition was considered resistant. However, even in this instance, it is possible that mixed culture sensitivities may provide the most valid information in mixed infections, since they more closely simulate the real clinical situation.     

The treatment of hemangiomas: with special reference to the role of steroid therapy.

Hemangiomas are the most common of all human birth defects. The author has reviewed a 25-year personal experience with treatment of over 1000 patients with a variety of common and rare developmental vascular anomalies. Attention is given to a more useful clinical classification of these disorders. The classification is intended to be helpful in estimating prognosis of the lesions and as a guide to the choice of therapy. Many treatment modalities are evaluated--some successful and some quite disappointing. Surgical excision, irradiation, CO2 freezing, sclerosing agents, cauterization, steroid therapy and watchful waiting are among the treatment methods evaluated. High dose--short course Prednisone therapy has proved to be a major new addition to the treatment of massive juvenile capillary hemangiomas. Numerous misconceptions have appeared in the medical literature. These are noted and a philosophic basis for present day management is suggested for each type angioma. The roles of growth, resolution, histologic picture and sense of deformity are considered in viewing the surgeon''s approach to these difficult and challenging problems. Some evidence and speculations are offered as to the etiology, neurogenic influences and physiological dynamics of the various hemangiomas.     

Proteolytic enzymes as adjuncts to antimicrobial prophylaxis of contaminated wounds.

When a tissue is injured, its vessels exhibit a marked increase in vascular permeability. Blood proteins, including fibrinogen, traverse the vessel walls and lead to the development of a surface coagulum. This inflammatory response continues until primary closure of the wound edges is accomplished. The thickness of the surface coagulum is roughly proportional to the time interval between wounding and closure. This coagulum encompasses the surface contaminants, preventing contact with either topical or systemic antibiotics. The presence of this surface coagulum limits the time in which antibiotic prophylaxis is effective. At three hours after injury, antimicrobial prophylaxis of contaminated wounds has no therapeutic value. Hydrolysis of the protein coagulum by proteolytic enzymes enhances the activity of the antibiotic in experimental wounds. The success of proteolytic enzymes as adjuncts to delayed antibiotic treatment can be correlated with the clot lysis activity of the enzymes in vitro. Travase, the most potent fibrinolytic enzyme, is the most effective adjunct to delayed antibiotic therapy of contaminated wounds. In contrast, the active enzymes found in Elase, which exhibit no significant clot lysis activity in vitro, do not potentiate the activity of antibiotics in wounds subjected to a delay in treatment. Travase prolongs the period of effective topical antibiotic action for at least eight hours in experimental contaminated wounds. The therapeutic merit of Travase is also apparent when the antibiotic is administered systemically. Travase shows promise as an adjunct to a variety of antibiotics that are effective against both gram-positive and gram-negative organisms. The results of these experimental studies support our belief that clinical studies support our belief that clinical studies should now be initiated to test the therapeutic value of Travase as an adjunct to antibiotics in heavily contaminated wounds subjected to an unavoidable delay in treatment.     

Skeletal muscle properties and performance in elite female track athletes

Summary Selected biochemical and physiological properties of skeletal muscle were studied in light of performance capabilities in 24 elite female track athletes. The feasibility of quantifying end point histochemistry and relating oxidative staining density (reduced nicotinomide adenine dinucleotide diaphorase: NADH-D) to whole body maximal oxygen consumption ( max) was also investigated, while muscle fiber types, classified according to alkaline APTase stains, were studied and related to muscle oxidative capacity (succinate dehydrogenase: SDH), max and “in vivo” torque-velocity properties. Muscle biopsies were taken from the vastus lateralis of each subject and maximal knee extensor torques were recorded at 30‡ from full extension at four selected velocities. While results confirm earlier reports on skeletal muscle properties and performance it was concluded that end point histochemistry could be reliably quantified and that an “oxidative” stain such as NADH-D correlates extremely well with max (r=0.86,p<0.001) whereas correlations between %slow twitch fibres (alkaline ATPase stain) and max were lower (r=0.44,p<0.05). Additionally, as knee extension velocity increased from 0–1.7 rad·s⁻¹ angle specific extensor torque production did not decline as observed in vitro and pentathletes displayed significantly larger torques at all velocities when compared to the other athletes. These data confirm that while myofibrillar ATPase staining correlates with force-velocity properties of muscle, max is better correlated with quantified oxidative staining. Supported in part by a Public Health Service Biomedical Research Support Grant to UCLA, Public Health Service Grant 10423 and by the National Aeronautics and Space Administration (NASA)     

Architectural alterations of rat hind-limb skeletal muscles immobilized at different lengths

Modifications in architectural profiles of the rat soleus (Sol), medial gastrocnemius (MG), and tibialis anterior (TA) muscles were studied after hind-limb immobilization with an external brace. The muscles were chronically lengthened, shortened, or maintained at approximately resting length (neutral) for 4 weeks, when muscle weight and length, and cross-sectional areas of fibers (F-XSA) and whole muscle were measured. Compared with control muscles, the Sol and MG immobilized in a lengthened position were able to maintain muscle weight better than when immobilized neutrally (approximately 85 versus 55% of control weight) due, in part, to elongation of muscle fibers of the Sol and MG (123 and 111% of control length, respectively). In addition, the F-XSAs of lengthened Sol and MG muscles were 72 and 20% greater, respectively, compared with neutrally fixed muscle fibers. Immobilization in a shortened position resulted in the most extreme muscle atrophy due to significantly shorter fibers (86% of control Sol; 74% of control MG) and reduced F-XSA (42% of control Sol; 42% of control MG). In contrast to the Sol and MG, muscle weight, fiber length, and F-XSA of the TA immobilized with the ankle in extreme plantarflexion were not significantly different from neurtrally fixed muscle. That the TA was unaffected in this position is due presumably to a difference in the anatomic attachment of the distal tendon of this muscle, compared with that of the Sol and MG. These results suggest that for muscle affected by immobilization at extreme joint angles, chronic lengthening is a potent stimulus for elongation of muscle fibers and more normally maintained F-XSA. In contrast, the removal of this stimulus leads to extreme muscle atrophy which is manifested by reductions in both muscle fiber length and F-XSA.