Instability due to unrecognised fracture-subluxations after apparently isolated injuries of the cervical spine

Instability may present at a different level after successful stabilisation of an unstable segment in apparently isolated injuries of the cervical spine. It can give rise to progressive deformity or symptoms which require further treatment. We performed one or more operations for unstable cervical spinal injuries on 121 patients over a period of 90 months. Of these, five were identified as having instability due to an initially unrecognised fracture-subluxation at a different level. We present the details of these five patients and discuss the problems associated with their diagnosis and treatment.     

Controlled trial of continuous inflating pressure for hyaline membrane disease

A controlled trial of elective intervention with continuous inflating pressure (CIP) was performed in infants with severe hyaline membrane disease who weighed more than 1000 g at birth. Infants entered the trial if their arterial oxygen tension (PaO2) fell below 60 mmHg while breathing a fractional inspired oxygen concentration (F1O2) greater than 0-95. 11 out of 12 infants in the CIP-treated group and 10 out of 12 in the control group survived. 7 treated and 6 control infants required mechanical ventilation. When CIP was started the Pao2 of the treated infants increased, and they breathed high concentrations of oxygen for a significantly shorter period than the control infants. During the 31-month duration of the trial 107 other infants with severe hyaline membrane disease were admitted who did not meet the criteria for entry to the trial. 37 survived after breathing high concentrations of oxygen (F1O2 greater than 0-60) spontaneously without any ventilatory assistance, and the remaining 70 infants were already being ventilated on their arrival in the unit, usually because they had required mechanical ventilation during transfer from other hospitals. The neonatal survival rate for those infants born in this hospital during the study period was 88% (50 out of 57 infants) and for those referred from other hospitals it was 69% (51 out of 74 infants). The maximum further increase in overall survival rate that might have been achieved in our population of infants if CIP had been initiated very early in the course of the illness was 5%--i.e. from 77% (101/131) to 82% (107/131).     

Thrombosis at venous insertion sites after inferior vena caval filter placement

Color Doppler flow imaging or compression ultrasound (US) was used to prospectively determine frequency of thrombosis at 54 venous insertion sites (47 in common femoral veins, seven in right internal jugular veins) after percutaneous placement of Greenfield filters for interruption of the inferior vena cava. Fifty-one filters were successfully placed in 51 patients with a dilator set or a balloon angioplasty catheter. Nine focal thrombi were detected in the common femoral vein (19%) and one in the right internal jugular vein (14%). Use of dilators induced eight thrombi (24%), compared with two (10%) from balloon catheters. The left common femoral vein had a high frequency of thrombosis, regardless of dilation technique (five of nine). Of nine patients with acute common femoral vein thrombosis, four became symptomatic within 10 days after the procedure. Patients may remain asymptomatic or have delayed symptoms; thus, US is valuable for determining patients at risk of thrombosis of the common femoral vein.     

Oncologic clearance with preservation of reconstructive options: literature review and the ‘delayed reconstruction after pathology evaluation (DRAPE)’ technique

Intraoperative frozen section and Mohs' micrographic surgery (MMS) are two techniques used to ensure oncological clearance without resorting to unnecessarily wide margins that might compromise reconstructive options for definitive wound closure. In addition to some technical issues, these techniques are suboptimal for resection of tumours such as melanoma, where specific tissue margins at histopathology are required to ensure minimal risk of local recurrence. We describe a technique that minimizes the amount of tissue excised and uses definitive paraffin sections interpreted in a pathology laboratory in order to delay reconstruction until after clear oncologic margins are obtained. This ‘delayed reconstruction after pathology evaluation (DRAPE)’ technique is particularly directed at extensive and complicated skin lesions, located in areas of the body that can be difficult to reconstruct and are prone to disfigurement and/or loss of function. A review of the literature is undertaken, establishing the role of each technique in achieving clear surgical margins. A case example is presented, highlighting the role of the DRAPE approach. The DRAPE technique is presented as a useful option for high‐risk lesions, especially within aesthetically sensitive regions or for complex reconstructions, and when reconstruction can be reasonably delayed while tumour clearance is established.