1/17. Operative management and outcome of complex wounds following total knee arthroplasty.This study describes the treatment protocol for and the outcome of the management of complex wounds around total knee replacements. An analysis of 28 patients (29 knees) with complex defects who had surgery between January 1, 1986, and July 30, 1996, was performed. A specific management protocol was applied to each knee on the basis of the size and depth of the wound, the presence of infection, and the quality of soft tissue. Primary treatment included local wound care, debridement, and skin grafting or coverage with a fasciocutaneous flap, pedicled muscle flap, or free muscle transfer. Postoperatively, knees were evaluated using the Knee Society objective score. Successful salvage of the lower extremity was obtained in 28 knees (97 percent) and of the knee prosthesis in 24 of 29 knees (83 percent). Secondary plastic surgery procedures were necessary in five knees (17 percent), and secondary orthopedic procedures were necessary in four knees (14 percent). Successful salvage of total knee arthroplasty in the presence of a complex wound requires early identification of infection, aggressive irrigation and debridement, and early appropriate soft-tissue coverage. The use of our proposed algorithm will facilitate management of these complex wounds.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
2/17. Latissimus dorsi pedicle flap for coverage of soft tissue defects about the elbow.Sixteen consecutive patients who were treated with a pedicled latissimus dorsi flap for complex soft tissue defects about the elbow were reviewed. The average defect size was 100 cm2. Thirteen of the 16 patients achieved stable wound healing with a single procedure. Three patients had partial necrosis of the latissimus and required additional coverage procedures. We recommend that the latissimus dorsi flap should not be routinely used to cover defects more than 8 cm distal to the olecranon. The flap should be closely monitored in the first 48 hours, drains should be routinely used at the recipient and donor sites, and the elbow should be maintained in an extended position for the first 5 days after the procedure. The latissimus dorsi flap may also have a prophylactic role in selected patients with compromised soft tissue coverage about the elbow. The pedicled latissimus flap can be performed under loupe magnification and requires no microsurgical skills or equipment.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
3/17. The interdisciplinary approach to oral, facial and head pain.BACKGROUND: Chronic oral, facial and head pain is a common clinical problem, and appropriate diagnosis and management are a challenge for health care professionals. patients often will first seek the care of dentists because of the pain's localization in the oral cavity and surrounding structures. This article emphasizes the importance of establishing accurate diagnoses and conducting appropriate triage of the patient with complex orofacial pain. CASE DESCRIPTIONS: The authors present two case reports illustrating the complex nature of oral, facial and head pain, and the potential and actual pitfalls in management of this condition. These representative cases demonstrate how orofacial pain--which appears to be localized in the peripheral dental and oral structures--can have extremely complex etiologies involving other anatomical structures, the central nervous system and psychological factors. The reports point to the need for the expertise of a number of specialists in such cases. CLINICAL IMPLICATIONS: If the symptoms and clinical findings do not appear to be consistent with typical oral disease, or if standard treatments do not alleviate the pain, the dental clinician must consider other, more complex orofacial pain diagnoses. The dental professional should not hesitate to make referrals to key specialists or to members of an interdisciplinary team at a pain treatment center who have the expertise to appropriately diagnose and manage chronic oral, facial and head pain.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
4/17. Uterine scar separation in patients undergoing trial of labor (TOL) in one army hospital.Before the mid-1980s, repeat cesarean section was the usual method of delivering all patients who had a previous cesarean section. With cesarean section rates exceeding 20% in the 1980s, a concerted effort to reduce this high rate was formulated in all military teaching hospitals. One proposed method to decrease the overall cesarean section rate was to reduce the number of repeat cesarean sections. trial of labor (TOL) with vaginal birth after cesarean section was one method of decreasing the high cesarean section rate. Although vaginal birth after cesarean section has a relatively high success rate and has been shown to be safe for mother and infant, TOL is not risk free. One of the potential complications of TOL is uterine scar separation, which may lead to perinatal mortality. This report discusses uterine scar separation during TOL during a 1-year period at one medium-size U.S. Army teaching hospital.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
5/17. Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy.BACKGROUND: Benign tracheo-neo-esophageal fistulas after esophagectomy are rare and treatment can be challenging. They can result from perioperative tracheal injury or various postoperative complications. methods: charts of 6 patients with a benign tracheoneo-esophageal fistula after subtotal esophagectomy treated in this institution between July 1993 and August 1999 were analyzed. RESULTS: Three men and 3 women (median age 61 years) developed a fistula after subtotal esophagectomy. Symptoms varied from mild swallowing difficulties to aspiration pneumonia and mediastinitis. Two patients with mild symptoms were treated conservatively. In 1 patient a long fistula was partly excised through the neck. In 3 patients the gastric tube was excluded or excised, with surgical closure of the tracheal defect. The alimentary tract was reconstructed by colonic interposition. There were no major complications. After a median follow-up of 1.6 years, all fistulas were closed. All patients were capable of sufficient oral intake. CONCLUSIONS: A benign tracheo-neo-esophageal fistula after esophagectomy is a rare, but serious complication. Site and size of the fistula, together with the severity of symptoms, should dictate management.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
6/17. Laparoscopic repair of acquired lumbar hernia.Lumbar hernias are rare; approximately 300 cases have been described in the literature since their first description. They are typically subdivided by categories such as congenital or acquired and by their location. Acquired lumbar hernias may follow trauma, poliomyelitis, loin incision, and the use of iliac crest as a donor site for bone grafting. Although they tend to grow in size and have a 25% risk of incarceration and 8% risk of strangulation, surgery is indicated once the lesion is confirmed. Many techniques have been described for surgical repair of lumbar hernias, including primary repair, local tissue flaps, and conventional mesh repair. All these open techniques require a large incision plus extensive dissection to expose the area. The first laparoscopic repair of lumbar hernia was described in 1996. The laparoscopic approach for lumbar hernia has significant advantages: it enables exact localization of the anatomic defect, the mesh can be placed deep into the defect allowing intraabdominal pressure to hold it in position, and it also has all the well-known advantages of the laparoscopic approach. We present two cases of laparoscopically repaired acquired lumbar hernias.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
7/17. Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammoplasty.Major sternal wound infection occurs in nearly 2% of patients following coronary artery bypass graft surgery. The relationship of this complication to gender has not been reported in detail, nor has female breast size previously been implicated as a factor increasing the risk of sternotomy dehiscence. We report two cases of sternotomy wound dehiscence in women with large, pendulous breasts undergoing myocardial revascularization surgery and postulate that the weight of large, unsupported breasts produced inferolateral tension on the midline sternotomy incisions, contributing to dehiscence of the wounds. Chest wall reconstruction was accomplished using pectoralis muscle flaps, and the procedures were combined with amputative reduction of the size of the breasts, with subsequently successful healing in each case. Combining sternal reconstruction with breast reduction surgery may lead to improved secondary outcome, and postoperative use of supportive brassieres may reduce the frequency of this complication.- - - - - - - - - - ranking = 2keywords = size (Clic here for more details about this article) |
8/17. Bronchial dehiscence associated with a large broncholith in a lung transplant recipient.A 63-year-old man who underwent single lung transplantation for advanced emphysema had a postoperative course complicated by asymptomatic bronchial dehiscence associated with a large broncholith. The stone eventually caused airway obstruction requiring partial fragmentation and incomplete extrication. We suggest that calcified nodes of significant size be removed at the time of surgery in the lung transplant recipient.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
9/17. Congenital melanocytic nevi.Congenital nevi are characterized by the appearance of pigmented areas that range in size, shape, surface texture, and hairiness. In most cases, the nevus remains stable and benign, but because of possible malignant transformation, nevi are often excised. In this case, a young boy was born with a hairy nevus below his lip extending inferiorly down the left side of his chin and upper neck. After two surgical excisions, the wound healing process was interrupted when his incision wound was split while jumping on his bed. With the professional assistance of occupational therapists, the scar should heal in an esthetically pleasing manner.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
10/17. Streptococcal infection and necrotizing fasciitis--implications for rehabilitation: a report of 5 cases and review of the literature.Five cases are presented of patients who were diagnosed with necrotizing fasciitis secondary to (1) hip disarticulation (in a paraplegic patient); (2) tooth abscess with extensive neck dissection, complicated by sepsis and hypotension with resultant dysphagia and ischemic encephalopathy; (3) below-knee amputation, anoxia, and severe debility; (4) emergent above-knee amputation; and (5) percutaneous endoscopic gastrostomy placement. The latter patient developed abdominal and chest wall necrotizing fasciitis that required skin grafting. Four patients were treated in an acute rehabilitation setting and returned home, and the fifth was rehabilitated in a subacute facility. This report emphasizes the importance of carefully monitoring rehabilitation patients, especially those with impaired sensation.- - - - - - - - - - ranking = 1keywords = size (Clic here for more details about this article) |
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