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Biomedical subjects

H A Winters

Publications and source records attributed to H A Winters.

18 recordsLinked to original sources
PubMed1999

Severe progressive osteoporotic spine deformity with cardiopulmonary impairment in a young patient. A case report.

STUDY DESIGN: This report describes a young patient with a rapidly progressive kyphosis caused by collapse of a severely osteoporotic thoracolumbar spine, which led to impairment of cardiopulmonary function. OBJECTIVES: To highlight the treatment strategy, difficulty of diagnosis, operative stabilization, and outcome. SUMMARY OF BACKGROUND DATA: Little is known about natural history, treatment options, and results of this condition. METHODS: The magnitude of bone loss was measured by dual-energy x-ray absorptiometry, and the deformity was visualized by computed tomography and magnetic resonance imaging. Laboratory investigations also were performed before and during halotraction in an attempt to establish a diagnosis. These data constituted the preoperation information required to assess later results of medical and surgical intervention. RESULTS: An extensive evaluation of possible underlying etiologies failed to identify a specific etiology. Before and during halotraction, bone mineral substitutes were given, partially correcting the bone mineral content as measured on repeated dual-energy x-ray absorptiometry scans. In addition, the thoracic kyphosis was partially corrected, from 100 degrees to 70 degrees Cobb's angle. Subsequently, a combined anterior and posterior stabilization was performed from C7 to S1 using a vascularized fibula graft, a double Isola rod system (AcroMed, Cleveland, OH), and a carbonate apatite cancellous bone cement to reinforce the pedicle screws. At follow-up assessment 40 months surgery, the patient was asymptomatic and fully mobilized, with radiographs showing complete incorporation of the grafts and no loosening of the fixation device. CONCLUSIONS: The diagnostic and therapeutic difficulties of progressive spine deformity caused by severe osteoporosis in young patients emphasizes the importance of a thoroughly planned treatment strategy. Halotraction is recommended to stop progression of the deformity, or even partially correct it, and to allow time to search for the diagnosis and bone mineral substitution. Surgical treatment using vascularized fibular strut grafts and a strong fixation device was successful. Biocompatible carbonated apatite cancellous bone cement was successfully used to reinforce pedicle screw fixation.

Absorptiometry, Photon↗
PubMed1999

Free vascularized bone graft in spinal surgery: indications and outcome in eight cases.

In selected spinal deformities the use of a vascularized graft to establish fusion may be considered: compared to a non-vascularized graft it has superior mechanical properties, resulting in greater graft strength and stiffness, and greater effectiveness in facilitating union. Eight patients with a progressive spinal deformity (four cases) and malignancy (four cases) were treated with resection and/or correction and stabilization. To facilitate (multi)level fusion vascularized fibular grafts were used in two cervical and two thoracolumbar deformities. Fibular (two cases) or iliac grafts (two cases) were used in four cases of spinal reconstruction after vertebrectomy for malignancy. In all patients complete incorporation of the graft was obtained within 5 weeks to 8 months postoperatively. Complications occurred in three cases: one patient had a transient laryngeal edema and laryngeal nerve palsy. Another patient had a non-fatal deep vein thrombosis with pulmonary embolisms, successfully treated with anticoagulants. A third patient developed a lung infection and subsequently a deep infection around the dorsal instrumentation; after hardware removal the infection was controlled. At the latest follow-up (mean 30 months, range 24-48 months) six out of eight patients are alive. One patient died 2.5 years after the intervention due to widespread metastases, while another patient died in the postoperative period due to unknown reasons. Vascularized bone graft in spinal surgery facilitates primary mechanical stability and rapid fusion, and it has higher resistance to infection. The variety of applications of a vascularized graft may extend the range of indications for the use of grafts in spinal surgery.

Adolescent↗
PubMed1999

Recurrent osteoblastoma of the hamate bone. A two-stage reconstruction with a free vascularized iliac crest flap.

An osteoblastoma in a carpal bone is very rare and presents a problem of reconstruction after wide tumour excision. We report a case of recurrent osteoblastoma of the right hamate bone with involvement of the ulnar carpal bones and soft tissues that was successfully treated by en bloc resection, temporary interposition of bone cement and fixation with K-wires, followed by reconstruction with a free vascularized iliac crest flap, tailored to the exact size of the defect, in a second procedure. Rapid fusion was achieved and hand function preserved with no evidence of recurrence 3 years postoperatively.

Adult↗
PubMed1999

Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study.

The vascularization of the skin paddle of 20 osteocutaneous fibula free flaps in 20 patients was studied. All skin paddles were designed over the proximal and middle third of the fibula. A parallel vascularization of the skin was found in 10 cases. In these cases, an axial (septo)musculocutaneous perforator was found to originate high in the peroneal artery or even in the popliteal artery. This branch runs parallel to the peroneal artery without any further connections with it. In 5 of these 10 cases, no other skin perforators were located within the boundaries of the skin paddle. Harvesting such a flap in the traditional way by blind inclusion of a muscle cuff results in ligation of the supplying vessel of the skin paddle and subsequent loss of the skin. In this series, this would have been the case in 5 of the 20 patients (25 percent). This might explain the bad reputation of the skin paddle of this flap. The high prevalence of the described vascular configuration in a proximally designed skin paddle justifies à vue dissection of all musculocutaneous perforators up to their origin, unless one or more septocutaneous perforators are found within the boundaries of the flap.

Fibula↗
PubMed1998

Stimulation of cartilage differentiation by osteogenic protein-1 in cultures of human perichondrium.

Exposure of progenitor cells with chondrogenic potential to recombinant human osteogenic protein-1 [rhOP-1, or bone morphogenetic protein-7 (BMP-7] may be of therapeutic interest in the regeneration of articular cartilage. Therefore, in this study, we examined the influence of rhOP-1 on cartilage formation by human perichondrium tissue containing progenitor cells with chondrogenic potential in vitro. Fragments of outer ear perichondrium tissue were embedded in clotting autologous blood to which rhOP-1 had been added or not (controls), and the resulting explant was cultured for 3 weeks without further addition of rhOP-1. Cartilage formation was monitored biochemically by measuring [&sup35;S]sulfate incorporation into proteoglycans and histologically by monitoring the presence of metachromatic matrix with cells in nests. The presence of rhOP-1 in the explant at the beginning of culture stimulated [&sup35;S]sulfate incorporation into proteoglycans in a dose-dependent manner after 3 weeks of culture. Maximal stimulation was reached at 40 microgram/ml. Histology revealed that explants treated with 20-200 microgram/ml rhOP-1, but not untreated control explants, contained areas of metachromatic-staining matrix with chondrocytes in cell nests. These results suggest that rhOP-1 stimulates differentiation of cartilage from perichondrium tissue. The direct actions of rhOP-1 on perichondrium cells to stimulate chondrocytic differentiation and production of cartilage matrix in vitro provide a cellular mechanism for the induction of cartilage formation by rhOP-1 in vivo. Thus, rhOP-1 may promote early steps in the cascade of events leading to cartilage formation. Therefore, rhOP-1 could be an interesting factor for regeneration of cartilage in articular cartilage defects.

Adolescent↗
PubMed1998

Correction of a dystrophic cervicothoracic spine deformity in Recklinghausen's disease.

A case is presented of a 14-year-old boy with neurofibromatosis who had a 92 degrees dystrophic kyphosis (as measured on radiographs between C3 and C7) of the cervical spine. He was treated successfully by posterior stabilization and anterior fusion using a free vascularized fibula graft. This method appears to be an attractive alternative to an avascular fibula graft and avoids the risk of graft resorption (creeping substitution), weakening (fracture), or nonunion during the process of bony consolidation. It provides a stable and longstanding anterior strut, essential in the management of high grades of kyphosis. At 1-year followup the patient has no symptoms, is fully mobile, and shows radiographically complete incorporation of the graft with no loss of correction.

Adolescent↗
PubMed1997

The peritoneal free flap: an anatomic study.

In view of a possible clinical application of an isolated microvascular peritoneal flap, an anatomic study was performed in order to determine the peritoneal vascular territory of the deep inferior epigastric artery. For this, the deep inferior epigastric artery was injected unilaterally with Araldite in 30 embalmed cadavers and bilaterally with india ink in 15 fresh cadavers. In 70 percent of the embalmed cadavers, a constant pattern of three branches from the deep inferior epigastric artery could be identified. The peritoneal vascular supply is not derived solely from these three branches but also from multiple small branches sprouting directly from the main stem of the deep inferior epigastric artery and from segmental and muscular branches. Therefore, classification of peritoneal branches arising from the deep inferior epigastric artery seems to be of little clinical importance. In all cases, the india ink injected in the deep inferior epigastric artery colored a similar territory of the parietal peritoneum. Considering the magnitude of the peritoneal vascularization by the deep inferior epigastric artery, implementation of an isolated free or pedicled peritoneal flap seems to be possible. Such a microvascular peritoneal flap vascularized by the deep inferior epigastric artery may be used, for example, for reconstruction of mucosal defects in the head and neck region.

Epigastric Arteries↗
PubMed1996

Nonfunctioning malignant paraganglioma of the posterior mediastinum with spinal cord compression. A case report.

STUDY DESIGN: Case report and review of the literature. OBJECTIVE: To present a case with an uncommon nonfunctioning malignant paraganglioma of the posterior mediastinum with compression of the spinal cord. An update survey is given with respect to diagnostic, histopathologic, and therapeutic aspects of paragangliomas. SUMMARY OF BACKGROUND DATA: Paragangliomas in the posterior mediastinum are uncommon and rarely may produce spinal cord compression. To illustrate the low incidence, only two cases of paraganglioma of the posterior mediastinum were reported by the Mayo Clinic, Rochester, Minnesota, during a 40-year period. METHOD: Case report and review of the literature. RESULT: The diagnosis was made by modern imaging techniques (computed tomography, magnetic resonance imaging, and metaiodobenzylguanidine scan) and verified by computed tomography guided per thoracic puncture. A wide local resection was performed; the patient is disease-free 1 year after surgery. CONCLUSION: The uncertainty of prognosis and possibility of local recurrence of paragangliomas even after a long period emphasizes the importance of wide local surgical resection with or without adjuvant therapy and makes long-term follow-up and continued surveillance of the patient mandatory.

Female↗
PubMed1996

Fibula free flap phalloplasty: modifications and recommendations.

Radial forearm flap phalloplasty should be regarded as the gold standard. The large forearm donor site scar, however, has led to the search for other donor areas. We present our modifications and recommendations for addressing the ideal goals of phalloplasty better when applying the fibula free flap. We recommend preconstruction and secondary anastomosis of the neo-urethra. Preoperative infiltration of the cutaneous nerve is recommended for planning of the sensate flap. The osseous part of the flap should be long enough to be fixed to the tunica albuginea. We recommend a longitudinal, rather than a transverse, design for the flap. For aesthetic reasons, the flap should include two triangular tongues. Even so, secondary surgery will be needed. The patient may be left with functional loss in the donor region. A case report illustrates all of these points. We conclude that the sensate fibula free flap has a place in phalloplasty in case the patient refuses a forearm scar.

Adult↗
PubMed1996

Clinical effectiveness of 99mTc-diphosphonate scintigraphy of revascularized iliac crest flaps.

Clinical assessment of the perfusion of the musculocutaneous portion of composite iliac crest free flaps was compared to 99mTc-diphosphonate (HDP) uptake in 14 patients who underwent primary oromandibular reconstruction after ablative cancer surgery. Bone scanning was performed on average at the 9-10th postoperative day (range 4-48) 3 h after intravenous injection of 550 MBq 99mTc-HDP. Eleven patients showed complete concordance between 99mTc-HDP uptake and soft-tissue status. Two patients showed uptake and viable muscle in spite of necrotic skin. One patient had a viable musculocutaneous flap but a photopenic defect in the bone graft; 6 months later, a small corresponding part of the bone was sequestrated. In this study, bone scanning and clinical assessment of muscle perfusion were 100% accurate in predicting viability of bone grafts. Skin viability was a less reliable parameter. It is concluded that bone scanning is not indicated as a routine investigation for revascularized iliac crest flaps and that clinical assessment of muscle perfusion is a reliable monitor of the early function of such flaps.

Adult↗
PubMed1996

The bipedicled iliac crest flap.

The use of the iliac crest flap based on the deep circumflex iliac artery and vein is well established in orofacial reconstruction. In cases where the deep circumflex iliac artery and vein are of inadequate size, or when large composite flaps are required, vascular augmentation can be achieved using the iliac branches of the iliolumbar artery and vein as an additional pedicle. Routine inclusion of this additional pedicle in iliac crest flaps creates extra safety with a low effort.

Adult↗
PubMed1996

Salvage of a "free flap" phalloplasty by distal arteriovenous fistula: case report.

Radial forearm-flap sensate free-flap phalloplasty was performed in a 32-year-old female-to-male transsexual. An arteriovenous loop was created by end-to-side anastomosis of the left greater saphenous vein to the femoral artery at the level of the femoral triangle. On the first postoperative day, the neophallus showed signs of impaired circulation, and a recent thrombus was removed from the venous pedicle. A distal fistula between the radial artery and a superficial vein was created, converting this possibly low-flow flap to a high-flow system. The flap could be salvaged entirely. Taking the well-recognized, long-term complications of arteriovenous fistulas into account, the authors do not recommend routine use of such a distal fistula. Still, in cases where vascular patency of the venous graft is shown not to be adequate, an adjunctive arteriovenous fistula created distally may salvage the flap.

Adult↗
PubMed1996

[Reconstruction possibilities after tumor surgery in the head-neck region].

Surgery and radiotherapy are the most important primary modalities for treatment of head and neck cancer. After excision of a tumour, a considerable defect may remain. Reconstructive surgery may serve several purposes: closure of the defect and restitution of functions such as respiration, swallowing, speech and chewing. Also, an esthetically satisfying appearance is aimed at. The planning of reconstructive surgery starts as soon as a patient presents with a new cancer. The most appropriate procedure is selected by a team of specialists, consisting of head and neck surgeon, a plastic and reconstructive surgeon and a maxillofacial surgeon. For defects of the mouth and oropharynx, a microsurgical free flap is the most versatile and safe choice of reconstruction nowadays. Suitable donor areas are the forearm, iliac crest and abdominal wall and the fibula. The graft, which may consist of skin, fascia, muscle, bone or combinations thereof, is revascularised in the defect area after microsurgical anastomosis of its vascular pedicle. Success percentages are greater than 95% and postoperative morbidity is reduced in contrast to conventional methods.

Head and Neck Neoplasms↗
PubMed1994

Scalping injuries: dos and don'ts.

Replantation is the treatment of choice in scalping injuries and should always be considered, even in case of a badly damaged scalp. Specific procedures regarding pre-, intra- and postoperative care are crucial to success in replantation. These include: haemodynamic stabilization of the patient without causing damage to possible donor vessels; cooling, cleaning and further proper care of the avulsed specimen; use of antibiotics and haemodilution to optimize the intra- and post-operative situation. The above is illustrated by a case history of successful replantation of a seriously damaged avulsed scalp.

Adult↗
PubMed1992

Gastric syphilis: five recent cases and a review of the literature.

OBJECTIVE: To describe five cases of early syphilis with gastric involvement and to review the literature pertaining to this disorder. DATA IDENTIFICATION: Five patients were diagnosed with gastric syphilis at Kings County Hospital and the Brooklyn Veterans Affairs Hospital between 1987 and 1990. English-language articles pertaining to gastric syphilis were identified by searching MEDLINE and by manually reviewing bibliographies of retrieved articles. STUDY SELECTION: Sources containing information pertinent to the clinical manifestations and diagnosis of gastric syphilis were selected. DATA SYNTHESIS: The most common clinical manifestations of gastric syphilis are abdominal pain, vomiting, and weight loss. Endoscopic findings in the stomach range from minimal nodularity and erythema to deep ulceration. Complications of gastric syphilis include hemorrhage, gastric outlet obstruction, and perforation. The diagnosis can be confirmed by serologic testing and by demonstration of spirochetes on silver and immunofluorescent stains of gastric mucosal biopsy specimens. Response to treatment is usually prompt and complete. CONCLUSIONS: The current syphilis epidemic will likely result in an increased incidence of gastric syphilis. Unless syphilis is considered as a cause of gastric mucosal inflammation and ulceration, misdiagnosis may delay appropriate treatment, and serious complications can occur.

Adult↗
PubMed1987

Are toxic oxygen radicals involved in the pathogenesis of reflex sympathetic dystrophy?

A crossover study was performed for patients with RSD to evaluate the therapeutic efficacy of the hydroxyl radical scavenger DMSO. All patients were given DMSO locally 5 times a day during one week, and a placebo during one week. Before and after each treatment, subjective evaluation was performed by both the patient and the examinor as to clinical activity of RSD, and measurement was performed of the range of motion (ROM) of all joints in the affected extremity. DMSO was the most effective treatment as to improvement of ROM (p = 0.035) and as to overall improvement (p = 0.001). The efficacy of the hydroxyl radical scavenger DMSO indicates that RSD primarily involves an inflammatory process rather than a sympathetic reflex. As during the last 20 years no single report was published studying RSD in terms of inflammation, it is suggested that such studies are urgently needed to elucidate the real nature of RSD.

Adult↗