Biomedical subjects
Publications and source records attributed to J Katsaros.
A technique of IP joint arthroplasty is described using costal cartilage with accompanying perichondrium. All patients presented following trauma to the IP joints; their ages ranging from 15 to 45 years. Five out of six cases showed improvement of symptoms and function following reconstruction of the traumatized joint.
The aim of soft-tissue replacement to the upper limb is twofold. The first is to restore as much functional tissue as possible, and the second is to achieve this in the shortest possible time. Of lesser consideration is the desire to achieve a good cosmetic result. In any given clinical situation, no single reconstructive procedure will maximally satisfy these aims. The personal philosophy expounded in this article exposes disadvantages as well as advantages of the many operations available to the upper limb surgeon. Each clinical problem is different from any other, so no blueprint or computer program is available to help the surgeon select an operation. It takes judgment based on knowledge and experience on the part of the surgeon to make the most appropriate selection. During the last two decades, free vascularized transfers have superseded some of the conventional pedicled flap operations, and this has been acclaimed quite rightly as a significant advance. By the same token, indications for the "older" techniques should remain in the armamentarium of the surgeon because in certain situations these may yet offer the best solution. A spin-off of the microsurgical era is the reverse forearm island flap, and in my view, this has become a new "star" in the recent era. It is fitting that it should have prominence in the reconstructive arena because it straddles the border between microsurgical and nonmicrosurgical techniques. It is a modern reminder that there are many ways to treat defects of the upper limb and that the responsibility of the surgeon is to be both imaginative and wise in securing the best possible result for the patient.
Twenty patients who had had upper limb reconstruction using the lateral arm free microvascular flap are reviewed. The size of the flap, modifications to the flap, and complications were documented. There was one flap failure, and nine flaps required surgical thinning at a second procedure. This sole disadvantage was outweighed in clinical usage by the advantages and versatility of the lateral arm flap.
Our experience with the lateral arm free flap over the last 7 years was reviewed in detail, placing emphasis on the clinical aspects and modifications of the flap. A total of 150 patients have undergone reconstructive procedures with the flap for small to medium-sized defects. This included 18 split flaps, 11 osteocutaneous flaps, 6 with vascularized triceps tendon, 5 neurosensory flaps, and 5 fascia-fat flaps. The donor-site scar was generally acceptable; only 3 patients required scar revision and 15 patients required debulking of the flaps. With use of the split flap for wide defects, tension-free primary closure of the donor site can be achieved. In most cases, a two-team approach may be adopted, thereby increasing the efficiency of this microvascular transfer.
The morphological distortion of the facial skeleton induced by untreated paediatric burns of the head and neck reinforces the theories of craniofacial growth and the modern principles of acute burn management and post-burn facial reconstruction.
A microvascular transfer of gastric tube and omentum was used to simultaneously reconstruct cervical soft-tissue and esophageal defects in five patients. All patients had previous high-dose radiation and multiple flap reconstructions. The largest esophageal and soft-tissue defects were 10 cm and 160 cm2, respectively. All wounds healed primarily except for one orocutaneous fistula. There was one death from an intraoperative stroke. The gastro-omental flap is useful in cases where the reconstructive surgeon is faced with both esophageal and soft-tissue defects--particularly in heavily irradiated patients who have few reconstructive options.
Eighteen free flap reconstructions of acute hand trauma were compared with 12 groin flap repairs as historical controls. The free flap group had a similar success rate, with fewer operations (though the same total operating time) and shorter hospital stay than the groin flap group. Complications were the same in both groups, but less secondary procedures were necessary in the free flap group. If flap cover is necessary, free flaps are a better way of obtaining skin cover in acute hand trauma.
A case of arterial occlusion occurred nine years after replantation of a thumb. Factors implicated were smoking and repeated blunt trauma to the first web space. The digit was successfully revascularized after excision of a segment of thrombosed arterial vein graft.
Five successful free flap transfers have been performed using the deep circumflex iliac artery system in sheep. The system is capable of providing cutaneous, myocutaneous, or osteomyocutaneous flaps, and details regarding these flaps are described.
Three cases of attempted ear replantation are presented. Successful revascularisation was achieved in all patients. However, in one case venous congestion and necrosis of the ear occurred at 7 days. Thorough initial debridement of skin and cartilage plus systemic heparinisation and haemodilution upon completion of the vascular anastomoses are considered important technical factors. When compared with other forms of reconstruction, ear replantation gives a superior result and is therefore advocated whenever possible.
The sheep provides a suitable model for simulation of grade III human tibial trauma. Management in humans can easily be simulated in the sheep. But variability can be controlled, and the effect of particular methods of management can be compared more accurately than in the human situation, with more scientific assessment possible.
Since 1978, 35 patients have undergone mandibular reconstruction with vascularized iliac crest. During this time, the technique of raising and shaping the iliac crest has undergone a series of modifications. Initially, osteocutaneous segments based first on the superficial circumflex iliac system and later on the deep circumflex iliac system were used. More recently, only the inner table of the ilium has been employed, and where intraoral lining is required, an ulnar forearm free flap has been added. Thirty-two patients were reconstructed successfully. Of the three anastomotic failures, one bony segment was able to survive as a free graft. There were no donor-site complications. With continued experience, operative morbidity has been minimized, while the technique has been modified to tailor the reconstruction to the specific requirements of the patient. It is concluded that vascularized iliac crest provides the most appropriate mandibular reconstruction for a range of congenital and acquired defects.
The results of 100 free microvascular transfers to the lower limb are presented. These show a high success rate with successful salvage of 95 limbs. The major complications were infection and delayed healing, osteomyelitis, and non-union. Early skin cover, within 14 days of injury, reduced the incidence of complications by half. Aggressive debridement and provision of early skin cover should be the aim of management of tibial trauma with tissue loss.
In a review of 61 patients with compound injuries to the upper and lower extremities. Operating Theatre costs were added to the costs of inpatient hospitalization after commencement of reconstruction with either a pedicled flap or free tissue transfer. The cost of pedicled groin flap to the upper limb and cross leg flap groups was double that of comparable free tissue transfer groups. The cost of abdominal tube pedicle to the lower limb was three times greater than for the free flap technique. The conclusion is drawn that apart from general advantages to the patient, the cost to the community is significantly reduced.
A reliable method of monitoring free vascularised jejunum to the head and neck region has been used in six patients. Preliminarily, the jejunum island flap is subdivided into major and minor segments. Transferred to the neck, the major part is used to reconstruct the oesophageal or pharyngeal defect, while the minor part supplied by the same segmental mesenteric artery is exteriorised through the neck incision. After five days direct monitoring, the marker segment is clamped, tied and excised before suturing the neck wound under local anaesthesia. No failures of the graft occurred. The effectiveness of this technique has surpassed all previously published and unpublished methods.
There is a highly dependable free flap donor site of moderate size on the posterolateral aspect of the distal upper arm. The area is supplied by the posterior radial collateral artery, a direct continuation of the profunda brachii. The flap area is supplied by a direct cutaneous nerve. It can be raised on its own, with underlying tendon, with bone, or with fascia only. This article describes our findings in 32 cadaver dissections and in 23 clinical cases.
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The use of a free bowel transfer to reconstruct pharyngo-oesophageal defects can only be accepted if the surgeon can guarantee that the microvascular techniques are near perfect. Experimental work in dogs demonstrates that high patency and graft survival rates can be achieved. The effectiveness of this technique in reducing morbidity and fistula formation is due to the rich blood supply to the graft which ensures sound and rapid healing. A case report is presented, demonstrating how quickly a patient can be rehabilitated after a radical pharyngo-laryngectomy.