Biomedical subjects
Publications and source records attributed to J O Kucan.
Burns of the feet pose unique and difficult problems in initial management, reconstruction, and the attainment of long-term functional results. The primary reconstructive goals for this region are unimpeded ambulation and weightbearing. These objectives can be achieved by adherence to established principles of wound management, a clear delineation of the reconstructive requirements of the foot, and a team approach toward attaining these goals.
Catfish are one of the few freshwater fishes known to be venomous. Although "finning" of the hand is a frequent injury incurred by catfish anglers that results in intense pain, it rarely results in any long-term sequelae. We present three cases in which acute soft-tissue infections developed, necessitating ray amputations in two patients. The unique habitat and anatomy of the catfish are described and preventive and therapeutic measures are discussed.
Twenty-six nail deformities secondary to ganglions of the distal interphalangeal joint were retrospectively reviewed to assess the important aspects of their management. The patients' ages ranged from 41 to 79 years. The long and index fingers were most commonly involved. A depression or groove was present in 23 of 26 digits reviewed. Two had gross disruption of the nail. Fifty-eight percent of the cysts had spontaneously drained or had been drained by the patient or a physician preoperatively. Degenerative arthritic changes were seen in 87 percent of those with x-rays or a radiology report available. Most underwent surgical removal of the cyst and debridement of associated osteophytes of the distal interphalangeal joint. The cyst was located above the germinal matrix in all but two digits. Osteophytes were found in all 20 digits in which the joint was explored. No recurrences were seen in those available for postoperative follow-up (22 of 25). Normal nail growth was found in 14 of 22, although follow-up was short in one. All eight postoperative nail deformities were quite mild and of little concern to the patient. There was no correlation between preoperative cyst drainage and aesthetic postoperative nail growth. Nail removal at the time of surgery appeared to be unnecessary unless the nail was grossly disrupted.
The use of cultured human keratinocytes in an in vitro comparison of topical antibacterial toxicity for epithelial cells was examined. The complement of three assessments allows testing of epithelial migration, growth, and survival. The three assessments included (1) flow cytometry for determination of cell survival, (2) a comparison of confluent cell culture growth after antibacterial exposures, and (3) an evaluation of cell migration using a technique of dermal explants to study radial migration. A comparative ranking of the toxicities of the various topical antibacterials was determined with the three assessments. This has confirmed anecdotal reports that many of the topical antibacterials are cell-toxic and may inhibit wound healing. This information can be directly extrapolated to the clinical setting, unlike many of the animal data for wound healing that currently exist.
The vascular territory of the pectoralis major muscle and overlying skin was studied by selective intraarterial dye injections in fresh cadavers. The area of skin overlying the anterior chest and abdominal wall beyond the limits of the pectoralis major muscle that can be elevated as an extended myocutaneous flap was determined. The cadaver injections were evaluated to determine the size and shape of the skin island used to reconstruct defects of the head, neck, and upper trunk with an extended skin paddle off the pectoralis major muscle. Pectoralis muscle flaps with variously shaped skin paddles, some extending beyond the limits of the muscle, were used in 27 patients to cover large soft-tissue defects of the upper thorax, face, and floor of the mouth and as a skin tube to reconstruct the cervical esophagus. The size of the skin paddle ranged from 5 x 7 cm to 26 x 16 cm. All flaps survived completely, and there were no major donor-site complications.
A 76-year-old woman was referred after results of the biopsy of an ulcerated mass of the right long finger suggested poorly differentiated squamous cell carcinoma. Excision and skin grafting were done and a diagnosis of malignant acrospiroma was established. These tumors are aggressive and 5-year survival rate may be as low as 30%. A ray amputation was subsequently done and the specimen was without residual tumor. At 14 months follow-up, the patient remains free of disease.
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A child with extensive soft-tissue defects following an attack by four pit bull terriers is presented. Some future procedures are required and she will have a permanent gait disability. The multidisciplinary management of this patient is described. The escalating problem of dog attacks in the United States is discussed. It is hoped that increased physician and public awareness will expedite the enactment and enforcement of effective vicious-dog legislation.
A 38-year-old female nurse was seen initially with several years' history of recurring intermittent ulnar wrist pain and paresthesias. The pain was aggravated by specific tasks using her hands, such as typing. Splinting and two steroid injections into the area gave only temporary relief. Surgical exploration revealed a segment of the ulnar nerve composing approximately 15% of its volume to split from the main trunk of the ulnar nerve, perforate the flexor carpi ulnaris tendon, and then rejoin the ulnar nerve. The nerve branch was extracted from the flexor carpi ulnaris by dividing approximately 15% to 20% of the tendon, allowing the nerve to be removed from the perforation, and anatomically relocated. The patient resumed her normal activities and has had no further discomfort in her wrist.
Sulfamylon (mafenide) solution, a potent experimental topical antimicrobial, is used in our burn unit to treat burn wounds both before and after skin grafting. The importance of fibrin to early graft adherence prompted this in vitro study of the effect of Sulfamylon upon fibrin clot. Assessing fibrinolysis by in vitro proteolysis of [125I] fibrin monomers, Sulfamylon, at relevant clinical concentrations, produced dose-related inhibition of streptokinase-mediated fibrinolysis. In addition, Sulfamylon had no intrinsic fibrinolytic activity. This antifibrinolytic property of Sulfamylon solution may, in vivo, protect against early graft loss when used on burn wounds and other potentially contaminated graft sites.
The craniofacial team at the University of New Mexico Medical Center in Albuquerque, New Mexico has treated a large population of Navajo Indians. Team awareness of the Navajo concept of health as man in balance with his environment has resulted in more expedient treatment of the Navajo children. An understanding of Navajo concerns with ghosts, skinwalkers, and rules for orderly living has allowed team members to integrate the family and the Navajo medicine man in caring for the children with craniofacial disease. Special concerns for informed surgical consent and genetic counseling of the Navajo are reviewed. Respect for the traditional Navajo healing ceremonies and special handling of disposed body parts in surgery are required of the health professionals caring for these people.
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Following an initial report urging conservative management of severe diabetic foot infections, the authors have managed 45 patients with a minimum 3-year follow-up. By using standard principles for soft-tissue infection, 78 percent of the patients healed minor amputation sites and maintained biped ambulation following the initial foot involvement. Only 22 percent required a major amputation at the time of the initial foot involvement. The 45 patients were followed and 22 (or 49 percent) developed a severe infection involving the contralateral foot within 18 months. Although 15 of the 22 patients developing contralateral infection (or 33 percent of the total series) required some type of amputation on the contralateral foot, the conservative approach allowed 64 percent of the patients with severe infections in both feet to maintain biped ambulation. This included 40 percent of the patients who required amputation of some portion of both feet.
A double-split gluteus maximus muscle flap has been described as a method for reconstructing difficult cases of rectal sphincter disruption secondary to trauma. Anatomic considerations and three case reports are documented. All three patients have derived nearly complete rectal continence after this procedure. The use of the inferior portion of only one gluteus maximus muscle preserves posterior hip stability and the proximal neurovascular supply to the portion of muscle that surrounds the anus. This procedure could potentially be used for rectal sphincter reconstruction in selected cases after ablative surgery in the anal region.
Xeroderma pigmentosum is an infrequently occurring disease characterized by premature solar skin degeneration owing to an inherent deficiency in the enzymatic process of excision repair of x-ray-induced DNA alterations. Currently, there are six known genetic forms of this disease. The presence or absence of central nervous system involvement is a manifestation of the heterogeneity of the disease. Survival beyond the third decade of life is unusual. The authors present a 46-year-old patient with proven xeroderma pigmentosum who manifests many characteristic features of this affliction and may be one of the oldest, if not the oldest, living survivor of this unusual disease.
One percent methylprednisolone acetate was evaluated as a pharmacologic agent in the prevention of dermal ischemia following burning. Standardized partial thickness burns were inflicted on guinea pigs. Burned guinea pigs were separated into five groups; one was treated with topical steroid, one with systemic steroid, one with both, one with emollient base without steroid, and one served as an untreated control. Histology and depth of dermal ischemia were evaluated by india ink perfusion technique. Untreated controls showed progressive dermal ischemia with complete absence of india ink-filled vessels in the dermis by 24 hours. Topical steroid alone improved dermal perfusion as suggested by relative levels of india ink filling. Topical steroid in the dosage used does not potentiate infection in standard burn wound sepsis models. Preservation of dermal appendages was seen secondary to improved dermal microcirculation with a ninefold increase in hair follicles in treated guinea pigs compared with controls.
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