Neurotized fasciocutaneous flaps and split-skin grafted muscle flaps are the most frequently used free flap alternatives for the reconstruction of weight-bearing surfaces of the foot. An objective comparison of the innate characteristics of these two flap types, with respect to long-term stability, has not been possible because sensory reinnervation in the fasciocutaneous flaps has been a confounding factor. This study compares nonsensate fasciocutaneous flaps (n = 9) with nonsensate split-skin grafted muscle flaps (n = 11), with mean follow-up periods of 34.3 and 31.3 months, respectively. Patients completed a form that included questions regarding degree of pain at the operative site, presence of ulcers, ability to wear normal shoes, employment status, and time spent standing on foot. Touch and deep sensation were evaluated with Semmes-Weinstein and vibration tests, respectively. Significantly less pain and less ulceration (p < 0.05) were observed in the fasciocutaneous group. Semmes-Weinstein monofilament tests revealed poorer results with split-skin grafted muscle flaps, compared with fasciocutaneous flaps. These results indicate that even if the sensory protection of fasciocutaneous flaps is not considered, these flaps have superior properties, compared with split-skin grafted muscle flaps.
Free flaps transferred to the lower extremity have a higher risk of failure, which may be expected to increase further with the use of vein grafts. The results of 103 consecutive free flaps to the lower extremities of 98 patients who were operated from March 1994 to December 1999 were evaluated to assess the reliability of vein grafts in lower extremity reconstruction. Five flaps were lost and the overall success rate was 95.1%. Eighty-four free tissue transfers in 79 patients were performed for the reconstruction of traumatic cases, and 81 of these flaps were performed in a delayed manner, between 1 week and 4 months after the injury. Interpositional vein grafts were used primarily in 22 flaps--all in traumatic cases--and 21 of them survived completely (95.4%). Primary vein grafts were used both for arteries and veins in 15 flaps and for arteries only in 7 flaps. The most common cause of tissue loss in these patients was a crush injury in earthquake survivors, followed by electrical injuries, gunshot injuries, motor vehicle accidents, and chronic infections. Free muscle flaps in 13 patients, skin flaps in 4 patients, osseous flaps in 2 patients, and temporal fascial flaps in 2 patients were the flaps of choice in vein graft reconstructions. Although a higher incidence of flap loss has been reported with the use of interpositional vein grafts than with regular transfers, and the technical and pathophysiological problems in flap transfers are also high in the lower extremity, the success rate in vein-grafted free flaps did not differ from that of the simple free flap transfers in the current series. This appears to be the result of meticulous preoperative planning and proper selection of recipient vessels during optimal operative conditions.
Objectives-To assess the effect of surgical cleaning of the skin on the pathergy phenomenon in Behcet's syndrome. Methods-The pathergy phenomenon was assessed in 183 patients with Behj;et's syndrome in a single blind study at 48 hours after a needle prick of the forearm skin, cleaned in the conventional way with alcohol, with 10% povidone iodine, with 100% chlorhexidine, and with a 4% aqueous solution of chlorhexidine. Results-The surgical cleaning of the forearm with povidone iodine before the application of the needle prick reduced the prevalence of the pathergy reaction to 27% from 48% in the conventionally (by alcohol swab) cleaned forearm. Cleaning the forearm with 100% chlorhexidine reduced the prevalence of the pathergy to 36% from 59% in the conventionally cleaned forearm. No significant changes were observed with a 4% aqueous solution of chlorhexidine. Conclusions-Surgical cleaning of the skin with disinfectants of various concentrations reduces the prevalence of a positive pathergy test in Beh9et's syndrome. This implies that more than the disruption of the structural integrity of the dermis and epidermis is involved in the production of the pathergy phenomenon in Beh9et's syndrome. The crucial point in understanding the pathergy reaction, we believe, is whether this sterile needle introduces any agent(s) into the epidermis or dermis when it penetrates the skin, or whether the reaction is produced solely by the mechanical disruption of epidermal or dermal components, or a combination of the two. Therefore we hypothesised that surgically cleaning the forearm before executing the pathergy reaction would decrease the skin response if the needle indeed introduced agent(s) on the skin into the epidermis and dermis. In a blind protocol we compared the pathergy reaction in the surgically cleaned forearms of patients with Behcet's syndrome with that in forearms of the same subjects which had been cleaned routinely with alcohol.Patients and methods Three groups of patients with Behcet's syndrome were studied. In each patient one forearm was cleaned in the conventional manner with an alcohol swab whereas the other forearm was cleaned for four minutes with: 10% povidone iodine (100% Betadine) (group A); 1 00% chlorhexidine solution (1 00% Savlon) (group B); and 4% aqueous chlorhexidine solution (40/o Savlon) (group C). Group A consisted of 94 patients, group B of 47 patients, and group C of 42 patients, all fulfilling the classification criteria for Behcet's syndrome.9The pathergy reaction was induced at two sites a few centimetres apart on each forearm, as previously reported,8 using a 20 gauge disposable needle for each site. Sterile gloves were used when applying the test to the surgically cleaned site. Immediately after the puncture, all the puncture sites were covered by sterile pads which were removed at 24 hours. The pathergy reactions were read blindly at 48 hours by two independent observers as either negative, doubtful, or one plus (presence of a papule) or two plus (presence of a pustule) react...
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