Question 31#

The following best classifies a patient with an acute osteomyelitis of the sternum which presents 2 weeks after median sternotomy and coronary grafting, and which is culture positive:

A. Pairolero Type A

Pairolero Type B. Pairolero classified sternal osteomyelitis into three categories. The first is characterised by a culture-negative serous discharge within days of surgery without cellulitis, chondritis or osteomyelitis. The second is acute, suppurative and culture positive osteomyelitis, and the third presents months after surgery and is often an acute-on-chronic osteomyelitis.

Question 32#

Which one of the following statements regarding Poland's syndrome is false?

A. It was first described by Alfred Poland in 1841

Its incidence is 1:2500 live births. E is false. Poland’s syndrome is a rare congenital anomaly characterised by unilateral chest wall hypoplasia and ipsilateral hand abnormalities. Literary data suggest its sporadic nature. The prevailing theory of its cause is hypoplasia of the subclavian artery or its branches, which may lead to a range of developmental changes. The incidence of Poland’s syndrome varies between groups (e.g. male versus female patients, congenital versus familial cases) and ranges from 1 in 7,000 to 1 in 100,000 live births.

References:

1. Fokin AA, Robicsek F. Poland's syndrome revisited. Ann Thorac Surg 2002; 74(6): 2218-25.

Question 33#

The following is false in breast reconstruction:

A. TRAM flaps reduce abdominal wall strength compared with DIEP flaps with resultant detriment to activities of daily living and quality of life

TRAM flaps reduce abdominal wall strength compared with DIEP flaps with resultant detriment to activities of daily living and quality of life. A is false. There is no evidence that the preservation of abdominal wall strength from DIEP flaps versus TRAM flaps translates to better maintenance of activities of daily living. Pedicled TRAM flaps are purported to have a higher incidence of flap necrosis and partial flap loss compared with free flaps. DIEP flaps are associated with less postoperative pain than TRAM flaps. There is no evidence than TRAM flaps result in abdominal hernias compared with DIEP flaps.

Question 34#

The following statements are true except:

A. Cutaneous perforators that do not originate from the deep inferior epigastric artery (peritoneocutaneous perforators) are rare findings when raising a DIEP flap

The use of the DIEP flap to reconstruct lower limb defects has not been described. This statement is incorrect; the use of DIEP flaps to reconstruct lower limb defects in 25 patients with promising results was described in 2005 ¹. A study of 375 DIEA perforator (DIEP) flaps (325 with preoperative CTA and 50 cadaveric dissections) showed that peritonealcutaneous perforators were rare anatomical variations (4/375: 1.1%) and that they may affect outcomes in DIEP flap surgery if not assessed preoperatively. Computed axial tomography (CTA) was significantly able to detect this anomaly and aid operative planning ². In a study of 138 DIEP breast reconstructions, 70 underwent pre-operative CTA analysis, and 68 had pre-operative Doppler investigation. Surgery time in the CTA group was significantly lower (p<0.001) than in the control group (264min [SD+/-62] versus 354min [SD+/-83]), respectively. The study suggested that the use of CTA helped reduce surgery time, and reduce the risk of postoperative complications ³. In addition, the time saved during DIEP flap surgery was shown to compare favourably to the cost of the computed tomographic angiography pre-operatively ⁴. A paper reviewing the radiation dose of routine investigations compared it to abdominal wall CTA and the background equivalent radiation dose (Table below) ⁵.

Radiation exposure with CTA in DIEP flap planning:

References:

1. Van Landuyt K, Blondeel P, Hamdi M, Tonnard P, Verpaele A, Monstrey S. The versatile DIEP flap: its use in lower extremity reconstruction. Br J Plast Surg 2005; 58(1): 2-13.
2. Whitaker IS, Rozen WM, Smit JM, Dimopoulou A, Ashton MW, Acosta R. Peritoneocutaneous perforators in deep inferior epigastric perforator flaps: a cadaveric dissection and computed tomographic angiography study. Microsurgery 2009; 29(2): 124-7.
3. Smit JM, Dimopoulou A, Liss AG, Zeebregts CJ, Kildal M, Whitaker IS, Magnusson A, Acosta R. Preoperative CT angiography reduces surgery time in perforator flap reconstruction. J Plast Reconstr Aesthet Surg 2008, Jul 31.
4. Rozen WM, Ashton MW, Whitaker IS, Wagstaff MJ, Acosta R. The financial implications of computed tomographic angiography in DIEP flap surgery: a cost analysis. Microsurgery 2009; 29(2): 168-9.
5. Rozen WM, Whitaker IS, Stella DL, Phillips TJ, Einsiedel PF, Acosta R, Ashton MW. The radiation exposure of computed tomographic angiography (CTA) in DIEP flap planning: low dose but high impact. J Plast Reconstr Aesthet Surg 2008, Dec 31.