Spinal reconstruction for osteomyelitis with free vascularized fibular grafts using intra-abdominal recipient vessels: A series of three cases
Reconstruction of bony defects in the surgical management of vertebral osteomyelitis is a challenging endeavor. Our objective is to report the use of intra-abdominal vessels as the recipient vessels for microanastomosis of vascularized bone graft and the use of a spinal cage for fixation. Three patients failed conservative treatment for vertebral osteomyelitis and suffered pathologic fracture. Their treatment consisted of staged posterior irrigation and debridement with segmental fixation, followed by a thoracoabdominal approach multiple-level corpectomy. Reconstruction was performed with a free vascularized fibular graft placed within a custom, expandable cage. The vascularized fibular graft was anastomosed to an intra-abdominal recipient vessel. All patients improved clinically with no neurologic deficits noted. All showed evidence of successful fusion. Free vascularized bone grafts continue to be an excellent option for multi-level spinal defects related to osteomyelitis. Intra-abdominal recipient vessels are appropriate recipient vessels, as their diameter, length, and accessibility allow vascularized bone graft reconstruction of vertebral column defects of the thoracolumbar region. These vessels are also easily accessible and the anastomoses can be performed in the superficial operating incision.
Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia
OBJECTIVE:To report a multiinstitutional experience of men presenting with infertility secondary to inguinal hernia repair using polypropylene mesh. SUMMARY BACKGROUND DATA/BACKGROUND:An estimated 80% of inguinal hernia operations involve placement of a knitted polypropylene mesh to form a "tension-free" herniorrhaphy. The prosthetic mesh induces a chronic foreign-body fibroblastic response creating scar tissue that imparts strength to the floor and leads to fewer recurrences. However, little is known about the long-term effects of the polypropylene mesh on the vas deferens, especially with regard to fertility. METHODS:Eight institutions in the United States reported a total of 14 cases of azoospermia secondary to inguinal vasal obstruction related to previous polypropylene mesh herniorrhaphy. Patient characteristics and operative findings were forwarded to 1 center for tabulation of data. RESULTS:Mean patient age was 35.5 years with an average duration of infertility of 1.8 years. Mean number of years between urologic evaluation and herniorrhaphy was 6.3 years. Types of inguinal hernia repair previously performed were: open (10), laparoscopic (2), or both (2). Nine patients had bilateral obstruction and 5 patients had unilateral obstruction with contralateral testicular atrophy or epididymal obstruction. Surgical exploration revealed a dense fibroblastic response encompassing the polypropylene mesh with either trapped or obliterated vas in all patients. Surgical reconstruction was performed in 8 of 14 men (57%). CONCLUSION/CONCLUSIONS:Reconstruction to restore fertility can be difficult secondary to fibrotic reaction. Before undergoing polypropylene mesh herniorrhaphy, men, especially of young reproductive age or with a solitary testicle, need to be carefully advised of potential obstruction and compromise to future fertility.