and that of Inglis showed that the problem of graft vein thrombosis is, as yet, unresolved. ... improved pressure distribution within the plantar contact area.
144
Comment
and that of Inglis showed that the problem of graft vein thrombosis is, as yet, unresolved. ROBIN G Cox MB BS MRCP FFARCS Staff Pediatric Anaesthetist and Intensivist Alberta Children's Hospital Calgary, Alberta, Canada
Reference I Aps C, Cox RG, Mayou BJ, Sengupta P. The role of anaesthetic management in enhancing peripheral blood flow in patients undergoing free flap transfer. Ann R Coll Surg Engl 1985;67: 177.
Bacterial colonisation of leg ulcers and its effect on the success rate of skin grafting It was interesting to read the letter by J M Porter (Annals, July 1988, vol 70, p263) in relation to bacterial colonisation of venous ulcers and its effect on the results of skin grafting. I believe' the presence or absence of infection is probably less important than the presence or absence of deoxygenated blood in veins in the immediate vicinity of the ulcer. These may be served by a deep perforating vein or a longitudinal branch of an incompetent saphenous vein running immediately beneath the ulcer. The reduced oxygenation of the blood causes impaired nutrition of the local tissues and reduced resistance to infection. Open removal of the perforating vein and/or the vein under the. ulcer usually leads to improved nutrition and early healing of the ulcer even without the need for skin grafting or excisionprovided the granulating surface is macroscopically clean. The ulcer can be incised from end to end to remove the longitudinal vein or this can be stripped out by a small wire and head without infecting the deep tissues. The rapidity with which healing may then occur is surprising. I have seen an ulcer which has been present for months or years heal within 2-3 weeks without the need for a skin graft. If the ulcer is large a graft may be appropriate, but patches of split skin are preferable to a whole sheet as this allows any exudate to escape between the small grafts rather than accumulate beneath the whole graft. The accumulated fluid may raise the complete graft or part of it from the surface of the ulcer and be responsible for a poor 'take'. DEREK MARTIN FRCS 41 Station Street Fairfield, NSW, Australia
Posterior tibial tendon rupture-a brief report We were interested to read Mr S C Chen's report on 'Posterior tibial tendon rupture' (Annals, September 1988, vol 70, p280) and would like to add a few comments. In our experience, in studies over 10 years of 'The Foot at Risk', the diagnosis of this tendon rupture is frequently missed, even where there has been an acute onset of symptoms. Chronic pain and change in foot shape usually present some time after the acute episode. Review of 16 patients with a history suggestive of the condition showed, on clinical examination, a ruptured tendon in only seven. It may well be in the remainder, that incomplete rupture had caused the pain and change in foot shape. We believe that a high arched, hypermobile foot often associated with inadequate first ray support predisposes to a maldistribution of pressure within the support area and a risk of tendon rupture. By simply repairing the tendon, one has not altered the underlying predisposing factors. Foot anatomy and pressure distribution are not necessarily restored to normality. Therefore, one might surmise that problems will recur. We have seen excellent results in a small number of cases where os calcis osteotomy as described by Rose (1) has been performed on patients where the rupture had caused consider-
able 'flat foot' deformity. Surgery has restored foot shape, improved pressure distribution within the plantar contact area and importantly produced a pain-free foot. E A W WELTON MB ChB Medical Research Assistant J H PATRICK FRCS Consultant Orthopaedic Surgeon RobertJones & Agnes Hunt Orthopaedic Hospital Oswestry, Salop
Reference I Rose GK. Pes planus. In: Jahss MH, ed. Disorders of the Foot. Philadelphia, Eastbourne, Toronto: W B Saunders
Company, 1982;486-520.
An improved method for securing nasogastric tubes The above article (Annals, September 1988, vol 70, p282) demonstrated an interesting method of securing a nasogastric tube. It certainly secures the nasogastric tube in the nose but the method is aesthetically unsightly, it requires a general anaesthetic, and there is risk of damage to the posterior aspect of the nasal septum leading to infection and life-threatening posterior epistaxis which can be difficult to control. Having tubes through both nasal cavities is uncomfortable and requires mouth breathing by the patient leading to dry mouth and oropharynx. Long-term sequelae include crusting in the posterior aspect of the nose and nasopharynx. N S VIOLARIs FRCS Registrar in ENT Surgety S KEDDIE FFARCS Consultant Anaesthetist Plymouth General Hospital Plymouth, Devon Concerning the report 'An improved method for securing nasogastric tubes' by P R Tophill and P J Finan (Annals, September 1988, vol 70, p282), this technique has been widely used both in head and neck environments in Europe and America. While acknowledgement has been made to Dr F Eckhauser of Ann Arbor, USA, to my knowledge this technique for 'Securing of intermediate duration feeding tubes' was written up by W F McGuirt and JohnJ Strout (Latyngoscopy, 1980, vol 90, no. 12, pp2046-8). I am sure somebody more senior in years to me will be able to identify a previous reference to this technique. PJ BRADLEY FRCSEd Consultant ENT Surgeon/Head and Neck Oncologist Queen's Medical Centre Nottingham
Unilateral lumbar facetjoint hypertrophy causing nerve root irritation All four patients showing this interesting syndrome (Annals, September 1988, vol 70, p3O7) may have been successfully and quickly treated by rhizolysis (1) as outpatients, under local anaesthetic and probably returned to the workforce on the same day, free from the pain which was their major disability. It would have been worth a try because rhizolysis is so easy, simple, safe and effective. Even if rhizolysis didn't work in all four patients, it does not preclude any other surgical treatment. As Karl Marx almost said, the patients had nothing to lose but their pains. SKYRME REES FRCS Consultant Surgeon Private Post Box 3954 GPO Sydney 2000, NSW, Australia
