Topographical Analysis of the Hamate for Proximal Pole Scaphoid Nonunion Reconstruction.

PURPOSE: To quantify the similarity of the surface topography of the proximal hamate and proximal pole of the scaphoid for nonunion reconstruction. METHODS: Using previously acquired computed tomographic scans of the wrist of 10 patients, the 2 bones were segmented and subsequently aligned using both a manual and automated technique. Surface error between corresponding articular surfaces was computed to determine the similarity of the shape of the 2 bones. RESULTS: The median distance between the 2 articulating surfaces for each patient was 1 mm or less for all cases. Maximum distance varied from 2.7 to 9.7 mm. The automated method improved alignment such that the maximum distance was 4.1 mm. Visual review of the alignment revealed that the maximum error occurred on or around the margin of the articulating surfaces. CONCLUSIONS: In most cases, the proximal hamate appears to be a suitable donor match to reconstruct proximal pole scaphoid nonunions. CLINICAL RELEVANCE: This study serves as a guide to practitioners when considering the suitability of the proximal hamate autograft for unsalvageable proximal pole scaphoid nonunions.

The Effect of Proximal Hamate Osteotomy on Carpal Kinematics for Reconstruction of Proximal Pole Scaphoid Nonunion With Avascular Necrosis.

Background: The purpose of this study is to determine the effects of proximal hamate transfer for proximal pole scaphoid reconstruction upon carpal kinematics. Methods: Eight fresh-frozen cadaveric wrists underwent evaluation of their radiocarpal and midcarpal motion after proximal hamate osteotomy. A wrist simulator was used to apply cyclical tension to the flexor carpi ulnaris (FCU), flexor carpi radialis (FCR), extensor carpi ulnaris (ECU), and extensor carpi radialis longus and brevis stitched together (ECR). Kinematic motion was captured using Moiré Phase Tracking 3-dimensional motion-tracking sensors (MPT, Metria Innovation, Inc, Milwaukee, Wisconsin) to evaluate the lunocapitate and scapholunate angles for each condition. Results: During wrist flexion-extension and radial-ulnar deviation, there were no statistically significant differences about the lunocapitate or scapholunate axis between the intact and post-hamate osteotomy conditions. Conclusions: The harvest of the proximal hamate for proximal pole scaphoid reconstruction does not appear to adversely affect wrist kinematics.

Scapholunate Ligament Internal Brace 360 Tenodesis (SLITT) Procedure: A Biomechanical Study.

Background Twelve paired fresh frozen cadaveric wrists were randomized to a 360-degree tenodesis repair group or the 360-degree tenodesis repair with an internal brace (suture tape) construct. Case Description The specimens were preloaded to 5 N and subsequently biomechanically loaded to failure, at a rate of 0.1 mm/s on a jig that allowed for axial load. The maximum load and mode of failure were recorded. Load to failure in the 360 tenodesis group with internal brace was 283.47 ± 100.25 N, compared with the 360 tenodesis group only, whose yield strength was 143.61 ± 90.54 N. The mode of failure within the internal brace construct was either through knot slippage, graft disruption, or bone separation from strength testing construct. The 360 tenodesis group tended to fail via graft slippage or graft rupture. Literature Review The management of scapholunate instability can be a difficult problem to treat. Traditionally, many of the surgical reconstructions have focused upon dorsal ligament reconstruction with Kirschner (K) wire fixation. This results in prolonged immobilization of the wrist with varied outcomes, in part due to the multiaxial instability that may persist due to concomitant volar ligament disruption. To address this instability, surgical techniques have been devised that address both the volar and dorsal ligament injuries. Clinical Relevance Scapholunate reconstruction with a 360-degree tenodesis and internal brace augmentation (SLITT procedure) provided superior biomechanical stability than tenodesis alone.

Comparing the Use of Injectable Fillers for the Youthful Lip and the More Mature Lip.

Enhancement of the lips with facial fillers is currently one of the most popular nonsurgical cosmetic treatments worldwide. Patients from all age ranges have interest in these treatments, but there is wide variance of their esthetic goals. Practitioners must be aware of the challenges posed by both the youthful and mature lip, which usually requires different approaches and techniques. This article reviews the lip anatomy, aging changes in the lips and perioral region, techniques to produce consistent results, and ways to manage and avoid potential complications.

Traumatic Divergent Elbow Dislocation with Associated Forearm Amputation in an Adult: A Case Report.

CASE: A 49-year-old right-hand-dominant man sustained an auger-related injury that resulted in open dislocation at the left wrist and palm, with complete amputation of the distal aspect of the forearm and the hand. The injury at the elbow included instability with an ulnar coronoid fracture, posterior dislocation of the ulna, and posterolateral dislocation of the radius. To restore stability of the forearm stump and elbow, we performed a complete resection of the radius, open reduction and internal fixation of the coronoid tip, a repair of the lateral collateral ligament, and transfer of the distal biceps tendon to the coronoid. CONCLUSION: The procedure stabilized the elbow, allowing for early mobilization. The patient was eventually fitted with a prosthesis that allowed him to return to full-time manual labor in a rural setting.

Scapholunate Ligament Internal Brace 360-Degree Tenodesis (SLITT) Procedure.

Background Scapholunate (SL) joint instability is one of the most common injuries of the wrist and may result from a fall or high-energy mechanism on the outstretched hand. The purpose of this case report is to describe the outcome of a 360-degree tenodesis to the SL joint with an internal brace (SLITT) for the treatment of SL instability. Case Description A 42-year-old male patient underwent SL ligament reconstruction with the SLITT procedure 12 months after injury. Given the intrinsic stability of the reconstruction, Kirschner (K) wires were not used and an early range of motion protocol was initiated. Thirteen months after his reconstruction, he was back at work with maintenance of his carpal alignment. Discussion Since its initial description, a myriad of different surgical techniques for SL instability have been devised with varied success. These include capsular shrinkage, dorsal capsulodesis, reduction-association with a screw of the scapholunate joint (RASL), scapholunate axis method (SLAM), bone ligament bone grafts, and a variety of tendon reconstructions. Possible explanations for this varied outcome may be related to the use of soft tissue reconstructions for irreducible injuries and reconstruction of only the dorsal SL ligament. In addition, many of these techniques involve prolonged immobilization with the use of K-wires. Clinical Relevance The SLITT procedure reconstructs both the volar and dorsal SL ligament. Given the added stability afforded by intrinsic bracing, we feel that this reconstruction may permit earlier range of motion without the need for K-wire stabilization.

The Suction Test: A Novel Technique to Identify and Verify Successful Repair of Peripheral Triangular Fibrocartilage Complex Tears.

Background The diagnoses of peripheral triangular fibrocartilage complex (TFCC) tears continue to be the subject of numerous investigations. Case Description We describe a novel arthroscopic technique that may be used as an adjunct with other arthroscopic maneuvers to diagnose and confirm repair of peripheral sided TFCC injuries. Literature Review The hook and trampoline tests are intraoperative techniques to diagnose TFCC tears. Clinical Relevance The suction test provides a means to detect peripheral tears and to confirm restoration of its tension post repair.

Carpal Realignment Using a Strip of Extensor Carpi Radialis Longus Tendon.

Scapholunate instability can lead to posttraumatic dysfunction of the wrist. If unrecognized, it commonly leads to degenerative osteoarthritis. Numerous reparative techniques have been proposed with mixed long-term success. We present a technique that uses a distally based strip of the extensor carpi radialis longus to better maintain reduction of the scaphoid and reconstruct the volar and dorsal scapholunate ligament and the scaphotrapezium-trapezoid ligament. To illustrate the technique, we describe a clinical case with 17 months of follow-up.

Histologic effects of resurfacing lasers.

By utilizing resurfacing lasers, physicians can significantly improve the appearance of sun-damaged skin, scars, and more. The carbon dioxide and erbium:yttrium-aluminum-garnet lasers were the first ablative resurfacing lasers to offer impressive results although these earlier treatments were associated with significant downtime. Later, nonablative resurfacing lasers such as the neodymium:yttrium-aluminum-garnet laser proved effective, after a series of treatments with less downtime, but with more modest results. The theory of fractional photothermolysis has revolutionized resurfacing laser technology by increasing the safety profile of the devices while delivering clinical efficacy. A review of the histologic and molecular consequences of the resurfacing laser-tissue interaction allows for a better understanding of the devices and their clinical effects.

Skin tightening technologies.

Radiofrequency (RF) and intense focused ultrasound (IFUS) are increasingly used to address skin laxity of the face and neck. Both nonablative RF and ultrasound create a heat-induced tissue response that leads to collagen remodeling and other ultrastructural changes. Although these treatments are not meant to replace surgical procedures, patient satisfaction in the majority of studies has been consistently high. This article discusses the various RF and IFUS technologies currently in use and reviews pertinent clinical studies evaluating their efficacy and safety.

Effects of voluntary wheel running on LPS-induced sickness behavior in aged mice.

Peripheral stimulation of the innate immune system with LPS causes exaggerated neuroinflammation and prolonged sickness behavior in aged mice. Regular moderate intensity exercise has been shown to exert anti-inflammatory effects that may protect against inappropriate neuroinflammation and sickness in aged mice. The purpose of this study was to test the hypothesis that voluntary wheel running would attenuate LPS-induced sickness behavior and proinflammatory cytokine gene expression in ~22-month-old C57BL/6J mice. Mice were housed with a running wheel (VWR), locked-wheel (Locked), or no wheel (Standard) for 10 weeks, after which they were intraperitoneally injected with LPS across a range of doses (0.02, 0.08, 0.16, 0.33 mg/kg). VWR mice ran on average 3.5 km/day and lost significantly more body weight and body fat, and increased their forced exercise tolerance compared to Locked and Shoebox mice. VWR had no effect on LPS-induced anorexia, adipsia, weight-loss, or reductions in locomotor activity at any LPS dose when compared to Locked and Shoebox groups. LPS induced sickness behavior in a dose-dependent fashion (0.33>0.02 mg/kg). Twenty-four hours post-injection (0.33 mg/kg LPS or Saline) we found a LPS-induced upregulation of whole brain TNFα, IL-1ß, and IL-10 mRNA, and increased IL-1ß and IL-6 in the spleen and liver; these effects were not attenuated by VWR. We conclude that VWR does not reduce LPS-induced exaggerated or prolonged sickness behavior in aged animals, or 24h post-injection (0.33 mg/kg LPS or Saline) brain and peripheral proinflammatory cytokine gene expression. The necessity of the sickness response is critical for survival and may outweigh the subtle benefits of exercise training in aged animals.

1550-nm nonablative laser resurfacing for facial surgical scars.

OBJECTIVE: To investigate the efficacy of 1550-nm (Fraxel SR1500 RE:Store; Solta Medical, Hayward, California) nonablative laser treatment of facial surgical scars. METHODS: In this prospective clinical study, a volunteer sample of 13 adults with Fitzpatrick skin types I to III and facial surgical scars with a postoperative duration longer than 6 months were enrolled. Subjects were treated once every 4 weeks for a total of 4 treatments. Initial settings for the 1550-nm nonablative laser were at energy level 40 mJ and treatment level 4 and were subsequently increased on each visit according to the patients' tolerance level. Using a previously validated Patient and Observer Scar Assessment Scale (POSAS), the study subject and an independent evaluator completed assessments of the scar at each visit. RESULTS: According to the Friedman test on ratings across all occasions after the first treatment to the last evaluation, there was a statistically significant improvement in the patient's assessment of the color, stiffness, thickness, and irregularity of the scar but not for pain or itching. For the observer's ratings, there was a statistically significant improvement in pigmentation, thickness, relief, and pliability but not for vascularization. CONCLUSIONS: Preliminary data suggest improved aesthetic results, demonstrating the potential use of fractional photothermolysis as a scar revision technique. Future studies with a longer follow-up period could elucidate the role of fractional photothermolysis in more permanent scar improvements.

Rhinoplasty5 pearls: value of the endonasal approach and vertical dome division.

Successful outcomes in rhinoplasty depend more on diagnosis than on approach or technique. When the needs of each patient are assessed on multiple occasions, operative performance improves and revision rates decline. The evolutionary track from an endonasal and excisional operation to the more commonly preferred external and restructuring technique is outlined in this article. The senior author's rationale and preference for the endonasal approach and the repositioning of cartilage in the tip using vertical dome division techniques is emphasized.

Primary closure of persistent tracheocutaneous fistula in pediatric patients.

OBJECTIVE: The aim of the study is to review the safety and efficacy of partial fistulectomy with 3-layered primary closure without postoperative intubation for persistent tracheocutaneous fistula (TCF). DESIGN: This is a retrospective study. SETTING: The study was conducted in a tertiary care pediatric hospital. PATIENTS: Records of 49 children treated for persistent TCF between 1996 and 2005 were reviewed. Patients were studied if the TCF was closed using a 3-layered primary closure, and they had at least 1 year of follow-up. Thirty-nine patients met inclusion criteria. RESULTS: All patients were extubated immediately after surgery. Drains were removed, and all patients were discharged on the first postoperative day. The most common indications for tracheostomy were prolonged intubation and subglottic stenosis. There were 2 major and 3 minor complications. One major complication involved subcutaneous emphysema that developed on the seventh postoperative day because of cough. The other involved a poorly controlled diabetic patient who developed a postoperative infection with dehiscence. All fistulas remained closed at follow-up. CONCLUSION: Partial excision and primary closure of persistent TCF is safe and effective. Drain placement and overnight observation are imperative. Careful patient selection is important. Routine postoperative intubation is not necessary.

Characterization and cloning of GP50, a Taenia solium antigen diagnostic for cysticercosis.

GP50, a Taenia solium protein diagnostic for cysticercosis has been cloned, sequenced, and characterized. GP50 is one diagnostic component of the lentil lectin purified glycoprotein (LLGP) antigens that have been used for antibody-based diagnosis of cysticercosis in a Western blot assay for nearly 15 years. GP50 is a glycosylated and GPI-anchored membrane protein. The native protein migrates at 50kDa, but the predicted molecular weight of the mature protein is 28.9. Antigenically active recombinant GP50 has been expressed in a baculovirus expression system. The antigenic activity of both the native and recombinant proteins is dependent upon the correct formation of disulfide bonds. GP50, purified from cysticerci, has two homologs expressed in the adult worm, TSES33 and TSES38. Both are diagnostic for taeniasis. In spite of the amino acid similarities between GP50 and the TSES proteins, each appears to be a stage-specific antigen. A preliminary evaluation of recombinant GP50 in a Western blot assay showed 100% specificity for cysticercosis and 90% sensitivity for cysticercosis positive serum samples reactive with the GP50 component of LLGP.

Management of T3 N0 and T4 N0 glottic carcinomas: results of a national survey.

OBJECTIVE: A survey was undertaken to document the clinical management of T3 and T4 pure glottic primary carcinomas and the management of the N0 neck by otolaryngologists and radiation oncologists. STUDY DESIGN AND SETTING: This study represents the results of a national survey of 250 otolaryngologists and 250 radiation oncologists regarding management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. RESULTS: Of the surveys sent, 208 completed questionnaires were received. Results of this survey suggest that 87% and 90% will treat the neck for a T3 N0 M0 and T4 N0 M0 glottic tumor, respectively, with a large number choosing to perform a radical neck dissection. CONCLUSIONS: A significant percentage of otolaryngologists perform neck dissections in the management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. Given the relatively low risk of occult metastasis, potentially high morbidity associated with overtreatment, and the lack of a well-designed outcome study investigating treatment alternatives, a prospective randomized study is needed to address the issue.