Differential Diagnosis of "Foot Drop": Implications for Peripheral Nerve Surgery.

BACKGROUND: At least 128,000 patients in the United States each year suffer from foot drop. This is a debilitating condition, marked by the inability to dorsiflex and/or evert the affected ankle. Such patients are rendered to a lifetime of relying on an ankle-foot orthosis (AFO) for walking and nighttime to prevent an equinovarus contracture. METHODS: This narrative review explores the differential diagnosis of foot drop, with a particular focus on clinical presentation and recovery, whether spontaneously or through surgery. RESULTS: Contrary to popular belief, foot drop can be caused by more than just insult to the common peroneal nerve at the fibular head (fibular tunnel). It is a common endpoint for a diverse spectrum of nerve injuries, which may explain its relatively high prevalence. From proximal to distal, these conditions include lumbar spine nerve root damage, sciatic nerve palsy at the sciatic notch, and common peroneal nerve injury at the fibular head. Each nerve condition is marked by a unique clinical presentation, frequency, likelihood for spontaneous recovery, and cadre of peripheral nerve techniques. CONCLUSION: The ideal surgical technique for treating foot drop, other than neurolysis for compression, remains elusive as traditional peripheral nerve procedures have been marred by a wide spectrum of functional results. Based on a careful understanding of why past techniques have achieved limited success, we can formulate a working set of principles to help guide surgical innovation moving forward, such as fascicular nerve transfer.

Anatomical and Technical Considerations in Fascicular Nerve Transfers for Foot Drop.

BACKGROUND: Foot drop is the common endpoint for a diverse set of nerve injuries, affecting over 128,000 in the United States each year. The level of injury, finite pace of regeneration, and/ exponential decay in the percentage of motor end-plates reinnervated over time may explain the limited success with natural recovery. Past nerve techniques have also been met with limited success. METHODS: This narrative review explores why past nerve techniques have failed to correct foot drop. RESULTS: Previously described nerve transfer techniques suffer from incompletely balancing the foot and ankle, poor donor-target nerve synergy, and/or not effectively bypassing the wide and oftentimes underappreciated zone of injury. For maximal stability, one should look to balance the foot in both dorsiflexion and eversion. Detailed descriptions and illustrations of the branching anatomy for the peroneal and tibial nerves are provided, with specific application to nerve transfer reconstruction. CONCLUSION: Based on an understanding of why past nerve techniques have failed to correct foot drop, a set of surgical principles can be codified to optimize functional outcomes. A surgical technique should be versatile enough to address foot drop from any of the three common pathways of injury (lumbar spine, sciatic nerve, and common peroneal nerve). With increasing familiarity using this once poorly understood anatomical region, limitations with past nerve transfer techniques may be overcome.

Recommendations for Therapy following Nerve Transfer for Children with Acute Flaccid Myelitis.

AIM: To provide recommendations for pre- and post-operative occupational and physical therapy for children with acute flaccid myelitis (AFM). METHODS: Writing panel members consisted of an interdisciplinary team of seven healthcare professionals specializing in the care of children with AFM. The panel reviewed background material on AFM, nerve transfer, and rehabilitation principles applied to pediatrics. Recommendations were prioritized if evidence was available. Where there was no known evidence to support a recommendation, this was noted. RECOMMENDATIONS: Communication and coordination among interprofessional team members are vital to a comprehensive family-centered rehabilitation program. Surgical planning should include team preparation accounting for frequency, duration, and timing of treatment, as well as individual characteristics and developmental status of the child. Recommendations for pre-operative and six phases of post-operative therapy address assessment, strengthening, range of motion, orthoses, performance of functional activity, and support of the family. CONCLUSION: Rehabilitation following nerve transfer in children with AFM requires interdisciplinary collaboration and a multisystem approach to assessment and treatment. As new evidence becomes available, recommendations may be revised or replaced accordingly.

A Systematic Review of Prognostic Factors for Sensory Recovery After Digital Nerve Reconstruction.

BACKGROUND: Successful digital nerve repair is crucial in preventing painful neuroma formation and restoring sensory function after traumatic hand injury. The purpose of this study is to identify prognostic factors affecting sensory recovery following digital nerve reconstruction. METHODS: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines including studies reporting patients 18 years and older, greater than 10 reconstructed digital nerves, and greater than or equal to 3 months follow-up. Studies with proximal nerve injuries in the same distribution or inadequate sensory data were excluded. Included studies were evaluated by methodological index for nonrandomized studies score. Possible predictors were examined using the t test and 1-way analysis of variance with α ≤ 0.05. RESULTS: Twenty-five studies met the inclusion criteria, consisting of 818 surgically reconstructed digital nerves (mean age, 38 years; 78% male) with a mean ± SD defect length of 1.5 ± 0.5 cm. Mean follow-up time was 22 months. Fifty-six percent of patients presented with concomitant injuries to tendons (31%) and the digital artery (13%). Mean ± SD time to surgical repair was 36 ± 73.8 days. Reconstructive techniques included 35% end-to-end primary neurorrhaphy, 31% nerve grafts, and 11% synthetic conduits. Postoperatively, 81% of the patients demonstrated sensory recovery of S3+/S4, with 45% complaining of hyperesthesia. Nerve reconstructions performed within 15 days of injury had significantly better static 2-point discrimination than delayed procedures (P = 0.02). Static 2-point discrimination measurements were also significantly better for shorter defect lengths (<1.3 cm, P = 0.05). No significant functional differences were found across age, follow-up time, injured digit or side, nor reconstructive technique. CONCLUSIONS: Digital nerve reconstruction has good to excellent sensory recovery in up to 81% of patients with improved results in nerve gaps less than 1.3 cm. Performing the reconstruction within 15 days of injury is also correlated with improved sensory recovery.

Reconstructive algorithms in the pediatric population.

Reconstruction of oncologic defects in the pediatric population is a unique challenge. Differences in patient comorbidities, size of the reconstructive components, response of the skeletally immature body to surgery and radiation, compliance, and overall recovery potential make the pediatric patient cohort distinct from the adult population. Considering that patients are enjoying longer life spans, it behooves the surgeon to reconstruct oncologic defects with durable and long-lasting tissue. Determining when to implement each of the reconstructive tools is based upon principles embodied by the reconstructive ladder and taking into account the defect-specific characteristics, including location and type of tissues involved. Within the setting of multi-disciplinary care, reconstruction can be associated with good long-term functional and aesthetic outcomes. J. Surg. Oncol. 2016;113:940-945. © 2016 Wiley Periodicals, Inc.

Computed tomography-based morphometric analysis of extended strip craniectomy for sagittal synostosis.

BACKGROUND: The purpose of this study is 2-fold: (1) to identify computed tomography (CT)-based morphometric parameters that differentiate the normal skull from one with sagittal synostosis and (2) to evaluate correction of sagittal synostosis with extended strip craniectomy and postoperative helmeting based on morphometric parameters. METHODS: An institutional review board-approved, retrospective review was carried out at the Hospital for Sick Children for all patients who underwent an extended strip craniectomy and postoperative helmeting for sagittal synostosis from 1999 to 2005. Inclusion criteria consisted of patients who underwent a routine craniofacial CT preoperatively and 12 months postoperatively. Craniofacial CT scans of age-matched control subjects were used for preoperative and postoperative comparison. RESULTS: Thirty-nine patients with sagittal synostosis met inclusion criteria. Median age at preoperative CT was 3.0 months. Nine control subjects were identified, with a median age at CT scan of 5.0 months. Patients with sagittal synostosis preoperatively had a significantly longer maximum cranial length, smaller maximum cranial breadth, more acute frontal takeoff and occipital incline angles, lower cephalic index, and an anteriorly positioned vertex. Postoperative CT scans (median, 17.0 months) were compared with 10 control subjects (median, 19.0 months). Patients with sagittal synostosis postoperatively had equivalent maximum cranial breadth, frontal takeoff, and occipital incline angles as compared with controls. Sagittal synostosis patients remained with a significantly longer maximum cranial length, lower cephalic index, and anteriorly positioned vertex. CONCLUSIONS: Twelve months following extended strip craniectomy and helmeting for sagittal synostosis, CT-based morphometric analysis demonstrated correction of cranial breadth, frontal bossing, and occipital bulleting. Skull length and vertex position did not fully correct.

Endocortical plating of the bandeau during fronto-orbital advancement provides safe and effective osseous stabilization.

BACKGROUND: Ectocortical resorbable plate fixation has become a standard method of fixation during fronto-orbital advancement (FOA) in young children. Plate hydrolysis occurs slowly and can cause visible prominences, sterile abscesses, and osseous depressions that can persist after complete resorption. Although endocortical placement avoids contour issues, the safety and effectiveness of this technique are undocumented. METHODS: A review of our prospectively collected craniofacial database was performed. All patients undergoing FOA by a single craniofacial team at a single institution from 1997 to 2011 were examined. Inclusion criteria were as follows: (1) unicoronal, bicoronal, or metopic synostosis; (2) resorbable endocortical fixation of the bandeau; and (3) follow-up for 1 year or longer. Evaluation included patient demographic data, postoperative clinical course, and computed tomography imaging when available. RESULTS: Seventy-three patients met the inclusion criteria. Fusion involved the unicoronal (n = 26), bicoronal (n = 19), and metopic (n = 28) sutures. Mean age at operation was 8.3 months (range, 2.7-35.5 mo), and follow-up was 4.5 years (range, 1.0-9.9 y). No endocortical or ectocortical sterile abscesses were documented in our series. Postoperative complications included hematoma (n = 2), infection (n = 2), wound breakdown (n = 3), cerebral contusion (n = 2), and cerebrospinal fluid leak (n = 1); none of these issues were related to endocortical absorbable fixation. Fifty-eight patients (80%) were categorized as Whitaker classification I/II; and 15 patients (20%), Whitaker classification III/IV. Postoperative computed tomography (mean follow-up, 4.6 y) was obtained in 34 patients (47%). All plates were completely resorbed, and there were no bone or soft tissue irregularities in the region where the plates were placed. CONCLUSIONS: Endocortical resorbable fixation is a safe and effective method of osseous stabilization during FOA for craniosynostosis in young children.

Correction of deformational plagiocephaly in early infancy using the plagio cradle orthotic.

BACKGROUND: The purpose of this study was to assess early treatment of deformational plagiocephaly using the Plagio Cradle, a modifiable cranial orthotic. METHODS: Infants were included if they had treatment of deformational plagiocephaly with the Plagio Cradle beginning at 4 months or younger. Patients were prospectively stratified by the age treatment was initiated: group 1: under 10 weeks (n = 50); group 2: 10 to 20 weeks (n = 113). Pretreatment and posttreatment calvarial asymmetry was measured using direct anthropometry and reported as a transcranial difference (TCD). The end point for therapy was a TCD of 5 mm or less, falling within 2 SDs of published normative data. RESULTS: One hundred sixty-three infants were included. Initial TCD was significantly higher for group 1 as compared with group 2 (initial TCD: 11.0 vs 9.0 mm; P < 0.05). Duration of therapy was significantly longer for group 1 as compared with group 2 (6.9 vs 5.7 week; P < 0.05). Following cradle use, group 1 infants demonstrated a significantly larger change in TCD in comparison to group 2 (change in TCD: 6.0 vs 4.0 mm; P < 0.001). At the conclusion of therapy, group 1 infants trended toward greater calvarial symmetry than group 2 patients (final TCD: 4.5 vs 5.0 mm; P = 0.06) and a higher frequency of cases with full correction of asymmetry (62.4% vs 52.2%; P = 0.16). CONCLUSIONS: The Plagio Cradle can fully correct deformational plagiocephaly early in life. Nevertheless, treatment is more effective if initiated before 10 weeks of age.

Computer-aided design and manufacturing in craniosynostosis surgery.

BACKGROUND: Considerable operative time is expended during the planning, shaping, and reconfiguring of the cranial vault in the pursuit of symmetry during open craniosynostosis surgery. Computer-aided design and manufacturing has recently been implemented in orthognathic surgery and complex craniomaxillofacial reconstruction as a means of optimizing operative accuracy and efficiency. In this report, we highlight our growing experience with this promising modality for the preoperative planning and intraoperative execution of cranial vault remodeling in patients with both simple and complex forms of craniosynostosis. METHODS: Computer-assisted surgical planning begins with acquisition of high-resolution computed tomography scans of the craniofacial skeleton. An Internet-based teleconference is then held between the craniofacial and biomedical engineering teams and provides a forum for virtual manipulation of the patient's preoperative three-dimensional computed tomography with real-time changes and feedback. Through virtual surgical planning, osteotomies are designed and calvarial bones reconfigured to achieve the desired cranial vault appearance. Cutting and positioning guides are manufactured to transform the virtual plan into a reality. RESULTS: From February to March 2012, 4 children (aged 9 months to 6 years) with craniosynostosis underwent computer-assisted simulation and surgery. Diagnoses included metopic, unicoronal (n = 2), and multisutural synostoses (sagittal and left unicoronal). Open craniofacial repairs were performed as virtually planned, including front o-orbital remodeling, fronto-orbital advancement, and anterior two-thirds calvarial remodeling, respectively. Cutting and final positioning guides demonstrated excellent fidelity and ease of use. CONCLUSIONS: Computer-aided design and manufacturing may offer a platform for optimizing operative efficiency, precision, and accuracy in craniosynostosis surgery, while accelerating the learning curve for future trainees.

Age at initial consultation for craniosynostosis: comparison across different patient characteristics.

BACKGROUND: The severity and dysmorphology that results from the premature fusion of one or more cranial sutures is not uniform. Less striking phenotypes may be more easily missed on routine screening, possibly leading to delayed diagnosis and treatment. The purpose of this study was to compare the age at initial presentation for the different forms of craniosynostosis. METHODS: The authors reviewed the records of all patients who underwent open craniofacial repair of craniosynostosis at a single institution from 1996 to 2009. Relationships between type of suture fusion and age at initial consultation were compared. RESULTS: Two hundred eleven patients (136 males, 75 females) were identified. Indications included sagittal (n = 96), metopic (n = 39), unicoronal (n = 33), bicoronal (n = 24), multisutural (n = 15), bilambdoidal (n = 3), and unilambdoidal (n = 1) synostoses. Seventeen patients (8.1%) had a craniosynostosis syndrome and 5 (2.4%) had a syndrome or disorder not typically associated with craniosynostosis [X-linked hypophosphatemic rickets (n = 3), achondroplasia (n = 1), and Beckwith Wiedemann (n = 1)]. Median age at initial consultation was 4.1 months; there was no gender difference. Patients with X-linked hypophosphatemic rickets presented at a significantly older age than nonsyndromic patients or those with a known craniosynostosis syndrome. Those with multisutural synostosis presented at a significantly older age than patients with sagittal or bicoronal synostosis. CONCLUSIONS: Patients with multisutural involvement or X-linked hypophosphatemic rickets had a significant delay in presentation for craniosynostosis. The latter group of patients may especially benefit from routine surveillance for craniosynostosis given their advanced age at diagnosis.

Diagnostic Accuracy of Manual Muscle Testing to Identify Nerve Transfer Candidates in Children with Acute Flaccid Myelitis.

BACKGROUND: Manual muscle testing is a mainstay of strength assessment despite not having been compared with intraoperative electrical stimulation of peripheral nerves. METHODS: Intraoperative electrical stimulation served as the reference standard in evaluating predictive accuracy of the Active Movement Scale (AMS) and the Medical Research Council (MRC) scale. Retrospective consecutive sampling of all patients with AFM who underwent exploration or nerve transfer at a pediatric multidisciplinary brachial plexus and peripheral nerve center from March of 2016 to July of 2020 were included. The nonparametric area under the curve (AUC) was calculated. Optimal cutoff score (Youden J ) and diagnostic accuracy values were reported. The AMS and MRC scale were directly compared for predictive superiority. RESULTS: A total of 181 upper extremity nerves (73 donor nerve candidates and 108 recipient nerve candidates) were tested intraoperatively from 40 children (mean age ± SD, 7.9 ± 4.9 years). The scales performed similarly ( P = 0.953) in classifying suitable donor nerves with satisfactory accuracy (AUC AMS , 71.5%; AUC MRC , 70.7%; optimal cutoff, AMS >5 and MRC >2). The scales performed similarly ( P = 0.688) in classifying suitable recipient nerves with good accuracy (AUC AMS , 92.1%; AUC MRC :, 94.9%; optimal cutoff, AMS ≤3 and MRC ≤1). CONCLUSIONS: Manual muscle testing is an accurate, noninvasive means of identifying donor and recipient nerves for transfer in children with acute flaccid myelitis. The utility of these results is in minimizing unexpected findings in the operating room and aiding in the development of contingency plans. Further research may extend these findings to test the validity of manual muscle testing as an outcome measure of the success of nerve transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

"Natural" decannulation in patients with Robin sequence and severe airway obstruction.

OBJECTIVES: Airway management in infants with Robin sequence (RS) remains controversial, ranging from conservative to operative methods. In some centers, tracheostomy remains the mainstay for those infants with severe respiratory obstruction. The goals of this retrospective case cohort study were to determine the length of time to decannulation without further surgical intervention (ie, "natural" decannulation) in patients with severe RS who underwent tracheostomy and to investigate potential factors associated with successful decannulation. METHODS: We reviewed all infants with RS treated at a large tertiary center from 1994 to 2010. Patients who had undergone tracheostomy were identified. Baseline demographics, complications, deaths, and time to "natural" decannulation were recorded. Statistical analysis was performed with univariate analysis and Kaplan-Meier log-rank tests. RESULTS: Of 61 infants with RS with obstructive events, 25 infants (14 with isolated RS and 11 with syndromic RS) required tracheostomy. At a mean follow-up of 4 years, the rate of tracheostomy-specific complications was 52%; the tracheostomy-specific mortality rate was 12%. Overall, 13 of 25 infants (52%) were "naturally" decannulated, with a median time to decannulation of 97 months. Patients with syndromic RS had a significantly longer median time to decannulation than did those with isolated RS (more than 73 months versus 19 months, respectively; p = 0.019). In addition, patients with long-term tracheostomy dependence had significantly higher maximum carbon dioxide levels before tracheostomy than did patients who were successfully decannulated (82.4 versus 63.2 mEq/L, respectively; p = 0.02). CONCLUSIONS: Tracheostomy in infants with RS is associated with inordinately high rates of mortality, morbidity, and long-term tracheostomy dependence, particularly in patients with syndromic RS and in those with high maximum carbon dioxide levels before tracheostomy.

Factors associated with failed hardware salvage in high-risk patients after microsurgical lower extremity reconstruction.

BACKGROUND: Lower extremity hardware salvage remains challenging in patients with complex comorbidities. The purpose of this study was to identify factors associated with failed hardware salvage after microsurgical lower extremity reconstruction. METHODS: A retrospective, institutional review board-approved review was performed of patients who underwent lower extremity hardware salvage via free tissue transfer from 2004 to 2010. Outcomes were binarized into successful versus failed hardware salvage, with failure defined as nonelective removal. Patient demographics, wound characteristics, microbiology, and pathology were compared. RESULTS: Thirty-four patients underwent lower extremity hardware salvage via free tissue transfer, with an average follow-up of 3.2 years (range, 0.3-7.0 years). Of these patients, 15 (44.1%) had successful hardware salvage and 19 (55.9%) required hardware removal. By demographics, a higher prevalence of multiple comorbidities was found in patients with failed hardware salvage. Wound characteristics revealed a significantly longer time to hardware coverage and longer duration of intravenous antibiotics in failed versus successful hardware salvage patients (38.9 vs 9.3 weeks, P=0.02; 6.5 vs 4.1 weeks, P=0.03, respectively). Initial wound cultures demonstrated a significantly higher frequency of positive growth in patients with failed versus successful hardware salvage (100.0% vs 57.1%, P=0.003). Initial pathology revealed a borderline-significantly higher frequency of chronic osteomyelitis in failed versus successful salvage patients (66.7% vs 33.3%, P=0.08). CONCLUSIONS: In this retrospective review of microsurgical lower extremity reconstruction, factors associated with failed hardware salvage included multiple comorbidities, longer time to hardware coverage, increased duration of intravenous antibiotics, positive initial wound cultures, and chronic osteomyelitis on initial pathology.

A systematic review of the outcomes of distal upper extremity bypass surgery with arterial and venous conduits.

PURPOSE: To conduct a systematic review of literature evaluating efficacy of venous and arterial grafts for distal upper extremity bypass surgery. METHODS: A PubMed search using MeSH terms "veins/surgery" OR "arteries/surgery" AND "radial artery/surgery" OR "ulnar artery/surgery" yielded 794 studies. Manual review produced 42 studies based on inclusion criteria of reported distal upper extremity bypass surgery, complete information on graft type used, examined patency of reconstruction, and described method for determining patency. Studies meeting inclusion criteria underwent data extraction focusing on demographics, revascularization site, conduit type, microsurgical technique, subjective/objective outcomes, and postoperative anticoagulation regimens. RESULTS: Sixteen studies met the inclusion criteria. In 145 patients, 152 grafts were performed for upper extremity revascularization, including 120 grafts for revascularization of distal ulnar artery circulation, 31 for distal radial artery circulation, and 1 for both distal ulnar and radial artery occlusions. Overall patency rate was 87% at an average follow-up of 34 months. Of 152 bypass grafts, 19 were arterial conduits. Donor sites included the deep inferior epigastric artery, subscapular artery, thoracodorsal artery, and descending branch of the lateral femoral circumflex artery. At a mean follow-up of 18 months, arterial conduit patency was 100%. The remaining 133 bypass procedures used vein grafts from various donor sites, including the saphenous, cephalic, and basilic veins. At an average follow-up of 37 months, overall vein graft patency rate was 85%. There was a statistically significant difference between patency rates of arterial conduits compared with venous conduits. All studies reported improved ischemic symptoms including reduction of cold sensitivity, pain, and digital ulceration. CONCLUSIONS: This review showed a high patency rate and clinical efficacy of distal upper extremity bypass surgery with a mean follow-up of almost 3 years. There may be a benefit of using arterial versus venous conduits, although further examination is needed given the small number of arterial reconstructions reported.

Outcomes in computer-assisted surgical simulation for orthognathic surgery.

Orthognathic surgery is a powerful tool to address skeletal discrepancies of the jaws; however, the model surgery and splint fabrication necessary to successfully complete this surgery are laborious and time consuming. Previous studies have described the utility of computer-assisted surgical simulation (CASS) to eliminate the need for plaster cast model surgery. This article evaluates the implementation of a CASS system for treatment planning and splint fabrication in a series of 11 orthognathic surgery patients. All patients were treatment planned using a CASS system for computer-simulated osteotomies and splint fabrication. As a safety measure, traditional model surgery and splint fabrication were also performed on all cases. Each case was evaluated for accuracy of cephalometric analysis, splint accuracy, splint durability, and ease of treatment planning. All splints fit as well, or better, than those fabricated using traditional methods. In 2 cases, occlusal cants were detected by the CASS system that were undetected by traditional cephalometric analysis and physical examination. In 1 case, the skeletal midline identified on the computed tomographic scan was incongruent with the soft tissue clinical midline of the face, and this discrepancy was recognized and compensated for by correlation of the physical examination and preoperative clinical photos.In this series of 11 patients, the CASS system proved to be an effective mechanism to treatment plan cases and prepare surgical splints for patients undergoing orthognathic surgery.

Factors related to blood loss during fronto-orbital advancement.

BACKGROUND: Blood loss during fronto-orbital advancement (FOA) remains a significant potential source of morbidity. This study explored variables that might correlate with calculated blood loss (CBL) during this procedure. METHODS: The authors reviewed infants with craniosynostosis who underwent primary FOA (1997-2009). Patient demographics, operative time, and mean arterial pressure (MAP) were recorded. Serial MAPs were averaged for a MAPmean and subtracted from preoperative baseline to calculate MAP%decrease. This provided indicators of both absolute and relative hypotension, respectively. Calculated blood loss was based on preoperative/postoperative hemoglobin values and transfusion volumes and accounted for hemodilutional effects. RESULTS: Ninety infants underwent FOA at an average age of 10.7 ± 12.9 months and mean weight of 9.0 ± 7.0 kg. Average operative time was 4.2 hours, and intraoperative MAP was 56.1 mm Hg, 22.6% lower than baseline. Mean CBL was 259.3 mL, or 39.3% of estimated blood volume, negatively correlating with surgical age (r = -0.033, P < 0.05) and positively trending with operative time (r = 0.55, P < 0.05). Absolute hypotension was associated with greater blood loss, as demonstrated by an inverse relationship between CBL and MAPmean (r = -0.19, P < 0.05). From the perspective of relative hypotension, no association was found between CBL and MAP%decrease. CONCLUSIONS: Greater operative efficiency and deferring operative correction to a later age may diminish blood loss during FOA. The study results also raise serious concerns regarding the hemodynamic benefits of controlled systemic hypotension.

Blood loss estimation during fronto-orbital advancement: implications for blood transfusion practice and hospital length of stay.

BACKGROUND: Reliable measurement of intraoperative blood loss remains a serious challenge during correction of craniosynostosis. This study analyzed the relationship between estimated blood loss (EBL) and calculated blood loss (CBL) in fronto-orbital advancement and its implications on blood transfusion practice and hospital length of stay (LOS). METHODS: The authors reviewed infants who underwent primary fronto-orbital advancement for craniosynostosis (1997-2009). Estimated blood loss was based on anesthesia records and CBL by preoperative/postoperative hemoglobin. Perioperative red blood cell transfusion (RCT) and hospital LOS were recorded. RESULTS: Ninety infants were included. Mean EBL was 42.2% of estimated blood volume (% EBV), and CBL was 39.3% EBV, without significant difference (P = 0.23). Bland-Altman analysis revealed that EBL was greater than CBL at lower levels of blood loss (≤47.0% EBV) and less than CBL at higher levels (>47.0% EBV). Mean intraoperative RCT was 45.8% EBV; overtransfusion was more frequent at lower levels of bleeding, and undertransfusion at higher levels. Postoperative RCT occurred more frequently with greater blood loss. Mean LOS was 3.7 days, increasing with CBL (hazard ratio of discharge, HR(discharge) = 0.988, P < 0.01), postoperative RCT (HR(discharge) = 0.96, P < 0.05), total RCT (HR(discharge) = 0.991, P < 0.05), and total intraoperative fluid (HR(discharge) = 0.999, P < 0.05). CONCLUSIONS: Estimated blood loss is a less accurate marker for CBL at the extremes of blood loss during fronto-orbital advancement. The tendency to overestimate blood loss with less intravascular volume loss can result in unnecessary transfusion, whereas underestimation with greater actual blood loss can lead to delay in resuscitation and longer hospitalization.

Surgical Complexity and Physician Compensation: An Analysis of Relative Under-Valuation for Pediatric Brachial Plexus Surgery.

BACKGROUND: Brachial plexus reconstruction (BPR) is a rapidly advancing field within hand surgery. BPR procedures are complex, time-intensive, and require microsurgical expertise. As physician reimbursement rates for BPR are poorly defined, relative to more common hand procedures, we sought to analyze compensation for BPR across different payor groups and understand the factors contributing to their reimbursement. METHODS: A retrospective review was performed of surgeries by a single senior staff member in a 4-year period to evaluate Current Procedural Terminology (CPT) codes from BPR cases. For comparison, all finger fracture fixations and skin graft reconstructions performed by the same surgeon over the same time period were analyzed as well. RESULTS: A total of 57 BPR cases, 94 finger fracture fixation cases, and 69 skin grafting cases met inclusion criteria. Among the top 5 insurance providers, average work relative value unit (wRVU)/hour was 6.55, 3.49, and 12.67 for BPR, fracture fixation, and skin grafts, respectively. Reimbursements were an average $685.76/hour for BPR, compared to $590.10/hour for fracture fixation and $1,197.94/hour for skin grafts. CONCLUSIONS: BPR demonstrates a relative undervaluation, in terms of reimbursement per hour, given the time and surgical skill required for such cases, particularly compared to shorter, less complex cases such as skin grafting and fracture fixation. We find that this discrepancy is amplified across multiple levels of coding, billing, and reimbursement. We suggest specific strategies for physician leadership to more directly participate in the financial decisions that affect themselves, their patients, and their specialty.

Amyloid Deposition: An Unusual Case of Deep Gluteal Syndrome and Sciatic Nerve Compression: A Case Report.

CASE: Soft-tissue amyloidomas are exceedingly rare, with only a few cases reported in the literature. There are no reports of sciatic nerve compression secondary to a soft-tissue amyloidoma. We report a unique case of a 71-year-old man with an incidentally found amyloidoma who was initially believed to have deep gluteal syndrome. He had a favorable outcome after surgical decompression. CONCLUSION: For patients who do not have classic examination and electromyography/nerve conduction findings of piriformis syndrome, providers should explore other etiologies of peripheral nerve compression including soft-tissue amyloidoma.