Relationship of the long thoracic nerve to the scapular tip: an aid to prevention of proximal nerve injury.

OBJECTIVE: The objective was to determine the course of the long thoracic nerve relative to the scapula as an aid to the prevention of proximal long thoracic nerve injuries. METHODS: Eighteen fresh cadavers (7 male, 11 female) were studied. Each was sequentially placed in the transaxillary and posterolateral thoracotomy positions, and the distance of the long thoracic nerve from the scapular tip and anterior scapular border was measured. The measurements were made bilaterally; the mean, standard deviation, and 99% confidence interval were calculated for each position by gender. RESULTS: Distances from the scapular tip to the long thoracic nerve are listed as mean/outer range: transaxillary thoracotomy, male 4.9/7.0 cm left, 5.2/7.5 cm right; female 4.3/5.0 cm left, 4.7/6.0 cm right; posterolateral thoracotomy, male 3.1/6.0 cm left, 4.5/5.1 cm right; female 3.2/4.5 cm left, 3.8/5.5 cm right. In all instances, the long thoracic nerve was furthest from the scapula at its tip. CONCLUSION: For patients positioned for a transaxillary thoracotomy, incision sites should be at least 7.5 and 6.0 cm anterior to the scapular tip for male and female patients, respectively. For patients in posterolateral thoracotomy positioning, incisions should be 6.0 and 5.5 cm anterior to the scapular tip for male and female patients, respectively. By using these anatomic guidelines, we believe that the incidence of iatrogenic proximal long thoracic nerve injury can be minimized.

Parathyroidectomy promotes wound healing and prolongs survival in patients with calciphylaxis from secondary hyperparathyroidism.

BACKGROUND: Calciphylaxis is a rare but life-threatening condition occasionally affecting patients with secondary hyperparathyroidism. Parathyroidectomy has been advocated as the only potentially curative intervention. METHODS: Between January 1989 and May 2000, 13 patients with pathologic/clinical criteria of calciphylaxis were treated at our institution. Of these 13 patients, 7 were managed with medical therapy alone, and 6 were referred for parathyroidectomy. The medical records were reviewed, and patients/relatives were interviewed. RESULTS: All patients had cutaneous wounds requiring local debridement predominantly located on the lower extremities or abdominal wall. Six patients underwent subtotal (3.5 gland) parathyroidectomy without morbidity. All 6 had significant reductions in parathyroid hormone levels after surgery (mean decrease, 94% +/- 0%), and all reported resolution of pain and healing of cutaneous wounds. Of the remaining 7 patients who had medical management alone, 5 eventually died of complications related to calciphylaxis. In comparing the 2 groups, patients who underwent parathyroidectomy had a significantly longer median survival than those who did not have surgery (36 vs 3 months, P =.021). CONCLUSIONS: Calciphylaxis frequently causes gangrene, sepsis, and eventual death. Parathyroidectomy can be performed with minimal morbidity and is associated with resolution of pain, wound healing, and a significantly longer median survival. Therefore, patients with secondary hyperparathyroidism and signs/symptoms of calciphylaxis should be referred promptly for consideration of parathyroidectomy.

Recurrent ventral herniation in Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome is an inherited collagen disorder characterized by skin hyperextensibility, joint laxity, and tissue friability. In this study, it was hypothesized that Ehlers-Danlos syndrome is frequently undiagnosed in patients who present for repair of ventral abdominal wall hernias. A retrospective chart review was conducted, and patients who had presented for elective repair of recurrent abdominal wall herniation were identified. In all patients, one or more prior attempts at repair with either mesh or autologous tissues had failed. Patients in whom abdominal wall components were lost secondary to extirpation or trauma, patients who had required acute closure, and patients with less than 2 months of follow-up were excluded. Twenty patients met these criteria. Twenty cases of recurrent ventral hernia repairs were reviewed, with special attention to identification of the preoperative diagnosis of Ehlers-Danlos syndrome. Patients ranged in age from 29 to 75 years, with a mean age of 54 years. Five patients were male (25 percent), and 15 were female (75 percent). The majority (95 percent) were Caucasian. The most common initial procedures were gynecologic in origin (35 percent). A precise closure technique that minimizes recurrence after ventral hernia repairs was used. With use of this technique, there was only one recurrence over a follow-up period that ranged from 2 to 60 months (mean follow-up duration, 25.7 months). Two patients with Ehlers-Danlos syndrome were identified, and their cases are presented in this article. The "components separation" technique with primary component approximation and mesh overlay was used for defect closure in the two cases presented. The identification of these two patients suggests the possibility of underdiagnosis of Ehlers-Danlos syndrome among patients who undergo repeated ventral hernia repair and who have had previous adverse postoperative outcomes. There are no previous reports in the literature that address recurrent ventral abdominal herniation in patients with Ehlers-Danlos syndrome.

Long-term physical impairment and functional outcomes after complex facial fractures.

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified. Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records. Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent). When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms. The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance. Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.

Traumatic optic neuropathy: a review of 61 patients.

The outcome of traumatic optic neuropathy was evaluated following penetrating and blunt injuries to assess the effect of treatment options, including high-dose steroids, surgical intervention, and observation alone. Factors that affected improvement in visual acuity were identified and quantified. Sixty-one consecutive, nonrandomized patients presenting with visual loss after facial trauma between 1984 and 1996 were assessed for outcome. Pretreatment and posttreatment visual acuities were compared using a standard ophthalmologic conversion from the values of no light perception, light perception, hand motion, finger counting, and 20/800 down to 20/15 to a logarithm of the minimum angle of resolution (log MAR). The percentage of patients showing visual improvement and the degree of improvement were calculated for each patient group and treatment method. Measurements of visual acuity are in log MAR units +/- standard error of the mean. Patients who sustained penetrating facial trauma (n = 21) had worse outcomes than patients with blunt trauma (n = 40). Improvement in visual acuity after treatment was seen in 19 percent of patients with penetrating trauma compared with 45 percent of patients with blunt trauma (p < 0.05). Furthermore, patients with penetrating trauma improved less than those with blunt trauma, with a mean improvement of 0.4 +/- 0.23 log MAR compared with 1.1 +/- 0.24 in blunt-trauma patients (p = 0.03). The patients with blunt trauma underwent further study. There was no significant difference in improvement of visual acuity in patients treated with surgical versus nonsurgical methods; however, 83 percent of patients without orbital fractures had improvement compared with 38 percent of patients with orbital fractures (p < 0.05). The mean improvement in patients without orbital fractures was 1.8 +/- 0.65 log MAR compared with 0.95 +/- 0.26 in patients with orbital fractures (p = 0.1). Twenty-seven percent of patients who had no light perception on presentation experienced improvement in visual acuity after treatment compared with 100 percent of patients who had light perception on admission (p < 0.05). The mean improvement in patients who were initially without light perception was 0.85 +/- 0.29 log MAR compared with 1.77 +/- 0.35 in patients who had light perception (p < 0.05). There were no significant differences in improvement of visual acuity when analyzing the effect of patient age and timing of surgery. Patients who sustain penetrating trauma have a worse prognosis than those with blunt trauma. The presence of no light perception and an orbital fracture are poor prognostic factors in visual loss following blunt facial trauma. It seems that clinical judgment on indication and timing of surgery, and not absolute criteria, should be used in the management of traumatic optic neuropathy.

Blindness after reduction of facial fractures.

Blindness in patients suffering maxillofacial trauma is usually caused by optic nerve or optic canal injuries. It is, however, an uncommon complication of facial trauma, with a reported incidence of only 2 to 5 percent. Blindness may also follow surgical repair of facial fractures. Many mechanisms, such as intraoperative direct nerve injury, retinal arteriolar occlusion associated with orbital edema, or delayed presentation of indirect optic nerve injury sustained at the time of the initial trauma, have been implicated in causing this blindness. In this article, four cases of visual loss after surgical repair of facial trauma are reported. In a review of the University of Maryland Shock Trauma experience with facial trauma over 11 years, we discovered that 2987 of the 29,474 admitted patients (10.1 percent) sustained facial fractures, and that 1338 of these fractures (44.8 percent) involved one or both of the orbits. One thousand two hundred forty of these patients underwent operative repair of their facial fractures. Three patients experienced postoperative complications that resulted in blindness, a total incidence of only 0.242 percent. Postoperative ophthalmic complications seem to be primarily mediated by indirect injury to the optic nerve and its surrounding structures. The most frequent cause of postoperative visual loss is an increase in intraorbital pressure in the optic canal. When our data were added to the summarized cases, blindness was attributable to intraorbital hemorrhage in 13 of 27 cases (48 percent). In addition, 5 cases in our review attribute the visual loss to unspecified mechanisms of increased intraorbital pressure, bringing the total cases of visual loss caused by intraorbital pressure or hemorrhage to 18 of 27 cases, or 67 percent. Within the restricted confines of the optic canal, even small changes in pressure potentially may cause ischemic optic nerve injury.

Blindness as a complication of Le Fort osteotomies: role of atypical fracture patterns and distortion of the optic canal.

Blindness in patients suffering maxillofacial trauma is usually caused by optic nerve or optic canal injuries. It is, however, an uncommon complication of facial trauma, with a reported incidence of only 3 to 5 percent. This incidence drops dramatically when fractures are performed in the controlled situation of orthognathic surgery. Given the rarity of ophthalmic complications after traumatic Le Fort I injuries, it is not surprising that few cases have been reported after orthognathic surgery. In this article, three cases of visual loss or skull base injury after elective Le Fort I osteotomy are described. All of these cases were presumably straightforward surgically and were performed by experienced surgeons. The literature is reviewed and the pathomechanics of each injury are experimentally explored in a cadaver model. To determine the presence of increased pressure on the optic nerve, optic canal deformation, or fractures extending to the skull base, two separate experiments were devised. In the first experiment, a pressure transduction system was used to document any significant forces that may be directly transmitted to the contents of the optic canal during pterygomaxillary separation. Then tested was the hypothesis that a stepped or tapered osteotomy will allow for a more predictable pterygomaxillary fracture. One of five cadaver specimens in group 1 demonstrated a transient increase in the right optic canal pressure during down-fracture of the maxilla. This change was less than 10 mmHg, and its duration was less than 5 seconds. The canal pressure returned to baseline with the completion of the fracture. In group 2, there was no documented pressure change with either osteotomy technique. Of note, in group 2, all specimens undergoing standard Le Fort osteotomy demonstrated uncontrolled propagation of the fracture lines superiorly in the pterygoid bones. The uncontrolled and unpredictable nature of pterygomaxillary disjunction may result in the extension of fractures to the skull base or the generation of deforming forces to the optic canal may compress or injure the optic nerve and its circulation. It is proposed that a stepped or tapered osteotomy will generate a more controlled pterygomaxillary separation during orthognathic surgery and may reduce the risk of devastating ophthalmologic complications.

Growth trajectory of children and adolescents with isolated cleft lip and/or palate through the first two decades of life.

A wide body of evidence shows that patients with clefts exhibit decreased growth in their early years. Less evidence regarding their growth trajectory, specifically their body mass indices (BMIs), in later years is available. This study analyzes BMIs of patients with isolated clefts and/or palate over time using age-adjusted BMI z-scores based on the CDC 2000 references for height and weight for age. At least two height and weight measurements were obtained during 2-10 years and at least two height and weight measurements were obtained during 10-20 years. Mean BMI z-score for all patients was 0.117. Males had a mean z-score of 0.087 and females a mean of 0.160 (p=0.407). Patients under 10 years of age had a mean z-score of 0.208, while patients older than 10 years had a mean z-score of -0.028 (p=0.223). While significance was not achieved in the statistical analysis, the results suggest that overall, the cleft population maintains a mean BMI that is similar to that of the general population during childhood and adolescence. A larger analysis is warranted to investigate this phenomenon further and to investigate specifically the rate of obesity within this group.

Closure of chronic abdominal wall defects: a long-term evaluation of the components separation method.

Incisional hernias and abdominal wall defects are frequently iatrogenic problems that have been found to complicate as many as 11% of all abdominal operations. Current techniques for closure of large, chronic abdominal wall defects have limitations. The use of local musculofascial flaps rather than fascial patches (i.e., the tensor fascia lata) or synthetic material for the repair of chronic abdominal wall defects is preferable. The superiority of innervated muscle flaps that provide dynamic abdominal support has been demonstrated. This report focuses on patients with chronic abdominal wall defects in whom previous techniques have failed. An algorithmic approach to planned reconstruction is presented utilizing the "components separation" technique as its foundation. Thirty-seven patients who underwent abdominal reconstruction following this algorithm are reviewed and their clinical course is outlined. The components separation technique provides a compound innervated and vascularized muscle flap for dynamic support of the reconstructed abdominal wall. The experience documented here and by others suggests that this technique is a safe and effective method for reconstructing the abdominal wall in patients with recurrent herniation. Enterocutaneous fistulas, however, continue to present a challenge to the surgeon.

Effects of hydroxyethyl-starch-bound deferoxamine on ischemia/reperfusion injury in chronic nerve compression.

The authors have demonstrated previously that pretreatment with deferoxamine, an iron chelator and antioxidant, at the time of release in acute nerve compression, provided protection against ischemia/reperfusion (I/R) injury. In the present study, they evaluated whether therapeutic intervention with hydroxyethyl-starch-bound deferoxamine (HES-DFO) at the time of release of the chronically-compressed peripheral nerve protects the nerve from I/R injury. The sciatic nerves of 43 male Sprague-Dawley rats, weighing 325 to 350 g, were subjected to 8 weeks of compression with Silastic tubing. The treatment group received intravenous HES-DFO (70 mg/kg) at the time of decompression, while the control group received an equal volume of intravenous hetastarch vehicle at the same time schedule and route. Nerve-tissue samples from the compression site, as well as contralateral noncompressed nerves, were assayed for malondialdehyde (MDA), a marker of I/R injury. The control group exhibited MDA levels up to five times normal, and did not return to normal for 21 days. In contrast, the HES-DFO group had MDA levels that were not statistically significantly different from normal levels. The results confirm that pretreatment with HES-DFO prior to the surgical decompression of chronically-compressed nerve provides marked protection against I/R injury.