Variant Plantaris Anatomy During Tendon Harvest.

The plantaris tendon is commonly used in upper extremity reconstruction as a tendon graft. Variations in plantaris anatomy are described as terminating proximally into the calcaneal tendon or gastrocnemius in certain cases, making the tendon an unusable length as a graft. A case of anomalous attachment of the gastrocnemius muscle to the plantaris tendon is described. After division of this attachment through a counterincision, complete harvest of the plantaris tendon was possible. Further exploration when resistance is encountered in standard plantaris tendon harvest is recommended to avoid unnecessary abandonment of a plantaris harvest.

Genioglossus Advancement: Technique Modification for Improved Chin Contour.

Genioglossus advancement plays an important role in the armamentarium of the obstructive sleep apnea surgeon and has gone through many iterations over several decades. A recently described technique involves creating a box osteotomy, which is carried through the inferior border of the mandible in order to increase recruitment of the suprahyoid musculature. Here we introduce a further modification of the technique that uses virtual planning to improve the safety and accuracy of genial tubercle capture. In addition, angulation of the lateral osteotomies enhances bone to bone contact. Before the osteotomy, the surgeon has the opportunity to drill the buccal plate to reduce the chin profile. This approach is particularly valuable in the patient who is prognathic at baseline or who becomes prognathic after simultaneous maxillomandibular advancement. Here we discuss this unique approach, demonstrating how the patient profile may be balanced even as the genial tubercle is advanced.

Preoperative Examination Is Not Associated with Postoperative Function following Radial Forearm Free Flap Harvest.

BACKGROUND: There is debate on the utility of a preoperative Allen test or ultrasound before radial forearm free flap (RFFF) harvest. This study sought to evaluate correlations between preoperative testing and donor-site morbidity. METHODS: A survey of plastic surgery and otolaryngology RFFF patients was conducted at a Midwestern academic center. The modified Cold Intolerance Symptom Severity (modCISS) and Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) instruments were administered. A retrospective chart review was performed to assess perioperative factors. RESULTS: Of 212 RFFFs completed over 7 years, 144 patients were contacted, and 71 patients completed the survey (33% response rate). Preoperative Allen test was negative in 92% of patients (65 of 71). There was no statistical association between Allen test and duplex ultrasound findings ( P = 0.19). Cold intolerance screening was positive on 20% of donor arms (14 of 71), with an average positive modCISS score of 39.0 ± 14.7. Disability was reported on the QDASH by 76% of patients (54 of 71), with an average score of 21.0 ± 22.3. There was no statistical correlation between preoperative Allen test or ultrasound classification and modCISS or QDASH score. There was a borderline positive correlation between modCISS and QDASH scores that did not reach statistical significance ( r = 0.22, P = 0.067). Operative characteristics also did not predict modCISS or QDASH scores. CONCLUSIONS: Following RFFF harvest, donor extremity cold intolerance is reported in 20% of patients, and extremity-related disability is reported in the majority of patients. Preoperative ultrasound and physical examination findings are not predictive of morbidity.

Le Fort I maxillary osteotomy in a Jehovah's Witness patient: strategies for minimizing blood loss and maximizing safety.

BACKGROUND: The Watch Tower Society, the main governing organization of the Jehovah's Witness (JW) faith, introduced the doctrine to refuse blood in 1945 and has been enforcing it since 1961. A member can be expelled for accepting prohibited blood components. Many reconstructive surgeries place patients at an increased risk for blood loss. There have been attempts at reducing the rate of transfusions in craniofacial surgery, even in patients not opposed to it. PRESENTATION: A 15-year-old female patient, who refused blood transfusion due to her faith, presented with a class III malocclusion, transverse maxillary constriction, and a lateral open bite. Surgery was deferred until the patient reached 18 years of age and had undergone preoperative orthodontics. A two-piece Le Fort I osteotomy was performed. Erythropoietin, oral iron, and tranexamic acid were used to minimize intraoperative blood loss. CONCLUSION: Here we discuss preoperative and intraoperative management strategies to ensure a transfusion-free environment for patients with religious objections to blood transfusions undergoing operations with increased bleeding risk.

Management of a Highly Vascular Low-grade Myofibroblastic Sarcoma of the Mandible.

An 11-year-old male patient presented with a large, highly vascular, destructive mandibular mass. An intraoral biopsy showed pleomorphic spindle cells arranged in intersecting fascicles, with scattered atypia. A diagnosis of low-grade myofibroblastic sarcoma was made. The lesion was treated with preoperative arterial embolization followed by surgical resection and reconstruction with a fibular osteomyocutaneous free flap. To our knowledge, no reports of highly vascular mandibular low-grade myofibroblastic sarcoma are available in the literature.

Treatment of type III supracondylar humerus fractures: adherence and limitations of American Academy of Orthopedic Surgeons Appropriate Use Criteria App.

The American Academy of Orthopedic Surgeons (AAOS) published Appropriate Use Criteria (AUC) in 2014 to aid physicians in the management of pediatric supracondylar humerus fractures. AUC should be evaluated in real practice, and if necessary modified based on identified problems. This study compares AAOS AUC recommendations with actual treatment performed in a cohort of patients treated for type III supracondylar humerus fractures. Medical record review of patients treated for type III supracondylar humerus fractures at our hospital from 2009 to 2016. Criteria required by the AAOS AUC were collected and entered into the AAOS AUC web-based application to determine the 'appropriateness' and score of each treatment. These were compared with the actual treatment the patient received. Over the study period, 585 patients (mean age: 6.5 years, 51% male, 49% female) were treated for type III supracondylar humerus fractures. Of the 585 cases, 561 (95.9%) were classified as 'appropriate', 24 (4.1%) as 'maybe appropriate', and 0 (0%) as 'rarely appropriate'. Of the 'maybe appropriate' cases there was a significant decrease in the proportion that deviated from the AUC over time (P = 0.0076). The main reasons for deviation were that an open reduction was performed due to difficulty with closed reduction (75% of deviations) or the surgery was not performed emergently (25% of deviations). The vague definition of 'emergent' and not allowing for open reduction if needed are limitations of the AUC that should be clarified or improved by the AAOS.

The amount of surgical correction of the main thoracic curve is the best predictor of postoperative clinical shoulder balance in patients with Adolescent Idiopathic Scoliosis.

PURPOSE: This study sought to analyze factors that predict postoperative shoulder balance based on clinical photography. METHODS: Based on inclusion criteria, 132 AIS patients were selected. Age, sex, and BMI of each patient were recorded. The following parameters were recorded from radiographs: clavicle angle, T1 tilt, the upper instrumented vertebra (UIV), lowest instrumented vertebra (LIV) thoracic kyphosis, lumbar modifier, preoperative and postoperative proximal thoracic Cobb angle, preoperative and postoperative main thoracic Cobb angle, and preoperative and postoperative thoracolumbar Cobb angle, if applicable. Two spine surgeons independently assigned the photographs shoulder balance grades based on the WRVAS (1-2 = Acceptable, 3-5 = Unacceptable). Surgeons were blinded as to whether the photographs were taken preoperatively or postoperatively. The shoulders were also graded as right high, left high, or balanced. RESULTS: Of all variables analyzed, only main thoracic Cobb angle correction (MTCAC) showed a statistically significant relationship with postoperative shoulder balance (p = 0.01). Odds of having unacceptable shoulder balance increase by 21% for every 5° increase in MTCAC (Adjusted OR = 1.21, 95% CI 1.015-1.452). The odds of unbalanced shoulders are 4.7 times higher for patients whose MTCAC is 40° or more (p = 0.001). Inter-rater reliability was excellent (k =0 .7). Intra rater reliability was perfect for Surgeon 1 (kappa = 1.0) and showed substantial agreement for Surgeon 2 (kappa = 0.8) CONCLUSIONS: Greater correction of main thoracic Cobb angle predicts unacceptable postoperative shoulder balance with 40° of correction signifying a major dichotomy between acceptable and unacceptable.

Gout Presenting as Acute Hip Pain in a Young Woman: A Case Report.

CASE: A 28-year-old previously healthy woman developed worsening right hip pain without any preceding trauma or injury. Because of concern for septic arthritis, she underwent arthroscopic irrigation and debridement. The culture specimens were negative; crystal analysis showed monosodium urate crystals, which are consistent with an acute gout flare. The patient was started on naproxen and prednisone therapy and had substantial improvement in hip pain. CONCLUSION: Gout is a common cause of joint pain in older individuals. While rare in younger patients, our case report shows that gout should be included in the differential diagnosis when a patient presents with acute monoarthritis, regardless of age.