Management of a Thumb-In-Palm Deformity in Adult Patients With Upper Motor Neuron Syndrome.

The thumb-in-palm (TIP) deformity in adults with upper motor neuron syndrome results from an imbalance of extrinsic and intrinsic muscular forces. Traditionally, the thumb is adducted against the index ray, and flexed to varying degrees at the metacarpophalangeal and interphalangeal joints. However, not all TIP deformities result from the same underlying imbalances. The severity of the deformity ranges over a spectrum dependent upon the involved muscle groups and underlying spasticity, myostatic contracture, and/or joint contractures. Surgical procedures for correcting a TIP deformity can be classified broadly as procedures used for functional, present volitional motor control, versus nonfunctional, absent motor control. Techniques include tenotomies, tenodeses, tendon lengthenings, tendon transfers, tendon reroutings, neurectomies, and joint releases. A focused physical examination is key in developing a patient-specific treatment algorithm.

Surgical Management of Spastic Shoulder Deformities in Adult Patients.

Spastic shoulder deformity in patients with upper motor neuron syndrome results from an imbalance of muscle forces about the shoulder girdle. In typical spastic deformities, the shoulder assumes an adducted and internally rotated posture. The severity of the deformity can range over a spectrum depending on the involved muscle groups, degree of spasticity, and presence of myostatic and/or joint contractures. Surgical options to correct the spastic shoulder deformity can be broadly classified as procedures for the functional versus nonfunctional shoulder or, in other words, preserved versus absent volitional motor control, respectively. Techniques include tenotomy, fractional lengthening, tenodesis, and periarticular soft tissue release. A focused physical examination is imperative in developing a patient-specific treatment algorithm.

Recurrent Syndrome of the Trephined in the Setting of Multiple Craniectomy and Cranioplasty.

Decompressive craniectomy is an increasingly implemented intervention for relief of intracranial hypertension refractory to medical therapy. Despite its therapeutic benefit, a myriad of short and long-term complications may arise when the once fixed-volume cranial vault remains decompressed. The authors present a case of recurrent Syndrome of the Trephined in a patient undergoing repeated craniectomy and cranioplasty.A 70-year old male with history significant for smoking and chronic obstructive pulmonary disease presented with frontoparietal subdural hematoma with midline shift following a ground level fall necessitating craniotomy and hematoma evacuation. Three months postoperatively, the patient developed an infection of his craniotomy bone flap necessitating craniectomy without cranioplasty. Six weeks post-craniectomy the patient began demonstrating right sided sensorimotor deficits with word finding difficulties. Alloplastic cranioplasty was performed following resolution of infection, with resolution of neurologic symptoms 6 weeks post cranioplasty. Due to recurrent cranioplasty infections, multiple alloplastic cranioplasties were performed, each with reliable re-demonstration of neurologic symptoms with craniectomy, and subsequent resolution following each cranioplasty. Final cranioplasty was successfully performed using a new alloplastic implant in combination with latissimus muscle flap, with subsequent return of neurologic function.Decompressive craniectomy is a life-saving procedure, but carries many short- and long-term complications, including the Syndrome of the Trephined. Our case is the first published report, to our knowledge, to demonstrate recurrent Syndrome of the Trephined as a complication of craniectomy, with reliable resolution of the syndrome with restoration of the cranial vault.

Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia.

INTRODUCTION: Skeletal reconstruction in severe grades of hemifacial microsomia (HFM) continues to be challenging. Traditional techniques of autografts and osseous distraction for reconstruction of the glenoid fossa, condyle, and ramus can fall short of expectations and can create new problems. This intercontinental study analyzes the role of alloplastic skeletal rehabilitation in severe HFM. METHODS: Ten consecutive patients with Pruzansky grade III HFM were reconstructed between October 2014 and July 2017 at 2 craniofacial centers following the same protocol. Data were gathered retrospectively from the medical records, including photographs and virtual planning records. Pre and postoperative photos were taken to compare occlusal status, interincisal opening, sagittal mandibular projection, and posterior facial height. Alloplastic reconstruction was accomplished using a custom designed titanium implant. RESULTS: Ten consecutive skeletally mature patients with HFM with failed traditional reconstructions were successfully treated with virtually planned alloplastic reconstructions (11 joints) and simultaneous orthognathic surgery. The glenoid fossa, condyle, and ramus on the affected sides were reconstructed with custom designed titanium implants. All patients achieved occlusal stabilization, normalization of posterior facial height and sagittal mandibular projection, and maintenance or improved inter-incisal opening. There were no major complications or repeated surgeries. Follow-up ranges from 6 to 50 months. CONCLUSION: Alloplastic reconstruction allows for precise vertical reconstruction of the ramus and condyle and sagittal repositioning of the mandibular body. The glenoid fossa component is firmly anchored to the skull base assuring a stable centric relation on the reconstructed side. Consistent and acceptable results can be achieved in skeletally mature patients.

Treatment of an Uncommon High-Pressure Orbital Injection Injury.

Injection injuries occur most commonly in the hand and digits; however, there are a limited number of reports in the literature describing injection injuries involving the orbit. High-pressure orbital injection injuries pose a number of unique challenges to the treating physician, and the approach to treating these injuries remains controversial. Often times, the extent of tissue damage is not fully appreciated at presentation, which may lead to missed diagnoses or inadequate initial treatment. In this study, the authors describe a rare incidence of high-pressure orbital injection injury. A 19-year-old male presented to the emergency department after injection of his left orbit with oil-based paint. Worsening clinical symptoms and increasing intraocular pressures within the first 24 hours necessitated take back to the operating room for orbital decompression and debridement. After an initial improvement in symptoms, the patient's clinical status deteriorated again, requiring further orbital decompression and additional periorbital debridement. Two weeks after initial presentation, soft tissue reconstruction of the surgical wounds was performed with full thickness skin grafts. The patient's globe and vision were both preserved. Orbital injection injuries, though rare, are potential globe threatening injuries. Physicians should have a low threshold for intervention and patient's must be observed closely over the first 72 hours after injury. Early diagnosis, prompt debridement, and a multidisciplinary approach are keys to improving patient outcomes.

Acute-Onset Quadriplegia With Recovery After High-Voltage Electrical Injury.

Although uncommon, electrical injuries are associated with significant morbidity and mortality. There have been several reports of neurological sequelae secondary to electrical injury; however, the neurophysiology is still not completely understood. These neurological complications pose the greatest risk for permanent disability. We present a case of acute-onset quadriplegia after high-voltage electrical injury without radiographic evidence. Two months after the injury, the patient went on to regain partial sensorimotor function. Only a few case reports in the literature exist describing neurological recovery after electrical burn-induced quadriplegia. These cases are reviewed.

The Directive Growth Approach for Nonsyndromic, Unicoronal Craniosynostosis: Patient and Clinical Outcomes.

Deformities of the cranium in patients with nonsyndromic single-suture synostosis occur because of growth restriction at fused sutures and growth over compensation at normal sutures. Traditional surgery includes ostectomies of the synostotic suture to release these restricted areas and osteotomies to enable immediate cranial remodeling. In the process of reshaping the cranium, traditional approaches usually involve obliteration of both the normal functioning suture and the pathologic suture. The directive growth approach (DGA) is a new, simpler, more natural way to repair deformities caused by single-suture cranial synostosis. The DGA works by reversing the original deforming forces by temporarily restricting growth in areas of over compensation and forcing growth in areas of previous synostotic restriction. Most importantly, it preserves a normal functioning suture to allow for improved future cranial growth. Eighteen consecutive nonsyndromic patients with unilateral coronal synostosis were used to illustrate the efficacy of the DGA. Ten patients who underwent DGA treatment were compared with a control group of 8 patients treated with traditional frontal orbital advancement. Postoperative three-dimensional computed tomography (CT) comparison measurements were taken, including bilateral vertical and transverse orbital dimensions, lateral orbital rim to external auditory canal, and forehead measurements from the superior aspect of the orbital rim to the pituitary fossa. The traditional treatment group showed absence of the coronal sutures bilaterally on long-term CT scans. The DGA group showed normal coronal sutures on the unaffected sides. Postoperative CT measurements showed no statistical difference between the 2 techniques (P < 0.05).

Treatment of Pyogenic Flexor Tenosynovitis in the Emergency Department Setting With WALANT Technique.

BACKGROUND: The standard of care for treatment of pyogenic flexor tenosynovitis (PFT) involves antibiotic therapy and prompt irrigation of the flexor tendon sheath, traditionally performed in the operating room. With the acceptance of wide-awake local anesthesia no tourniquet (WALANT) hand surgery and its potential ability to minimize time to flexor tendon sheath irrigation, we sought to determine whether closed irrigation of the flexor tendon sheath could be safely and effectively performed in the emergency department setting with WALANT technique. METHODS: A retrospective review was conducted of the senior author's hand surgery consultations over a 12-month period. Six patients were identified who were diagnosed with PFT and subsequently underwent irrigation of the flexor tendon sheath using WALANT technique. Patient outcomes such as length of hospital stay, need for reoperation, infectious etiology, perioperative complications, and postprocedure range of motion (ROM) were identified. RESULTS: Six patients with diagnosis of PFT underwent irrigation of the flexor tendon sheath in the emergency department with local anesthesia only. The irrigation procedures were all well-tolerated. One patient required reoperation due to lack of appropriate clinical improvement following initial irrigation. Four of 6 patients regained their preinjury ROM while the remaining 2 patients had mild proximal interphalangeal joint extension lag. There were no complications associated with the procedures. CONCLUSIONS: Surgical treatment of PFT with closed irrigation of the flexor tendon sheath in the emergency department utilizing WALANT technique was safe, effective, and well-tolerated. Local anesthesia alone can be used effectively for irrigation procedures of the flexor tendon sheath.

Peri-prosthetic Fat Grafting Decreases Collagen Content, Density, and Fiber Alignment of Implant Capsules.

BACKGROUND: Lower capsular contracture rates have been observed with peri-prosthetic fat grafting. We investigated the effect of fat grafting on capsular characteristics and peri-prosthetic collagen density, content, and fiber alignment. METHODS: Forty miniature tissue expanders were placed on the backs of 20 rats. After four weeks, both inguinal fat pads were harvested, homogenized, and injected into peri-prosthetic tissue of the right tissue expander (fat graft) while the left served as control. The animals were killed at three (10 rats) and 12 weeks (10 rats), and full thickness peri-prosthetic samples were histologically processed for morphology (H&E) and collagen type and content (picrosirius red). RESULTS: An 8.1% increase in adipose peri-prosthetic thickness was associated with a 10% decrease in collagen content at any time point (P = 0.004). Fat-grafted capsules displayed a 59% reduction in % total collagen when compared with controls (P < 0.001). There were no differences in capsular thickness. Fat-grafted samples were 54 times more likely to have a higher inflammation score and 69 times more likely to have a lower capsular density score than their nongrafted counterparts (P < 0.001 and P = 0.001, respectively). The extent of inflammation decreased over time in all samples (P = 0.002). Additionally, fat-grafted samples were 67 times more likely to have a lower fiber alignment score than the controls (P < 0.001). CONCLUSIONS: Enhancement of peri-prosthetic tissue with fat grafting decreases collagen content, density, and fiber alignment of implant capsules. These findings support clinical application of fat grafting in prosthetic breast surgery to potentially decrease capsular contracture.

Development of a Plastic Surgery Supply Cart: Patient Outcomes and Quality of Care.

BACKGROUND: Plastic surgeons experience unique quality issues related to the specialty nature of patient procedures. Lack of accessibility to specialty supplies is a rate-limiting variable that impacts treatment efficiency and hospital resources. This study had the following goals: (1) to develop a mobile plastic surgery cart and (2) to assess the impact of a plastic surgery cart on time to treatment of consults. METHODS: Two plastic carts were developed using preexisting hospital supplies. Cart composition was designed and approved by hospital staff. A prospective study was conducted to assess overall time to treatment of patient consults throughout the hospital comparing a plastics cart versus a traditional hunt and gather methodology. One surgeon recorded time to treatment with and without the plastics cart for each consult during on-call duty hours over a 6-month period. RESULTS: A total of 40 patients were treated for either head or neck (60%) or hand-related (40%) cases. The average time (minutes) to treatment across all procedures with the plastics cart was 3.7 ± 1.9 versus 46.3 ± 60.0 without the plastics cart. The maximum time to treatment was 9.5 minutes with the plastics cart and 3 hours without the plastics cart. Usage of the plastics cart resulted in a significant reduction in total time to treatment of 42.5 ± 60.3 minutes (P < 0.0001). CONCLUSIONS: A specialty supplies cart has quality improvement implications for patients, physicians, and hospitals. Increased accessibility of specialty supplies may significantly reduce the time to treatment for plastic surgery patient consults throughout a hospital.