Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures.

Lower extremity wounds associated with fractures and bony defects often require secondary orthopedic procedures after flap coverage has been performed. In this study, we compare complications between muscle and fasciocutaneous flaps after secondary orthopedic procedures. A retrospective chart review study of all lower extremity soft tissue reconstructions by a single surgeon over seven years yielded a subgroup of patients who underwent secondary orthopedic procedures, including hardware removal, hardware revision, and bone grafting after flap reconstruction. Of 355 lower extremity, soft tissue reconstructions for orthopedic coverage performed in the time period studied, 102 patients underwent secondary orthopedic procedures after flap reconstruction. Of these, 54 received muscle flaps (52.94%), and 48 received fasciocutaneous flaps (47.06%). Using this subgroup of 102 patients, we compared muscle and fasciocutaneous flaps using three categories of wound complications following these secondary procedures: There were no superficial wounds requiring local wound care only in the muscle flap group (0%, n = 0) versus 4.17% (n = 2; p = 0.130) in the fasciocutaneous flap group. There were 2 lost flaps requiring surgical debridement and additional skin grafting in the muscle flaps group (3.70%) versus 2 (4.17%; p = 0.904) in the fasciocutaneous flap group. In the third category, flap loss requiring additional soft tissue reconstruction was 18.52% (n = 10) in the muscle group versus 2.08% (n = 1; p = 0.008) in the fasciocutaneous flap group. Our data support the existing literature indicating that fasciocutaneous flaps can tolerate secondary procedures better than muscle flaps and should initially be considered in patients with higher probability of needing additional orthopedic procedures after reconstruction.

Successful Salvage of Delayed Venous Congestion After DIEP Flap Breast Reconstruction.

Objective: Failure rates of microvascular autologous breast reconstruction are reportedly low. When failure of the microvascular anastomoses does occur, it is most likely to be salvaged if detected early. Flap compromise or venous congestion occurring several weeks later is uncommon and with significantly lower salvage rates. Methods: We present a unique case of delayed venous congestion of a single-perforator deep inferior epigastric perforator flap breast reconstruction in which the usual pedicle thrombosis was not identified. Presentation of the flap compromise occurred 72 hours postoperatively and again in the delayed setting 5 weeks after surgery, from suspected compression at the perforator level. Results: The deep inferior epigastric perforator flap was successfully salvaged with conservative measures, and the flap healed without fat necrosis or further complication. Conclusion: This case highlights the higher risk of flap compromise with reconstructions in a radiated field and potentially with single-perforator flaps.

Improvement of Color Vision Following Posterior Cranial Vault Distraction for Crouzon Syndrome.

Crouzon syndrome (CS) is one of the craniosynostosis syndromes that leads to early fusion of cranial sutures and increased intracranial pressure. Intracranial hypertension is a serious complication that may lead to vision loss and cognitive impairment. Early detection and management are necessary to prevent complications. The authors present a patient with CS who underwent posterior cranial vault reconstruction with internal distraction after multiple episodes of headache and papilledema. The patient was unaware of any loss of color vision before the surgery; however, he noted an improvement in his color vision after the surgery. Color vision deficits may be an early sign of intracranial hypertension and finding these deficits using noninvasive testing methods may be an indication for early intervention.

Variation in post-adenotonsillectomy admission practices in 24 pediatric hospitals.

OBJECTIVES/HYPOTHESIS: There is controversy about which children should be admitted after adenotonsillectomy (T&A) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after T&A in tertiary care pediatric hospitals. STUDY DESIGN: Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database. METHODS: There were 29,920 T&As performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions. RESULTS: Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-T&A admission rates. Admission rates ranged from >94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA. CONCLUSIONS: Post T&A admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night. LEVEL OF EVIDENCE: 4.

A systematic review of skin substitutes for foot ulcers.

BACKGROUND: Bioengineered and allograft-derived skin substitutes are increasingly available and marketed for use in the healing of chronic wounds. Plastic surgeons should have evidence-based information available to guide their use of these products. The authors systematically reviewed the literature to determine the published outcomes and effectiveness of different skin substitutes for healing chronic foot ulcers. METHODS: A broad literature search of the MEDLINE, EBSCO, EMBASE, and the Cochrane Central Register of Controlled Trials databases was undertaken. Relevant studies were selected by three independent reviewers to include randomized controlled trials or systematic reviews examining the use of skin substitutes on foot ulcers. Results were narrowed further by the application of predetermined inclusion and exclusion criteria. Studies were assessed for quality and data were extracted regarding study characteristics and objective outcomes. RESULTS: Of an initial 271 search results, 15 randomized controlled trials, one prospective comparative study, and five systematic reviews were included in the systematic review. Most of the included clinical studies were of moderate to low quality by objective standards, and reported results using cell-based skin substitutes. The primary outcome examined, success rate of complete healing, was equivalent to or better than that of standard therapy for all skin substitutes examined. CONCLUSIONS: A convincing body of evidence supports the effectiveness of living cell-based skin substitutes as an adjunctive therapy for increasing the rate of complete healing in chronic foot ulcers when basic tenets of wound care are also being implemented. Acellular skin substitutes also show some promise for treatment of foot wounds but require further study. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

MUC5B Is the predominant mucin glycoprotein in chronic otitis media fluid.

Chronic otitis media (COM), e.g. "glue" ear is characterized by middle ear effusion and conductive hearing loss. Although mucous glycoproteins (mucins), which contribute to increased effusion viscosity, have been analyzed in ear tissue specimens, no studies have been reported that characterize the molecular identity of secreted mucin proteins present in actual middle ear fluid. For this study, effusions from children with COM undergoing myringotomy at Children's National Medical Center, Washington, DC were collected. These were solubilized and gel fractionated, and the protein content was identified using a liquid chromatography tandem mass spectrometry (LC-MS/MS) proteomics approach. Western blot analyses with mucin specific antibodies and densitometry were performed to validate the mass spectrometry findings. LC-MS/MS results identified mucin MUC5B by >26 unique peptides in six of six middle ear effusion samples, whereas mucin MUC5AC was only identified in one of six middle ear effusions. These findings were validated by Western blot performed on the same six and on an additional 11 separate samples where densitometry revealed on average a 6.4-fold increased signal in MUC5B when compared with MUC5AC (p = 0.0009). In summary, although both MUC5AC and MUC5B mucins are detected in middle ear effusions, MUC5B seems to be predominant mucin present in COM secretions.

Conformational and noncovalent complexation changes in proteins during electrospray ionization.

Electrospray ion sources efficiently produce gas-phase ions from proteins and their noncovalent complexes. Charge-state distributions of these ions are increasingly used to gauge their conformations in the solution phase. Here we investigate how this correlation is affected by the spraying conditions at the early stage of droplet generation, prior to the ionization process. We followed the folding behavior of model proteins cytochrome c and ubiquitin and the dissociation of the noncovalent holomyoglobin complex. Spray current measurements, fast Taylor cone imaging, and mass analysis of the generated ions indicated that the protein structure experienced conformational or complexation changes upon variations in the spraying mode of the electrospray ionization source. These effects resulted in a departure from the original secondary, tertiary, and quaternary structure of proteins, possibly introducing artifacts in related studies. Therefore, if a particular gas-phase ion conformation is required or correlations with the liquid-phase conformations are studied, it is advantageous to maintain a particular spraying mode. Alternatively, spraying mode-induced changes can be utilized to alter the structure of proteins in, for example, time-resolved experiments for the study of protein folding dynamics.