The Impact of Clinical Practice Guidelines on Preoperative Antibiotic Administration for Carpal Tunnel Release.

Background: In 2015, the American Association of Plastic Surgeons (AAPS) published a consensus statement against the routine use of preoperative antibiotic prophylaxis to prevent surgical site infection in clean hand surgery. The American Academy of Orthopaedic Surgeons (AAOS) similarly cited "insufficient evidence" in its Appropriate Use Criteria guidelines to support the use of antibiotics in carpal tunnel surgery. Nonetheless, its administration remains a common practice during clean hand surgery. We sought to evaluate the impact of the above guidelines on preoperative antibiotic administration. Methods: An institutional review board-approved retrospective chart review of consecutive patients with carpal tunnel syndrome treated with open carpal tunnel release (CTR) at our institution was performed in the 2 years before and after publication of AAPS/AAOS guidelines. Patient demographics and surgical outcomes were reviewed. Incidence of antibiotic administration, patient demographics, and surgeon factors were collected. Results: A total of 770 primary open CTR procedures were performed in the studied years. In 2013 and 2014, 83.9% of patients received preoperative antibiotics. In 2017 and 2018, 48.2% of patients received preoperative antibiotics. Of the variables analyzed, immunosuppression, history of diabetes, and poorly controlled diabetes (A1c > 7) were found to be statistically significant in its positive correlation to prophylactic preoperative antibiotic use. Diabetes was not associated with surgical site infections. Conclusion: Patients were more likely to receive preoperative antibiotics before the publication of the AAPS/AAOS clinical practice guidelines. Patients with diabetes regardless of their glycemic control are more likely to receive preoperative antibiotics.

Microstructure and Corrosion Behavior of Sn-Zn Alloys.

In the present work, the microstructure, phase constitution, and corrosion behavior of binary Sn-xZn alloys (x = 5, 9 and 15 wt.%) were investigated. The alloys were prepared by induction melting of Sn and Zn lumps in argon. After melting, the alloys were solidified to form cast cylinders. The Sn-9Zn alloy had a eutectic microstructure. The Sn-5Zn and Sn-15Zn alloys were composed of dendritic (Sn) or (Zn) and eutectic. The corrosion behavior of the Sn-Zn alloys was studied in aqueous HCl (1 wt.%) and NaCl (3.5 wt.%) solutions at room temperature. Corrosion potentials and corrosion rates in HCl were significantly higher compared to NaCl. The corrosion of the binary Sn-Zn alloys was found to take place by a galvanic mechanism. The chemical composition of the corrosion products formed on the Sn-Zn alloys changed with the Zn weight fraction. Alloys with a higher concentration of Zn (Sn-9Zn, Sn-15Zn) formed corrosion products rich in Zn. The Zn-rich corrosion products were prone to spallation. The corrosion rate in the HCl solution decreased with decreasing weight fraction of Zn. The Sn-5Zn alloy had the lowest corrosion rate. The corrosion resistance in HCl could be considerably improved by reducing the proportion of zinc in Sn-Zn alloys.

Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review.

BACKGROUND: The appropriate use of narcotics for postoperative pain control is controversial because of potential medication-induced complications. The authors sought to determine the effects of narcotics in the pediatric population following cranial vault remodeling operations. METHODS: A retrospective review was performed on 160 consecutive patients who underwent cranial vault remodeling for craniosynostosis. RESULTS: There was a statistically significant difference in total morphine equivalents in the group that experienced no emesis and those with at least one episode of emesis (0.97 morphine equivalents/kg versus 1.44 morphine equivalents/kg; p = 0.05). There was a statistically significant difference in hospital morphine equivalents in the group with documented respiratory events (average, 2.3 morphine equivalents/kg versus 1.3 morphine equivalents/kg in the nonevent group; p = 0.006). The patients who received dexmedetomidine had a trend toward a decrease in hospital narcotic administration with equivalent pain control (1.2 morphine equivalents/kg versus 1.9 morphine equivalents/kg; p = 0.09). There was a statistically significant positive correlation between total morphine equivalents for the hospitalization and hospital stay ( r = 0.27, p = 0.001). The amount of morphine equivalents used in the first 24 hours was also found to be an independent predictor of a respiratory event ( p = 0.002 by multivariate logistic regression). Independent positive predictors of hospital stay were age ( p < 0.001), intensive care unit time ( p < 0.001), and total morphine equivalents for the hospitalization ( p = 0.001) by multivariate analysis with linear regression. CONCLUSION: The authors' study demonstrates improvement in outcomes with decreased use of narcotics, which establishes that there is a need to further explore postsurgical recovery outcomes with multimodal pain control. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Complications of Cosmetic Surgery Tourism: Case Series and Cost Analysis.

BACKGROUND: Cosmetic surgery tourism is increasing exponentially. Patients seek cosmetic procedures within the United States and abroad, lured by lower cost procedures, shorter waiting lists, and affordable airfare and hotel accommodations. Unfortunately, operations are often performed by non-board-certified plastic surgeons, sometimes not even by plastic surgeons. Preoperative counseling, frequently limited to a video-chat with an office secretary, provides inadequate discussion regarding potential complications. Postoperative care is careless and rarely involves the operating surgeon. Complications are frequent, with management falling into the hands of plastic surgeons unfamiliar with the patient's care. Furthermore, the physician, rather than the patient or hospital, faces the largest cost burden. OBJECTIVES: The authors sought to explore their institution's experience treating complications of cosmetic tourism and investigate associated costs. METHODS: The retrospective review of 16 patients treated for complications related to cosmetic surgery tourism plus cost analysis revealed a substantial discrepancy between money saved by undergoing surgery abroad and massive costs accrued to treat surgical complications. RESULTS: The most common complication was infection, often requiring surgery or IV antibiotics on discharge. Mean cost per patient was $26,657.19, ranging from $392 (single outpatient visit) to $154,700.79 (prolonged admission and surgery). Overall, the hospital retained 63% of billed charges, while physicians retained only 9%. The greatest amount paid by any single patient was $2635.00 by a patient with private insurance. CONCLUSIONS: Cosmetic tourism has severe medical repercussions for patients and complications that burden hospitals, physicians, and the US medical system. Physicians treating the complications suffer the greatest financial loss.

Giant Dermatofibrosarcoma Protuberans With Bilateral Orbital Involvement.

Dermatofibroma sarcoma protuberans (DFSP) is a rare, locally aggressive soft tissue sarcoma with a tendency for recurrence after excision. Although reports of unilateral orbital and bilateral eyelid disease exist, there have been no prior reports of DFSP with bilateral orbital involvement and no previously described cases of DFSP associated with transient optic neuropathy. The authors present a case report of a 34-year-old woman with a giant scalp DFSP involving the bilateral orbits. Despite radical resection with 5 cm margins where possible, multiple positive margins remained including deep positive margins at the bilateral superomedial retroseptal soft tissue. The patient completed adjuvant radiation for surgically unresectable disease. This case highlights the challenge of achieving local control given the disease extent and infiltration of the bilateral eyelids and orbits. This is the first reported case of DFSP with bilateral orbital involvement and associated transient optic neuropathy.

Repair of the musculocutaneous nerve using the vagus nerve as donor by helicoid end-to-side technique: an experimental study in rats.

Although several donor nerves can be chosen to repair avulsed brachial plexus nerve injury, available nerves are still limited. The purpose of this study is to validate whether the vagus nerve (VN) can be used as a donor. Eighteen Sprague-Dawley male rats were divided into three groups (n = 6). The right musculocutaneous nerve (McN) was transected with differing subsequent repair. (1) HS-VN group: a saphenous nerve (SN) graft-end was helicoidally wrapped round the VN side (epi-and perineurium was opened) with a 30 ° angle, distal SN end was coapted to the McN with end-to-end repair. (2) EE-PN group: a SN was interpositionally grafted between the transected phrenic nerve (PN) and the McN by end-to-end coaptation. (3) Sham control group: McN was transected and not repaired and postoperative vital signs were checked daily. At three months, electrophysiology, tetanic force, wet biceps muscle weight, and histology were evaluated. Every tested mean value in HS-VN group was significantly greater than the EE-PN or the sham control groups (p < 0.05 or p < 0.005). The mean recovery ratio of regenerated nerve fibers was 96% and, in HS-VN group, the mean recovery ratio of CMAP was 79%. No vital signs changed in any group. There was no statistical difference (p > 0.5) between the mean VN nerve-fiber numbers of the segments proximal (2237 ± 134) and distal (2150 ± 156) to the VN graft-attachment site. Histological analysis revealed no axon injury or intraneural scarring at any point along the VN. This study demonstrated that VN is a practical and reliable donor nerve for end-to-side nerve transfer. © 2017 Wiley Periodicals, Inc.

Increasing Calcium Level Limits Schwann Cell Numbers In Vitro following Peripheral Nerve Injury.

Background After peripheral nerve injury, there is an increase in calcium concentration in the injured nerves. Our previous publications have shown that increase in calcium concentration correlated well with degree of nerve injury and that local infusion of calcitonin has a beneficial effect on nerve recovery. Schwann cells play a pivotal role in regeneration and recovery. We aim to examine cultured Schwann cell survivals in various concentrations of calcium-containing growth media and the effect of calcitonin in such media. Methods To establish baseline in postinjury state, crush injury was induced in male Sprague-Dawley rats' sciatic nerves. Extra- and intraneural calcium concentrations were measured. To study Schwann cell survival, uninjured sciatic nerve segment was harvested and cultured in media containing various amounts of calcium. To study the effect of calcitonin, nerve harvest and culture were done in four additional media: (1) normal control, (2) normal control with calcitonin, (3) high calcium medium, and (4) high calcium medium with calcitonin. Schwann cells were studied and analyzed under fluorescent conditions. Results With increasing calcium concentration, there was a significant decrease in the number of Schwann cells. For the experimental groups, in which calcitonin had been added to the growth medium, there were similar amounts of Schwann cells present in both high and low calcium-containing medium. Conclusion Schwann cells are sensitive to increasing calcium concentration. Calcitonin counteracts the detrimental effects of high calcium on Schwann cell survival. This can have significant future clinical implications for patients with peripheral nerve injuries.

Best time window for the use of calcium-modulating agents to improve functional recovery in injured peripheral nerves-An experiment in rats.

Peripheral nerve injury can have a devastating effect on daily life. Calcium concentrations in nerve fibers drastically increase after nerve injury, and this activates downstream processes leading to neuron death. Our previous studies showed that calcium-modulating agents decrease calcium accumulation, which aids in regeneration of injured peripheral nerves; however, the optimal therapeutic window for this application has not yet been identified. In this study, we show that calcium clearance after nerve injury is positively correlated with functional recovery in rats suffering from a crushed sciatic nerve injury. After the nerve injury, calcium accumulation increased. Peak volume is from 2 to 8 weeks post injury; calcium accumulation then gradually decreased over the following 24-week period. The compound muscle action potential (CMAP) measurement from the extensor digitorum longus muscle recovered to nearly normal levels in 24 weeks. Simultaneously, real-time polymerase chain reaction results showed that upregulation of calcium-ATPase (a membrane protein that transports calcium out of nerve fibers) mRNA peaked at 12 weeks. These results suggest that without intervention, the peak in calcium-ATPase mRNA expression in the injured nerve occurs after the peak in calcium accumulation, and CMAP recovery continues beyond 24 weeks. Immediately using calcium-modulating agents after crushed nerve injury improved functional recovery. These studies suggest that a crucial time frame in which to initiate effective clinical approaches to accelerate calcium clearance and nerve regeneration would be prior to 2 weeks post injury. © 2017 Wiley Periodicals, Inc.

Effect of calcitonin on cultured schwann cells.

INTRODUCTION: After nerve injury, calcium concentrations in intranerve fibers quickly increase. We have shown that functional recovery of injured nerves correlates with calcium absorption. A slight increase in calcium reduces the number of Schwann cells present. Calcitonin therapy greatly improves regeneration by accelerating calcium absorption. We examined the effect of adding calcitonin to higher concentration calcium media on cultured Schwann cells. METHODS: The cells, isolated from intact sciatic nerves, were cultured with normal or higher concentration calcium media with or without calcitonin. Schwann cells were incubated with anti-S-100, goat-anti-mouse, and propidium iodide and then viewed through fluorescent light and phase-contrast microscopy for observation and analysis. RESULTS: The cells in each calcitonin-containing medium showed many Schwann cells, however, the cells in the higher concentration calcium media showed fewer and more defective Schwann cells. CONCLUSION: These results show that calcitonin protects against the harmful effects of excessive calcium encountered in peripheral nerve injury. Muscle Nerve 56: 768-772, 2017.

The Surgical Treatment of Robin Sequence.

BACKGROUND: We present an outcomes analysis of the surgical treatment of Robin sequence including all infants and comorbid conditions treated by tongue-lip adhesion (TLA) or mandibular distraction osteogenesis (MDO). METHODS: A 19-year single-institution, multisurgeon retrospective review of all syndromic and nonsyndromic neonates with Robin sequence treated with TLA (1994-2004) or MDO (2004-2013) was performed. Comorbid conditions were recorded in all patients. Outcomes include incidence of tracheostomy, improvement in obstructive breathing, and surgical complications. Need for repeat distraction and conversion from TLA to MDO were included as secondary end-points. Polysomnography data were recorded preoperatively at 1 month and 1 year as a measure of airway improvement. RESULTS: Seventy-four MDO patients and 15 TLA patients during the study period met inclusion criteria. There was no significant difference in mean age at intervention (32.1 ± 29.0 vs 35.5 ± 32.1 days), birth weight (2.9 ± 0.7 vs 3.2 ± 0.6 kg), prematurity (23.0 vs 35.7%), or intrauterine growth restriction (31.1 vs 15.4%). Central nervous system anomalies (24.3% vs 0.0%; P < 0.04) and gastrostomy tubes (66.2% vs 33.3%; P < 0.03) were present more frequently in MDO patients versus TLA patients. Rates of other organ system anomalies were similar between the groups. The success rate was significantly higher in the MDO group (90.5% vs 60.0%; P < 0.008). Postoperative tracheostomies occurred in 8.1% of the MDO group and 33.3% of the TLA group (P < 0.02). Preoperative apnea-hyponea index was similar between the two groups (38.3 vs 38.1). The apnea-hyponea index was significantly improved in the MDO group at 1 month (4.0 vs 21.7; P < 0.002) and 1 year (5.7 vs 20.5; P < 0.005). Surgical complications were statistically less in the MDO group (20.3 vs 53.3%; P < 0.02). CONCLUSIONS: In the heterogeneous population of Robin sequence, MDO demonstrates superior outcomes measures at 1 month and 1 year compared to TLA. Fewer complications occurred in the MDO group compared to the TLA.

Cumulative Brain Injury from Motor Vehicle-Induced Whole-Body Vibration and Prevention by Human Apolipoprotein A-I Molecule Mimetic (4F) Peptide (an Apo A-I Mimetic).

BACKGROUND: Insidious cumulative brain injury from motor vehicle-induced whole-body vibration (MV-WBV) has not yet been studied. The objective of the present study is to validate whether whole-body vibration for long periods causes cumulative brain injury and impairment of the cerebral function. We also explored a preventive method for MV-WBV injury. METHODS: A study simulating whole-body vibration was conducted in 72 male Sprague-Dawley rats divided into 9 groups (N = 8): (1) 2-week normal control; (2) 2-week sham control (in the tube without vibration); (3) 2-week vibration (exposed to whole-body vibration at 30 Hz and .5 G acceleration for 4 hours/day, 5 days/week for 2 weeks; vibration parameters in the present study are similar to the most common driving conditions); (4) 4-week sham control; (5) 4-week vibration; (6) 4-week vibration with human apolipoprotein A-I molecule mimetic (4F)-preconditioning; (7) 8-week sham control; (8) 8-week vibration; and (9) 8-week 4F-preconditioning group. All the rats were evaluated by behavioral, physiological, and histological studies of the brain. RESULTS: Brain injury from vibration is a cumulative process starting with cerebral vasoconstriction, squeezing of the endothelial cells, increased free radicals, decreased nitric oxide, insufficient blood supply to the brain, and repeated reperfusion injury to brain neurons. In the 8-week vibration group, which indicated chronic brain edema, shrunken neuron numbers increased and whole neurons atrophied, which strongly correlated with neural functional impairment. There was no prominent brain neuronal injury in the 4F groups. CONCLUSIONS: The present study demonstrated cumulative brain injury from MV-WBV and validated the preventive effects of 4F preconditioning.

Mandibular Distraction Osteogenesis in Low-Weight Neonates with Robin Sequence: Is It Safe?

BACKGROUND: The aim of this study was to evaluate the efficacy, safety profile, and complications associated with mandibular distraction osteogenesis performed in infants weighing less than 4 kg with Robin sequence. METHODS: An 11-year retrospective review of all infants (younger than 6 months) with mandibular distraction osteogenesis-treated Robin sequence was performed. Patients weighing less than 4 kg (experimental) and 4 kg or more (control) who underwent mandibular distraction osteogenesis were compared. Demographics, medical comorbidities, improvement in apnea/hypopnea index, need for tracheostomy, repeated distraction, and complications were evaluated. RESULTS: One hundred twenty-one patients underwent mandibular distraction osteogenesis. Eighty-one patients weighed less than 4 kg and 40 weighed 4 kg or more. The mean follow-up was 2.8 years in patients weighing less than 4 kg and 3.0 years in the control group. Mean age and weight at the time of distraction were 23 days and 3.1 kg, respectively, in the study group; and 2.7 years and 11 kg, respectively, in the control group. There was no significant difference in success of mandibular distraction osteogenesis to treat airway obstruction in the group weighing less than 4 kg compared with the control group (92.6 percent versus 88.9 percent; p = 0.49). The most common complication in each group was surgical-site infection (9.9 percent and 20.0 percent; p = 0.15). Overall complication rates were similar between the two groups (17.3 percent versus 25.0 percent; p = 0.34). The rates of repeated distraction were similar between the two groups (6.3 percent and 13.5 percent; p = 0.28). CONCLUSIONS: Mandibular distraction osteogenesis is a safe and effective treatment modality for infants weighing less than 4 kg with severe airway obstruction. The efficacy, safety, and complication profiles are not significantly different from those of larger patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparison of Peripheral Nerve Axonal Area Differences in Central and Peripheral Zones of Injured and Repaired Nerves.

BACKGROUND: Histological analysis remains a cornerstone approach for the investigation of peripheral nerve regeneration. This study investigates a newly recognized histological difference between peripheral and central zones within the regenerating nerve trunks. PURPOSE: The purpose of the study was to determine if the nerve axonal area (NXA) in regenerating peripheral nerves differs within central and peripheral areas, when viewed in cross-section. METHODS: A total of 14 rats were divided into two groups, and subjected to different injuries to the right sciatic nerve. Group 1: Transection injury with immediate repair. Group 2: Crush injury without any treatment. The left sciatic nerve was left uninjured and served as a control in each rat. Following 4 weeks of recovery, nerve trunk cross-sections were prepared. Computerized techniques were then employed to divide nerve sections into central and peripheral zones and calculate corresponding NXA values for subsequent statistical analysis. RESULTS: NXA of injured nerves was greater within peripheral as compared with the central zones, independent of injury type (p < 0.05). No statistically significant difference existed within the control groups or between the injury methods with regards to NXA regeneration extent. CONCLUSION: NXA in regenerating peripheral nerves was greater in the peripheral zones than within the central zones.

Mandibular distraction for Robin sequence associated with laryngomalacia.

INTRODUCTION: Protocols for the treatment of Robin sequence (RS) consider the presence of laryngomalacia as a contraindication to mandibular distraction osteogenesis (MDO). The authors report their institutional experience of MDO applied to infants with RS and associated laryngomalacia. METHODS: An 8-year (2005-2013) retrospective review of all infants with RS and laryngomalacia who underwent MDO at a tertiary care children's hospital was performed. Patients were excluded if they possessed an airway anomaly other than laryngomalacia. Laryngomalacia was identified on laryngoscopy before MDO. Laser supraglottoplasty was performed at the discretion of the otolaryngologist. Recorded variables included preoperative and postoperative AHI, syndromic diagnosis or genetic anomalies, cardiac, central nervous system (CNS), and gastrointestinal (GI) abnormalities. The primary outcomes measured were avoidance or decannulation of tracheostomy and decrease in postoperative AHI. RESULTS: Eleven infants met inclusion criteria. Mean follow-up was 28 months. 18.2% of patients had a syndromic diagnosis, 36.4% cardiac, 9.1% CNS, and 72.7% GI abnormalities. Mean preoperative AHI was 46.1 ± 31.8 and mean postoperative AHI was 4.1 ± 3.0 (P = 0.002). All patients without a tracheostomy before intervention avoided tracheostomy after MDO. One patient had a tracheostomy before MDO and was subsequently decannulated. One patient died 1 year after MDO due to complex congenital heart disease. CONCLUSIONS: Infants with RS and laryngomalacia can be successfully treated with MDO to relieve upper airway obstruction. Close cooperation with a pediatric otolaryngologist and treatment of laryngomalacia can significantly enhance tracheostomy avoidance in infants with Robin sequence.

Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons.

BACKGROUND: There is a growing concern for microbial resistance as a result of overuse of antibiotics. Although guidelines have focused on the use of antibiotics for surgery in general, few have addressed plastic surgery specifically. The objective of this expert consensus conference was to evaluate the evidence for efficacy and safety of antibiotic prophylaxis in plastic surgical procedures. METHODS: THE AUTHORS: searched for existing high-quality systematic reviews for antibiotic prophylaxis in the literature from the MEDLINE, Cochrane Library, and Embase databases. All synonyms for antibiotics were combined with terms for relevant plastic surgery procedures. The searches were not limited by language, and included all study designs. In addition, supplemental hand searches were performed of bibliographies of relevant articles, and extensive "related articles." Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons to reach consensus recommendations. RESULTS: Database searches identified 4300 articles, from which 2042 full-text articles were identified for eligibility. De novo meta-analyses were performed for each plastic surgical category. In total, 67 studies met the inclusion criteria, including nine for breast surgery, 17 for head and neck surgery, 10 for orthognathic surgery, seven for rhinoplasty/septoplasty, 19 for hand surgery, five for skin surgery, and two for abdominoplasty. CONCLUSIONS: Systemic antibiotic prophylaxis is recommended for clean breast surgery and for contaminated surgery of the hand or the head and neck. It is not recommended to reduce infection in clean surgical cases of the hand, skin, head and neck, or abdominoplasty.

Neural systemic impairment from whole-body vibration.

Insidious brain microinjury from motor vehicle-induced whole-body vibration (WBV) has not yet been investigated. For a long time we have believed that WBV would cause cumulative brain microinjury and impair cerebral function, which suggests an important risk factor for motor vehicle accidents and secondary cerebral vascular diseases. Fifty-six Sprague-Dawley rats were divided into seven groups (n = 8): 1) 2-week normal control group, 2) 2-week sham control group (restrained in the tube without vibration), 3) 2-week vibration group (exposed to whole-body vibration at 30 Hz and 0.5g acceleration for 4 hr/day, 5 days/week, for 2 weeks), 4) 4-week sham control group, 5) 4-week vibration group, 6) 8-week sham control group, and 7) 8-week vibration group. At the end point, all rats were evaluated in behavior, physiological, and brain histopathological studies. The cerebral injury from WBV is a cumulative process starting with vasospasm squeezing of the endothelial cells, followed by constriction of the cerebral arteries. After the 4-week vibration, brain neuron apoptosis started. After the 8-week vibration, vacuoles increased further in the brain arteries. Brain capillary walls thickened, mean neuron size was obviously reduced, neuron necrosis became prominent, and wide-ranging chronic cerebral edema was seen. These pathological findings are strongly correlated with neural functional impairments.

Calcitonin pump improves nerve regeneration after transection injury and repair.

INTRODUCTION: After nerve injury, excessive calcium impedes nerve regeneration. We previously showed that calcitonin improved nerve regeneration in crush injury. We aimed to validate the direct effect of calcitonin on transected and repaired nerve. METHODS: Two rat groups (n = 8) underwent sciatic nerve transection followed by direct repair. In the calcitonin group, a calcitonin-filled mini-osmotic pump was implanted subcutaneously, with a catheter parallel to the repaired nerve. The control group underwent repair only, without a pump. Evaluation and comparison between the groups included: (1) compound muscle action potential recording of the extensor digitorum longus (EDL) muscle; (2) tetanic muscle force test of EDL; (3) nerve calcium concentration; and (4) nerve fiber count and calcified spot count. RESULTS: The calcitonin pump group showed superior recovery. CONCLUSIONS: Calcitonin affects injured and repaired peripheral nerve directly. The calcitonin-filled mini-osmotic pump improved nerve functional recovery by accelerating calcium absorption from the repaired nerve. This finding has potential clinical applications.

Airway Obstruction and the Unilateral Cleft Lip and Palate Deformity: Contributions by the Bony Septum.

BACKGROUND: Patients with unilateral cleft lip and palate (CLP) deformities commonly develop nasal airway obstruction, necessitating septoplasty at the time of definitive rhinoplasty. We assessed the contribution of the bony septum to airway obstruction using computed tomography (CT) and cone beam CT (CBCT). METHODS: A 2-year retrospective review of all subjects with unilateral CLP who underwent CBCT imaging (n = 22) and age-matched controls (n = 9) who underwent CT imaging was conducted. Control CT scans were used to determine the segment of nasal septum comprised almost entirely of bone. The CBCT of the nasal airway was assessed using Dolphin software to determine the contribution of the bony septum to septal deviation and airway obstruction. RESULTS: The nasal septum posterior to the midpoint between anterior and posterior nasal spine is comprised of 96% bone. The nasal airway associated with this posterior bony segment was 43.1% (P < 0.001) larger by volume on the non-cleft side in patients with unilateral CLP. The average septal deviation within the posterior bony segment was 5.4 mm, accounting for 74.4% of the maximal deviation within the nasal airway. The average airway stenosis within the posterior bony nasal airway was 0.45 mm (0-2.2 mm). CONCLUSIONS: In patients with unilateral CLP, the bony nasal septum can demonstrate significant deviation and airway stenosis. Surgeons should consider a bony septoplasty in their treatment algorithm in unilateral CLP patients who have reached skeletal maturity.

The surgical correction of Pierre Robin sequence: mandibular distraction osteogenesis versus tongue-lip adhesion.

BACKGROUND: The authors present an outcomes analysis of mandibular distraction osteogenesis versus tongue-lip adhesion in the surgical treatment of Pierre Robin sequence. METHODS: A retrospective, 15-year, single-surgeon review was undertaken of all nonsyndromic neonates with Pierre Robin sequence treated with mandibular distraction osteogenesis (2004 to 2009; n = 24) or tongue-lip adhesion (1994 to 2004; n = 15). Outcomes included time of extubation, length of intensive care unit stay, incidence of tracheostomy, and surgical complications. Polysomnography data were collected 1 month and 1 year postoperatively. Sleep study data included changes in oxygen saturation and apnea-hypopnea index. RESULTS: There were no postprocedure tracheostomies in the mandibular distraction osteogenesis group and four tracheostomies in the tongue-lip adhesion group. The preoperative oxygen saturations were significantly lower in the mandibular distraction osteogenesis group compared with tongue-lip adhesion (76.5 percent versus 82 percent; p < 0.05). Preoperative apnea-hypopnea index was significantly higher in the mandibular distraction osteogenesis group compared with the tongue-lip adhesion group (47 versus 37.6; p < 0.05). Despite these preoperative differences, patients undergoing mandibular distraction osteogenesis demonstrated significantly higher oxygen saturation levels at 1 month (98.3 percent versus 87.5 percent; p < 0.05) and 1 year postoperatively (98.5 percent versus 89.2 percent; p < 0.05) and lower apnea-hypopnea index at 1 month (10.9 versus 21.6; p < 0.05) and 1 year postoperatively (2.5 versus 22.1; p < 0.05) compared with tongue-lip adhesion. Surgical complications were comparable between the two groups. CONCLUSIONS: In nonsyndromic patients with Pierre Robin sequence, mandibular distraction osteogenesis demonstrates superior outcome measures regarding oxygen saturation, apnea-hypopnea index, and incidence of tracheostomy compared with tongue-lip adhesion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Complications associated with neonatal mandibular distraction osteogenesis in the treatment of Robin sequence.

BACKGROUND: Robin sequence (RS) is defined as a triad of retrognathia, glossoptosis, and airway obstruction. Although several studies have reported on the efficacy of mandibular distraction, the risks associated with this operation remain unclear. An outcomes analysis focusing on complications is reported here. METHODS: A 7-year retrospective review of all patients with RS treated with mandibular distraction was performed. Recorded variables included associated medical comorbidities, improvement in apnea/hypopnea index, need for tracheostomy, repeat distraction, and complications. Complications associated with mandibular distraction were categorized as major, moderate, or minor. They included surgical site infection (SSI), device failure, temporomandibular joint ankylosis, facial nerve injury, hypertrophic scarring, self-extubation premature ossification, and fibrous nonunion. RESULTS: Fifty patients were identified. Four patients (8%) required tracheostomy following distraction, and 3 required repeat distraction. There were 0% major, 12% moderate, and 18% minor complications. Moderate complications were device failure (2%), SSI requiring return to the operating room (2%), and SSI requiring intravenous antibiotics (8%). Minor complications were SSI managed with oral antibiotics (12%), self-extubation (4%), and transient facial nerve palsy (2%). The most common complication was SSI (22%), of which 90.9% were successfully treated by antibiotics alone. There was a 0% rate of temporomandibular joint ankylosis. CONCLUSIONS: Mandibular distraction is a safe and effective treatment option for infants with RS and severe airway obstruction. The most common complication is infection; the majority of cases are successfully treated with antibiotics alone.