Avascular Necrosis of the Scaphoid-Preiser Disease: Outcomes of 39 Surgical Cases.

PURPOSE: There is no established treatment standard for patients with idiopathic avascular necrosis of the scaphoid, also known as Preiser Disease. We evaluated outcomes of operative interventions performed for patients diagnosed with Preiser Disease and assessed scaphoid morphology in the contralateral wrists. METHODS: We performed a retrospective review of all patients undergoing surgery for Preiser disease between 1987 and 2019 at our institution. A total of 39 wrists in 38 patients were identified. The mean age was 37 years at the time of surgery, and the median follow-up time was 5.3 years. The patients were classified according to the Herbert and Kalainov classifications. Pre- and postoperative pain and functional outcomes were evaluated, and Mayo Wrist Scores were calculated. Reoperations for complications were recorded. Scaphoid shapes were assessed for wide/type 1 and slender/type 2 scaphoids in the contralateral unaffected wrist in patients with unilateral disease. RESULTS: Overall, pain and Mayo Wrist Scores improved, while flexion/extension decreased slightly and grip strength remained stable. In a comparison of the 2 main surgery groups, 17 wrists with a pedicled vascular bone graft and 12 wrists with salvage surgery (4-corner fusion/proximal row carpectomy) showed similar functional outcomes. Similar outcome scores were found regardless of preoperative Herbert or Kalainov classifications. Radiographic morphologic evaluation of the contralateral side determined that 4 of 8 patients had a slender scaphoid shape, which has been shown to have a more limited vascular network when compared to full scaphoids. CONCLUSIONS: A treatment algorithm of Preiser disease is lacking and the optimal surgical treatment remains controversial. Pedicled vascular bone grafts had similar functional outcomes as salvage procedures, but preserving the scaphoid was possible in 70% of the pedicled vascular bone graft cases. A slender scaphoid is potentially more common in patients with Preiser disease who undergo surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Partition of Pectoralis Major Musculocutaneous Flap as a Salvage Procedure for Simultaneous Coverage of the Exposed Carotid Artery and Reconstruction of Cervical Esophagus.

BACKGROUND: In advanced pharyngoesophageal cancer patients, a critical event is represented by the failure of primary reconstruction with exposure of the carotid artery and partial or total defect of the cervical esophagus. For these high-risk patients, a partitioned pectoralis major musculocutaneous (PMMC) flap can prevent carotid blowout and provide skin for simultaneous esophageal reconstruction. METHODS: Twenty-six patients needing pharyngoesophageal reconstruction together with coverage of carotid artery exposure were included in this retrospective case series. The patients were treated with a partitioned PMMC flap, based on the branching pattern of the pectoral branch of the thoracoacromial artery and the perforators of the pectoralis major muscle, to simultaneously reconstruct the defect and provide coverage for the carotid artery. RESULTS: In 25 patients, the partitioned PMMC flap reconstructions resulted in complete wound healing without occurrence of carotid blowout syndrome or fistula formation. Minor complications as partial flap necrosis (7.7%) and strictures formation (7.7%) were recorded but did not compromise reconstruction. Twenty-two patients were able to adopt a semisolid diet, and 4 had recurrence of cancer. CONCLUSIONS: The partitioned PMMC flap reconstruction represents a useful salvage solution to simultaneously restore the continuity of the alimentary tract and provide reliable coverage for the exposed carotid artery.

Pediatric Mandibular Central Giant Cell Granuloma: Neoadjuvant Immunotherapy to Minimize Surgical Resection.

ABSTRACT: Central giant cell granuloma (CGCG) is a relatively uncommon benign bony lesion accounting for approximately 7% of all non-neoplastic lesions of the jaw. The clinical behavior of CGCG can vary from a slow-growing, painless lesion to fast-growing and locally destructive. When such a lesion involves the mandible, this can be quite debilitating for the patient, inhibiting oral intake and requiring an extensive resection and bone graft reconstruction. The authors present a case of effectively decreasing the surgical morbidity associated with a large and rapidly growing CGCG of the mandible in a pediatric patient. Neoadjuvant immunotherapy with denosumab (human monoclonal antibody) facilitated treatment of the tumor without the need for a large resection which would have otherwise necessitated a vascularized bony mandibular reconstruction. Consideration of neoadjuvant medical management of CGCG as the primary treatment is advocated.

Traumatic Cranio-Orbital Injury: Reconstruction Using Extraocular Muscles.

Cranio-orbital trauma is an uncommon yet devastating injury, especially one in the setting of a high-energy gunshot wound. Such injuries were historically reported in the setting of military conflict, and are associated with vision-threatening complications, often resulting in anophthalmos. The authors report a case of a self-inflicted gunshot wound to the eye, which requires orbital enucleation with exposed frontal lobe dura. To address the exposed dura, the extraocular muscles were utilized from the enucleation procedure to cover the defect in the acute setting prior to final staged reconstruction.

Predictive Value of Nutritional Markers for Wound Healing Complications in Bariatric Patients Undergoing Panniculectomy.

BACKGROUND: Hypoproteinemia and nutritional deficiencies are common after bariatric surgery, and although massive weight loss (MWL) patients experience increased wound complication rates, the association has not been causatively determined. OBJECTIVES: This study investigated preoperative nutritional parameters and wound complications in MWL patients (postbariatric and diet-controlled) undergoing panniculectomy at 2 academic institutions. METHODS: One hundred sixty-one consecutive patients undergoing elective panniculectomy after bariatric surgery or diet-controlled weight loss were identified. Patient demographics and nutritional indices (serum protein, albumin, and micronutrient levels) were analyzed. Complications including wound separation, infection, and operative debridements were compared. Post hoc comparisons tested for correlation between complications and nutritional markers. RESULTS: Postbariatric patients lost an average of 151 lb and presented at an average of 32 months after gastric bypass. Diet-controlled weight loss patients lost an average of 124 lb. Despite MWL, albumin levels were higher in the bariatric group (3.8 vs 3.4 g/dL, P < 0.05). Conversely, bariatric patients experienced increased wound complications (27% vs 14%; P < 0.05). Factors which were found to correlate to increased risk of wound dehiscence and infection were elevated body mass index at time of panniculectomy and amount of tissue removed. Multivariate analysis did not show serum albumin or percent weight loss to independently predict complications. CONCLUSIONS: Bariatric patients presenting for elective operations are at risk for protein and micronutrient deficiency. Despite aggressive replacement and normalization of nutritional markers, bariatric patients experience increased wound complications when compared to nonbariatric patients and traditional measures of nutritional evaluation for surgery may be insufficient in bariatric patients.

Validation of the Clenched Fist View in Detecting Scapholunate Ligamentous Injury.

BACKGROUND: The purpose of this study was to determine the predictive value of the clenched fist stress views in identifying scapholunate ligament injuries. METHODS: An institutional review board-approved retrospective chart review was conducted of adult patients who underwent diagnostic arthroscopy with a ligamentous wrist injury from 2015 to 2020. Standard posteroanterior, lateral, and clenched fist stress radiographs were reviewed and scapholunate ligament gaps recorded. RESULTS: A total of 124 patients were included, of which 88 had normal standard radiographs and clenched fist radiographs. The positive predictive value of the clenched fist view was 69%, whereas the negative predictive value was 58%. The sensitivity of the clenched fist view was 40%, while the specificity was 82%. Of those patients with a negative clenched fist view, 42% were found to have an arthroscopic Geissler classification of 3 or higher scapholunate ligament injury. CONCLUSIONS: Despite the emphasis on stress radiographic views, a normal stress clenched fist view does not preclude arthroscopic findings of a Geissler class 3 or greater injury in symptomatic patients. The sensitivity of a clenched fist view is only 40%. These findings question the utility of stress radiographs when assessing for scapholunate ligament injuries.

NanoScope Arthroscopy: Lessons Learned in the First 75 Cases.

Background The field of arthroscopy has exponentially grown in the past decade, especially in the realm of upper extremity surgery. Description The use of smaller cameras and further advancements in arthroscopy technology have allowed innovative expansion in the application of arthroscopy in small joints. Clinical Relevance Included in the advancements is the NanoScope, a 1.9-mm flexible scope specifically designed for small joint visualization.

Latest Trends in Subpectoral Breast Reconstruction.

There has been a shift in recent years toward a growing popularity of implant-based breast reconstruction, especially in the setting of increased frequency of concurrent contralateral prophylactic mastectomy. Advancements in implant safety and technology have also allowed for an expanding implant reconstruction practice across the country. The traditional approach is immediate two-stage implant reconstruction with placement of a tissue expander within a subpectoral pocket. The introduction of acellular dermal matrix has revolutionized implant-based breast reconstruction, allowing surgeons the opportunity to minimize morbidity while maximizing aesthetic outcomes. There have also been advances in the management of postoperative pain control as well as secondary revision surgery.

Intraoperative anatomy of the vascular supply to the medial femoral condyle.

The arterial anatomy of the medial femoral condyle (MFC) for vascularized bone grafting has been extensively studied in cadaveric specimens. A majority of cadaveric studies have limited numbers of specimens, and the data from these studies are extrapolated to the surgical environment. The purpose of this study is to evaluate the vascular anatomy of the medial femoral condyle in a large clinical series. A retrospective review of operative reports was conducted of medial femoral condyle and trochlea vascularized bone grafts performed by the senior surgeons between 2005 and 2018. A total of 113 patients were included in the study. Demographic data, preoperative diagnosis, and type of graft harvested were collected. The descending genicular artery, a branch of the superficial femoral artery, was the dominant pedicle in 77% of cases. It was also the dominant arterial pedicle for medial femoral trochlea (MFT) bone grafts in 7 out of the 9 cases (77.8%). The superomedial genicular artery was the dominant pedicle in 23% (26 of 113 total) of all cases. In eight patients, a descending genicular branch was not identified. The superomedial genicular artery was absent in 2% of cases (2 of 113). The descending genicular artery was the dominant arterial pedicle for vascularized bone grafts from the medial femur and was present in 93% of cases. This is in contrast to published cadaveric studies showing the artery was present in 89% of specimens.

Cost analysis of enhanced recovery after surgery in microvascular breast reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been shown in multiple surgical specialties to decrease hospital length of stay (LOS) after surgery. ERAS in breast reconstruction has been found to decrease hospital LOS and inpatient opioid use. ERAS protocols can facilitate a patient's recovery and can potentially increase the quality of care while decreasing costs. METHODS: A standardized ERAS pathway was developed through multidisciplinary collaboration. It addressed all phases of surgical care for patients undergoing free-flap breast reconstruction utilizing an abdominal donor site. In this retrospective cohort study, clinical variables associated with hospitalization costs for patients who underwent free-flap breast reconstruction with the ERAS pathway were compared with those of historical controls, termed traditional recovery after surgery (TRAS). All patients included in the study underwent surgery between September 2010 and September 2014. Predicted costs of the study groups were compared using generalized linear modeling. RESULTS: A total of 200 patients were analyzed: 82 in the ERAS cohort and 118 in the TRAS cohort. Clinical variables that were identified to potentially affect costs were found to have a statistically significant difference between groups and included unilateral versus bilateral procedures (p = 0.04) and the need for postoperative blood transfusion (p = 0.03). The cost regression analysis on the two cohorts was adjusted for these significant variables. Adjusted mean costs of patients with ERAS were found to be $4,576 lesser than those of the TRAS control group ($38,688 versus $43,264). CONCLUSIONS: Implementation of the ERAS pathway was associated with significantly decreased costs when compared to historical controls. There has been a healthcare focus toward prudent resource allocation, which dictates the need for plastic surgeons to recognize economic evaluation of clinical practice. The ERAS pathway can increase healthcare accountability by improving quality of care while simultaneously decreasing the costs associated with autologous breast reconstruction.

Desmoid tumor following abdominally-based free flap breast reconstruction.

Desmoid tumors are fibroblastic connective tissue tumors that most commonly develop within the anterior abdominal wall. The etiology of desmoid tumors has not been well defined; however, hereditary, hormonal, traumatic, and surgery-related causes have been implicated. Desmoid tumors are believed to arise from musculoaponeurotic structures. Development in the breast is very rare. Several reports of desmoid tumors arising in the vicinity of the fibrous capsule of a breast implant have been described, but to date, the authors are not aware of any published cases following autologous breast reconstruction. This report describes a desmoid tumor developing after a muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction and subsequent surgical management.

Comparison of Ulnar Intrinsic Function following Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer: A Matched Cohort Study of Proximal Ulnar Nerve Injury Patients.

BACKGROUND: There are few studies supporting supercharge end-to-side nerve transfer for high ulnar nerve injury. The current study hypothesized that patients with a supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer would demonstrate superior return of intrinsic function compared with conventional treatment only. METHODS: A retrospective matched-cohort study matched supercharge end-to-side transfer patients based on age, level of injury, and mechanism to ulnar nerve injury patients who did not have the transfer. The primary outcome was return of ulnar intrinsic function, based on clinical examination and/or electromyography. Dichotomous and continuous variables were compared with Fisher's exact and t tests, respectively. RESULTS: Thirteen supercharge end-to-side patients were identified (>1 year follow-up). The average age of both cohorts was 35 years. Ulnar nerve transection above the proximal third of the forearm represented 54 percent of patients; compressive injuries represented 46 percent. Eleven supercharge end-to-side transfer patients (84 percent) demonstrated intrinsic function recovery compared with five (38 percent) non-supercharge end-to-side patients (p < 0.05). Average time to initial motor recovery was similar between the two groups (supercharge end-to-side, 2.9 months; non-supercharge end-to-side, 3.8 months; p > 0.2). Intrinsic function return was more likely following nerve transection with the supercharge end-to-side procedure (85 percent versus 14 percent; p = 0.03), whereas compression injuries had comparable intrinsic function return regardless of the supercharge end-to-side transfer (67 percent versus 67 percent; p = 1.0). CONCLUSIONS: This matched cohort study demonstrates that the supercharge end-to-side transfer results in increased ulnar intrinsic reinnervation following ulnar nerve injury. This finding may be most relevant following transection injuries. Improved outcomes associated with supercharge end-to-side and ulnar nerve repair warrant further investigation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction.

BACKGROUND: Many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction. METHODS: MEDLINE, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking postoperative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS: Thirty-one studies met the inclusion criteria. After evidence review, one study represented two of nine stars on the Newcastle-Ottawa Scale, two studies represented three stars, six studies represented four stars, seven studies represented five stars, 11 studies represented six stars, and four studies represented seven stars. CONCLUSIONS: The results of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence is low. Synthetic materials have higher complication rates and allogeneic grafts have nipple projection comparable to that of autologous grafts. Further investigation with high-level evidence is necessary to determine the optimal material for nipple reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Transconjunctival lower lid blepharoplasty with and without fat repositioning.

The transconjunctival approach to lower lid blepharoplasty provides access for both fat resection and transposition to soften tear trough deformities and correct infraorbital fat herniation. Overall, there is a paradigm shift that has focused more on enhancing lower lid-cheek shape and contour and preserving orbital volume

The management of festoons.

The management of patients with festoons is a highly challenging undertaking with potential to drastically alter the appearance of those afflicted. Traditional teaching has focused on excision and tightening of the pathologic muscle with subsequent removal of excess skin. Recognition of the interactions between all subunits of the face has resulted in a recent shift in focus, with the new trend being techniques aimed at redraping the soft tissues with the intent of reproducing a more natural rejuvenation of the lower lid­cheek interface. Where direct excision techniques simply remove the deformed tissue, redraping techniques actually elevate the midface soft tissues and tighten the pathologically lax orbicularis muscle, thereby counteracting the downward descent associated with the aging process. The optimal treatment is as yet unclear but seems to be a combination of elevation of soft tissue, tightening of orbicularis muscle, and removal of excess skin and or muscle to properly address all the manifestations of this interesting process.

Disparities in completion of substance abuse treatment between and within racial and ethnic groups.

OBJECTIVE: To evaluate disparities in substance abuse treatment completion between and within racial and ethnic groups in publicly funded treatment in Los Angeles County, California. DATA SOURCE: The Los Angeles County Participant Reporting System with multicross-sectional annual data (2006-2009) for adult participants (n = 16,637) who received treatment from publicly funded programs (n = 276) for the first time. STUDY DESIGN: Retrospective analyses of county discharge and admission data. Hierarchical linear regressions models were used to test the hypotheses. DATA COLLECTION: Client data were collected during personal interviews at admission and discharge for most participants. PRINCIPAL FINDINGS: African Americans and Latinos reported lower odds of completing treatment compared with Whites. Within-group analysis revealed significant heterogeneity within racial and ethnic groups, highlighting primary drug problem, days of drug use before admission, and homelessness as significant factors affecting treatment completion. Service factors, such as referral by the criminal justice system, enabled completion among Latinos and Whites only. CONCLUSIONS: These findings have implications for reducing health disparities among members of racial and ethnic minorities by identifying individual and service factors associated with treatment adherence, particularly for first-time clients.

Thickness profiling of formaldehyde-fixed cells by transmission-through-dye microscopy.

Conventional light microscopy techniques are poorly suited for imaging the vertical cell dimension. This can be accomplished using transmission-through-dye (TTD) imaging, in which cell thickness is directly converted into image intensity in the presence of extracellular dye with strong absorption. We have previously described applications of TTD to living cells using the dye Acid Blue 9 (AB9) to generate contrast. In this work, we investigated the possibility of extending TTD to chemically fixed cells. This would depend on preservation of cell impermeability to the dye; by using a method based on fluorescence quenching, we found that formaldehyde-fixed cells remain impermeable to AB9. Fixation enables imaging of cell surfaces in the presence of high concentrations of AB9, bringing the vertical resolution to several nanometers per pixel; that is at least an order of magnitude better than resolution achievable with live cells. TTD images collected with high-NA objectives are often contaminated by Becke lines resulting from intracellular organelles, and we show how to distinguish them from features on the cell surface. Quantification of cell thickness and volume on fixed cells is also possible during the early stages of fixation; this can be useful, for example, for measuring volume kinetics following rapid introduction of a stimulus.