Treatment of an Ulnar Fracture Bone Defect Using Heterotopic Bone Autograft: A Case Report.

CASE: Autologous bone grafting has wide applications for the treatment of bony defects. Generally, cancellous or corticocancellous bone grafts are used depending on the characteristics and size of the bony defect and wound bed. The use of heterotopic bone as a potential source of bone graft has not been widely reported. We present a 56-year-old right-hand-dominant male victim of dog mauling who sustained a right ulnar fracture with a 5-cm bony defect, treated with the use of heterotopic bone autograft. CONCLUSION: Heterotopic bone can be successfully used as an autograft in the treatment of bony defects.

Adipose Tissue Drives Response to Ischemia-Reperfusion Injury in a Murine Pressure Sore Model.

BACKGROUND: Ischemia-reperfusion injury contributes significantly to the pathogenesis of chronic wounds such as pressure sores and diabetic foot ulcers. The authors' laboratory has previously developed a cyclical murine ischemia-reperfusion injury model. The authors here use this model to determine factors underlying tissue response to ischemia-reperfusion injury. METHODS: C57BL/6 mice were subjected to cycles of ischemia-reperfusion that varied in number (one to four cycles) and duration of ischemia (1 to 2 hours). For each ischemia-reperfusion condition, the following variables were analyzed: (1) digital photographs for area of necrosis; (2) hematoxylin and eosin staining and immunohistochemistry for inflammatory infiltrate; and (3) expression of inflammatory markers by quantitative polymerase chain reaction. In addition, human adipocytes and fibroblasts were cultured in vitro under conditions of hypoxia and reoxygenation, and expression of inflammatory markers was analyzed by quantitative polymerase chain reaction. RESULTS: Increases in both ischemia-reperfusion cycle number and ischemia duration correlated with increased areas of epithelial necrosis both grossly and histologically, and with an increase in cellularity and neutrophil density. This increased inflammatory infiltrate and a significant increase in the expression of proinflammatory markers (Hmox1, interleukin-6, interleukin-1, and monocyte chemoattractant protein-1) was observed in adipose tissue subjected to ischemia-reperfusion injury, but not in dermis. These results were mirrored in human adipose tissue. CONCLUSIONS: The authors further characterize a novel, reproducible murine model of ischemia-reperfusion injury. The results of their study indicate that adipose tissue is less tolerant of ischemia-reperfusion than dermal tissue. Rather than being an "innocent bystander," adipose tissue plays an active role in driving the inflammatory response to ischemia-reperfusion injury.

Neonatal Compartment Syndrome Associated With Disseminated Intravascular Coagulation.

Neonatal compartment syndrome is a rare, but devastating limb-threatening condition that requires early recognition and timely surgical intervention. We discuss the clinical presentation and management challenges of a neonate with forearm compartment syndrome and disseminated intravascular coagulation.

Surgical duration and risk of venous thromboembolism.

IMPORTANCE: There is a paucity of data assessing the effect of increased surgical duration on the incidence of venous thromboembolism (VTE). OBJECTIVE: To examine the association between surgical duration and the incidence of VTE. DESIGN, SETTINGS, AND PARTICIPANTS: Retrospective cohort of 1,432,855 patients undergoing surgery under general anesthesia at 315 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2011. EXPOSURE: Duration of surgery. MAIN OUTCOMES AND MEASURES: The rates of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE within 30 days of the index operation. Surgical duration was standardized across Current Procedural Terminology codes using a z score. Outcomes were compared across quintiles of the z score. Multiple logistic regression models were developed to examine the association while adjusting for patient demographics, clinical characteristics, and comorbidities. RESULTS: The overall VTE rate was 0.96% (n = 13,809); the rates of DVT and PE were 0.71% (n = 10,198) and 0.33% (n = 4772), respectively. The association between surgical duration and VTE increased in a stepwise fashion. Compared with a procedure of average duration, patients undergoing the longest procedures experienced a 1.27-fold (95% CI, 1.21-1.34; adjusted risk difference [ARD], 0.23%) increase in the odds of developing a VTE; the shortest procedures demonstrated an odds ratio of 0.86 (95% CI, 0.83-0.88; ARD, -0.12%). The robustness of these results was substantiated with several sensitivity analyses attempting to minimize the effect of outliers, concurrent complications, procedural differences, and unmeasured confounding variables. CONCLUSIONS AND RELEVANCE: Among patients undergoing surgery, an increase in surgical duration was directly associated with an increase in the risk for VTE. These findings may help inform preoperative and postoperative decision making related to surgery.

Tabbed tissue expanders improve breast symmetry scores in breast reconstruction.

BACKGROUND: Achieving symmetry is a key goal in breast reconstruction. Anatomically shaped tabbed expanders are a new tool in the armamentarium of the breast reconstruction surgeon. Suture tabs allow for full control over the expander position and thus inframammary fold position, and, in theory, tabbed expanders mitigate many factors responsible for poor symmetry. The impact of a tabbed expander on breast symmetry, however, has not been formally reported. This study aims to evaluate breast symmetry following expander-implant reconstruction using tabbed and non-tabbed tissue expanders. METHODS: A chart review was performed of 188 consecutive expander-implant reconstructions that met the inclusion criteria of adequate follow-up data and postoperative photographs. Demographic, oncologic, postoperative complication, and photographic data was obtained for each patient. The photographic data was scored using a 4-point scale assessing breast symmetry by three blinded, independent reviewers. RESULTS: Of the 188 patients, 74 underwent reconstruction with tabbed expanders and 114 with non-tabbed expanders. The tabbed cohort had significantly higher symmetry scores than the non-tabbed cohort (2.82/4±0.86 vs. 2.55/4±0.92, P=0.034). CONCLUSIONS: The use of tabbed tissue expanders improves breast symmetry in tissue expander-implant-based breast reconstruction. Fixation of the expander to the chest wall allows for more precise control over its location and counteracts the day-to-day translational forces that may influence the shape and location of the expander pocket, mitigating many factors responsible for breast asymmetry.

The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients.

BACKGROUND: Reduction mammaplasty is commonly performed in women who are considered obese by the body mass index (BMI) classification of the World Health Organization. OBJECTIVES: The authors compare complication rates among breast reduction patients, stratified by BMI, across multiple institutions. METHODS: A retrospective analysis was performed of all reduction mammaplasties in the database of the National Surgical Quality Improvement Program for 2006 through 2010. Demographic, comorbidity, and BMI data were collected. Data on medical and surgical complications, reoperation, and mortality were collected through 30 days postsurgery. RESULTS: Of 2492 patients, 55% were considered obese (BMI >30). The overall rate of surgical complications was 4.0%, increasing from 2.4% for BMI <25 to 7.1% for BMI >45 (P = .006), with an adjusted odds ratio of 2.97 for BMI >45 versus BMI <25. The most common surgical complication was superficial surgical site infection; it was found in 2.9% of patients, increasing from 2.1% for BMI <25 to 5.1% for BMI >45 (P = .03). The medical complication rate was 0.6%, and the reoperation rate was 2.1%. There were no deaths. A maximal point analysis showed that BMI ≥39 was associated with a significantly higher complication rate, with an odds ratio of 2.38. CONCLUSIONS: Reduction mammaplasty is a safe surgical procedure, even when performed on obese patients. However, patients with higher BMI have a greater risk of surgical site complications. This risk should be discussed preoperatively with obese patients.

The weave technique for nipple reconstruction.

Traditional nipple reconstruction relies on local flap techniques. However, there are several problems associated with local flap reconstruction including loss of projection, widening of the base width, and difficulty working around the mastectomy scar. This study presents a variation of traditional local flap nipple reconstruction, which is termed the weave technique. Rather than using two flaps to create base width, the weave technique uses one. By controlling the base width, this may serve to sustain long-term projection. Second, filling the inside of the nipple with the second flap may contribute to longer term projection. Because there is no third flap, it is easier to orient the nipple with respect to the mastectomy scar. To date, the senior author has used this method to reconstruct 55 nipples in 40 patients, with 415 days (range 191-733) mean follow-up time. This includes 45 (82%) nipple reconstructions after tissue expander-implant reconstruction. The use of this technique has produced excellent aesthetic results with nipple projection and site healing. The majority of patients have been satisfied with their nipple reconstruction. Three patients had wound healing difficulties, including two (3.6%) that healed with conservative wound care and one (1.8%) in a radiated patient requiring surgical revision. There were no other revisions necessary and no infections. In summary, the weave technique is a suitable modification to the popular C-V technique that maintains the benefits and simplicity of the aforementioned flap while potentially reducing projection loss, conserving base width, and allowing greater flexibility for nipple placement.

Use of the tabbed expander in latissimus dorsi breast reconstruction.

Latissimus dorsi (LD) myocutaneous flap breast reconstruction with a tissue expander/implant is a post-mastectomy option often used as a salvage procedure for a failed tissue expander (TE). The patient is traditionally placed in the lateral decubitus position for flap dissection and is re-prepped and re-draped in the supine position for placement of the tissue expander. A new generation of anatomically-shaped, tabbed tissue expanders are increasingly being used in place of traditional untabbed expanders. The innovative suture tabs allow for more predictable and controlled expander placement while the patient is in the lateral decubitus position, eliminating the need to reposition the patient intraoperatively. The objective of this study was to evaluate the use of tabbed tissue expanders in latissimus dorsi breast reconstruction, with respect to total operative time, complication rates, and aesthetic outcomes. The outcomes of 34 LD breast reconstruction procedures with tissue expanders were evaluated. Eight patients received tabbed tissue expanders with no position change, while 26 patients underwent an intraoperative position change. Demographic information, total operative time, and follow-up complication data were collected. Aesthetic outcomes were evaluated by three blinded individuals using a validated scoring scale. The mean operative time for procedures with no position change was 107 minutes. The mean operative time for position change cohort was 207 minutes. There was no statistical difference in complication rates or aesthetic outcomes between the two groups. In conclusion, tabbed tissue expanders decrease operative time by eliminating the need for an intraoperative position change without influencing complication rates while maintaining equivalent aesthetic outcomes.