Decannulation and Airway Outcomes With Maxillomandibular Distraction in Treacher Collins and Nager Syndrome.

BACKGROUND: Treacher Collins syndrome is a rare disorder (1/50,000 live births) with features that include hypoplastic orbitozygomatic complex with downward slanting eyes, and maxillary/mandibular retrusion. Obstructive sleep apnea and tracheostomy-dependence are common. This study presents the outcomes of skeletal distraction on avoidance of tracheostomy and decannulation in this patient population. METHODS: The authors reviewed charts of all patients with Treacher Collins syndrome who underwent craniofacial reconstruction from 2003 to 2016. Primary outcome measures included decannulation of tracheostomy dependent patients and avoidance of tracheostomy. Secondary outcome measures included cephalometric parameters, polysomnography scores, and airway exposure scores on direct laryngoscopy. RESULTS: Twenty-five patients underwent mandibular and maxillary advancement to resolve upper airway obstruction. Mandibular distraction was performed in 24 of 25 patients, and maxillary distraction in 14 of 25 patients. Maxillary distraction was combined with mandibular distraction in 13 of 17 to accomplish greater advancement and counter-clockwise rotation of the entire maxillary-mandibular complex. Six of 7 patients, 85.7%, avoided a tracheostomy and 39% (7 of 18) were decannulated. Cephalometric changes in sella-nasion-A point, sella-nasion-B , occlusal plane angle, and posterior airway space were equivalent between the groups who were able to clear their obstruction and those who were not. CONCLUSIONS: Treacher Collins is a very challenging disease in which to resolve airway obstruction. Thus, thorough evaluation of the entire airway for all levels of obstruction is critical to successful outcomes. Future collaborative efforts between multiple institutions can help to increase our understanding and effective management of this rare disease.

The battle of words and the reality of never events in breast reconstruction: incidence, risk factors predictive of occurrence, and economic cost analysis.

BACKGROUND: The Centers for Medicare and Medicaid Services has a list of 10 hospital-acquired conditions for which hospitals and physicians will not be reimbursed because it deems such conditions are preventable and should be considered "never events." To evaluate the validity of this premise, the authors conducted a real-life analysis of the incidence and categories of never events occurring in a breast reconstruction cohort of a multisurgeon plastic surgery practice. Cost analysis of estimated revenue loss and risk factors associated with the development of never events are enumerated. METHODS: A retrospective chart review of postmastectomy patients undergoing breast reconstruction from 2008 to August of 2010 was conducted. A total of 297 patients were identified and International Classification of Diseases, Ninth Revision codes corresponding to the never events of interest were applied to the study population. RESULTS: Of the 297 patients, 24 (8.08 percent) developed never events in two categories: surgical-site infections (7.74 percent) and catheter-related urinary tract infections (0.34 percent). There were no complications in the remaining eight categories. Overweight body mass index and diabetes were strong independent risk factors for the development of never events (p < 0.0001). Cost estimates of associated revenue loss and economic analysis reveal substantial financial burdens to physicians and hospitals as a result of nonreimbursement. CONCLUSIONS: The "one-size-fits-all" approach of the Centers for Medicare and Medicaid Services may be misplaced and misleading. Certain risk factors are independent predictors of developing a never event, making it impossible to classify certain outcomes as "never" occurrences. The never events pendulum may have swung immensely to the left, and it is time to attain a much-needed equilibrium. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Pediatric cranial vault defects: early experience with beta-tricalcium phosphate bone graft substitute.

Pediatric calvarial defects may result from numerous causes. Availability of bone is often limited because of the child's age, and bone substitutes may be needed to reconstruct the defects. A bone substitute composed of ultraporous beta-tricalcium phosphate (Orthovita, Malvern, PA) is an osteoconductive product successfully used in orthopedic surgery. However, its application in cranial vault reconstruction is largely unstudied. The purpose of this investigation was to determine the healing rate of bone defects with the use of this product.A retrospective review was performed of patients in whom beta-tricalcium phosphate was used. Patient population consisted of 23 patients. Mean surgical age was 35 months. Reconstructions consisted of 20 craniosynostosis corrections and 3 posttraumatic repairs. The average defect size was 37 cm (range, 4.6-210 cm). Average follow-up was 12.7 months.At 2 months, 19 (79%) of 23 patients achieved healing of their defect, defined as the absence of persistent bone gaps. Persistent areas of bone weakness occurred in 3 patients at 4 months and 2 patients at 6 months. By 9 months, only 1 patient had not healed. This patient had the largest original defect of 210 cm. Defects taking longer than 2 months to heal measured 83 cm, whereas healed defects were 32 cm. No patients required treatment for graft-related problems such as infection or exposure.Early experience with beta-tricalcium phosphate bone substitute shows good healing of pediatric calvarial vault defects by 2 months, with no graft-associated complications. It seems most effective in the repair of smaller defects less than 40 cm.

Infrainguinal atherectomy: a retrospective review of a single-center experience.

By decreasing plaque burden, atherectomy provides an alternative to angioplasty and stenting as a means of revascularizing patients with peripheral arterial disease. A new atherectomy device (SilverHawk) has recently been approved by the Food and Drug Administration, but the results with its use are unclear. We analyzed a series of consecutive patients undergoing atherectomy. We retrospectively reviewed the charts of 35 patients undergoing infrainguinal (IF) atherectomy in 38 limbs. The Trans-Atlantic Inter-Society Consensus (TASC) classification and Society of Vascular Surgery runoff scores were calculated. Time to event analysis was performed using Kaplan-Meier estimates. Risk factors affecting patency were analyzed with a multivariate Cox model. Mean patient age was 70 +/- 9.6 years. Indications for intervention were claudication (26%), rest pain (21%), and tissue loss (53%). Femoropopliteal (FP) atherectomy was performed in 68% and tibial atherectomy in 32%. For FP lesions, the TASC distribution was A, 42%; B, 23%; C, 4%; and D, 15%. The average lesion treatment length was 9.4 +/- 10.6 cm (range 1-40), and the runoff score was 5.1 +/- 3.5. For tibial lesions, the TASC distribution was A, 0%; B, 17%; C, 8%; and D, 75%. The average lesion treatment length was 9.2 +/- 6.0 cm (range 2-20), with a runoff score of 5.4 +/- 2.4. A total of 39% of patients had prior IF interventions. Adjunctive angioplasty of the atherectomized lesion was performed in 55% of cases, stenting in 0%, and adjunctive therapy for tandem lesions in 39%. The postoperative ankle-brachial index increased by 0.30 +/- 0.14 and toe pressures increased by 40 +/- 32.4 mm Hg. Mean follow-up was 10 +/- 8 months (range 0.3-23). During the studied period, seven patients required major limb amputation and five open surgical revascularization. Total primary and secondary patency rates were 66% and 70% at 1 year, respectively. Primary and secondary patency rates for FP atherectomy were 68% and 73% at 1 year, respectively. The limb salvage rate was 74% at 6 months. Patients with prior interventions in the atherectomized segment had an almost 10-fold decrease in primary patency. Atherectomy produces acceptable results, similar to those in reported series of conventional balloon angioplasty/stenting. Patients with prior IF interventions had a nearly 10-fold decrease in primary patency. A greater than sixfold decrease in patency rates was noted in patients who underwent simultaneous inflow or outflow procedures, but this finding did not reach statistical significance (p = 0.082). Future studies should focus on cost comparisons with other treatments such as angioplasty and stenting, and prospective randomized trials should be performed to compare these treatment alternatives.