Donor-Site Morbidity and Functional Status following Medial Femoral Condyle Flap Harvest.

BACKGROUND: The medial femoral condyle free vascularized bone flap is a valuable alternative to other types of vascularized bone grafts. The donor-site morbidity and functional outcomes after flap harvest have not been fully appreciated. The authors report the postoperative outcomes and analyze the impact of increasing the size of the flap on knee donor-site morbidity. METHODS: A retrospective chart review of patients who underwent medial femoral condyle flap surgery between 2001 and 2012 at their institution was performed. The size of the flap was stratified, based on the largest dimension, into three groups. Demographics, outcomes, and complications related to the flap donor site were recorded and analyzed. Subsequently, functional status was assessed by administering a validated condition-specific measure. A univariate logistic regression analysis was performed, and results were analyzed. RESULTS: A total of 75 patients were identified. Average age was 29.5 ± 15.2 years. Average follow-up time was 13 months. The overall complication rate was 18.6 percent. Paresthesia in the saphenous nerve distribution was the most common complication. Increasing the size of the flap resulted in a significant elevation in complication risk (p < 0.05). A total of 47 patients completed the Lower Extremity Functional Scale questionnaire. The average Lower Extremity Functional Scale score was 72.12 ± 14.18. Fifty-one percent (n = 24) scored 80 points, indicating a normal level of function on average. CONCLUSIONS: The medial femoral condyle flap has overall acceptable donor-site morbidity, with a good level of function postoperatively. Larger flaps are associated with a greater number of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patient-specific polyetheretherketone implants for repair of craniofacial defects.

BACKGROUND: Large cranial defects represent reconstructive challenges. Polyetheretherketone (PEEK) implants are preoperatively tailored to the exact size of the defect and exhibit an excellent combination of strength, durability, and environmental resistance. This study presents our experience with patient-specific PEEK implants with computer modeling. METHODS: A retrospective chart review was conducted on all patients who underwent cranioplasty treated by a PEEK implant between 2007 and 2012. Analysis of the preoperative and perioperative data as well as outcome analysis was performed. RESULTS: A total of 11 patients were included. Mean age was 46 years. The indication for cranioplasty was bone flap infection and subsequent removal in 8 patients, traumatic bone loss in 2 patients, and acquired defect due to cancer resection in 1 patient. The mean time to PEEK cranioplasty since the patient's last operation was 16 months. The mean defect size was 74 cm(2). The mean surgical blood loss was 124 mL. The mean length of stay was 3 days. Complications included 1 postoperative bleeding that required reoperation, but the PEEK implant was successfully salvaged. The mean time to follow-up was 6 months. CONCLUSIONS: Use of patient-specific PEEK implants is a good alternative for alloplastic cranioplasty. It is associated with low morbidity as reported in our series, with additional advantages including strength, stiffness, durability, and inertness. It would be beneficial to assess the longer-term outcomes; however, it appears at first glance that PEEK implants show great promise in calvarial reconstruction.

Optimizing functional and aesthetic outcomes of upper limb soft tissue reconstruction.

This article highlights reconstructive principles in flap selection, use, and insetting to optimize functional and aesthetic outcomes after upper extremity reconstruction. The concept of respecting the aesthetic units of the hand during reconstruction is discussed. A current literature review of the aesthetic outcomes using various flaps, such as fasciocutaneous, fascia only, and muscle flaps, is provided. An approach based on aesthetic unit principles to upper extremity reconstruction is also highlighted to help optimize outcomes.

Osteoarthritis of the wrist.

This article reviews pathogenesis and treatment of wrist osteoarthritis. Because there is no cure for osteoarthritis, treatment is directed at symptomatic relief. Surgical treatment is reserved for patients who have failed nonoperative modalities. This article reviews the surgical treatment of wrist osteoarthritis with an emphasis on selection of the appropriate procedure. Literature guiding surgical treatment with patient outcomes is reviewed.

Cat bite infections of the hand: assessment of morbidity and predictors of severe infection.

PURPOSE: To assess the overall morbidity of cat bites to the hand and identify risk factors for hospitalization after such an injury. METHODS: All patients recently treated at our institution for cat bite injuries to the hand were retrospectively reviewed. We identified 193 patients in a 3-year period between January 1, 2009, and December 31, 2011. Patient demographics, medical history, physical examination findings, laboratory values, and long-term follow-up data were collected. Univariate and multivariate statistical regression were used to analyze the data. RESULTS: Thirty percent (n = 57) of patients with cat bites to the hand were hospitalized. The average length of stay for these patients was 3.2 days. Of the hospitalized patients, 67% (n = 38) underwent irrigation and debridement, with 8 patients requiring more than 1 operation. Complications were common among these patients. Risk factors associated with hospitalization included smoking, immunocompromised state, and location of bite over a joint or tendon sheath. Physical examination findings of erythema and swelling at presentation were also associated with increased risk of hospitalization. Time from bite to presentation, white blood cell count, erythrocyte sedimentation rate, and C-reactive protein values at presentation were not associated with hospitalization. CONCLUSIONS: Cat bite injuries to the hand can progress to serious infection. The treatment of such infections often requires hospitalization, intravenous antibiotic therapy, and operative treatment. Clinical findings suggestive of the need for hospitalization include location of the bite over a joint or tendon sheath, erythema, pain, and swelling. These findings should increase concern for a severe infection and warrant hospitalization and urgent consultation with a hand surgeon. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Three-dimensional preoperative virtual planning and template use for surgical correction of craniosynostosis.

BACKGROUND: Surgical correction of craniosynostosis aims to remodel the cranial vault to achieve a morphology approaching that of age-matched norms. However, current surgical technique is highly subjective and based largely on the surgeon's artistic vision in creating a normal head shape. Here, we present our technique and report our experience with the use of virtual surgery using computer-assisted design (CAD)/computer-assisted manufacturing (CAM) techniques to create a prefabricated template for the planning of osteotomies and the placement of bone segments, to achieve standardised, objective and precise correction of craniosynostosis. METHODS: Four patients who underwent cranial vault remodelling (CVR; three metopic synostosis and one sagittal synostosis) underwent virtual surgical planning (VSP) preoperatively using CAD/CAM techniques. VSP allows pre-planning of osteotomies to achieve the desired cranial vault shape. Surgical osteotomies and placement of bone segments were performed intra-operatively based on prefabricated templates. RESULTS: All patients demonstrated markedly improved head shape postoperatively. One patient developed a subdural haematoma 6 weeks postoperatively subsequent to a fall where he hit his head. The haematoma was drained and a soft spot was present in that location 3 months postoperatively. CONCLUSION: The use of virtual surgery and prefabricated cutting guides allows for a more precise and rapid reconstruction. Surgical osteotomies are pre-planned and rapidly performed using a template, and precise placement of calvarial bone segments is achieved without the need for subjective assessment of the desired calvarial shape. In addition, patients and families have a significantly better understanding of the disease process and anticipated surgery preoperatively with the visualisation achieved through virtual surgery. This results in better alignment of hopes and expectations between the parents and surgeons.

Impact and outcome of human acellular dermal matrix size for immediate and two-stage breast reconstruction.

BACKGROUND: Following mastectomy, patients may choose to have breast reconstruction with autologous tissue or implants. Human acellular dermal matrix has been described as a tissue supplement where the implant is covered, without requiring further muscle elevation or dissection. The authors evaluated the impact of different matrix sizes. METHODS: Fifty-two patients (average age, 48.5 years) and 88 operated breasts were evaluated. The cohort was divided into two, depending on matrix size. In group A, a small matrix with a surface area of 48 or 96 cm was used. In group B, a larger matrix with either 128 or 160 cm was used. Intraoperative fill volumes, expansion procedure, and complications were analyzed. RESULTS: Size difference was significant (69.2 versus 135.5 cm). The calculated mean initial filling volume-to-excised pathology tissue weight ratio and the initial filling-to-final implant volume ratio were significant. Average number of fills to reach final expansion volume was 62.3 percent, or 4.7 times lower in group B. Seven complications were reported without any statistical difference between groups. CONCLUSIONS: This study suggests that using a larger human acellular dermal matrix in breast reconstruction offers a potential to increase the initial expander fill volume-to-breast pathology weight ratio and initial expander fill volume-to-final implant volume ratio. Larger matrices can reduce the number of subsequent expansions and may even decrease the risk of postoperative complications. This study also revealed that using a larger matrix is a safe method that does not increase complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Gynecomastia in adolescent males.

Gynecomastia is defined as an enlargement of the male breast. It is often benign, and can be the source of significant embarrassment and psychological distress. A general medical history and careful physical examination are essential to distinguish normal developmental variants from pathological causes. Treatment is geared toward the specific etiology when identified. In the majority of cases of pubertal gynecomastia, observation and reassurance are the mainstays of therapy as the condition usually resolves naturally. Pharmacological treatment and surgery are recommended only in selected cases.

The effect of epidural anesthesia on muscle flap tolerance to venous ischemia.

BACKGROUND: Venous ischemia is a major cause of failure after free tissue transfers and replantations. The combination of general and epidural anesthesia leads to vasodilatation and improves tissue perfusion. Postoperative pain relief and sympathetic blockage are additional benefits of epidural anesthesia. The purpose of this study was to determine whether epidural anesthesia has benefits on microcirculation and neutrophil functions in muscle flaps subjected to venous ischemia. METHOD: Thirty Sprague-Dawley rats were divided into three groups: group I, general anesthesia; group II, spinal anesthesia; and group III, epidural anesthesia. Cremaster flaps were prepared, postcapillary venules were selected under intravital videomicroscopy, and flaps were subjected to venous ischemia. Images were recorded from preselected postcapillary venules before venous ischemia (baseline) and following reperfusion. Neutrophil rolling and adhesion, functional capillary density, and diameters of postcapillary venules were evaluated. RESULTS: The increase in rolling neutrophils in group III was significantly lower than in groups I and II at 60 and 120 minutes. Change of adherent neutrophils in group III was significantly lower than in groups I and II at 15, 60 and 120 minutes. There was significantly more reduction in inner diameter of postcapillary venules in groups I and II compared with group III. Functional capillary density in groups I and II was significantly lower than in group III. CONCLUSION: Epidural anesthesia regulated neutrophil functions, salvaged functional capillaries, and prevented vasoconstriction of postcapillary venules in cremaster muscle flaps subjected to venous ischemia. Spinal and general anesthesia, however, were found to be ineffective in improving microcirculation of muscle flaps subjected to venous ischemia.

Naringenin inhibits neointimal hyperplasia following arterial reconstruction with interpositional vein graft.

Vessels respond to injury by a healing process that includes the development of neointima. Stenosis secondary to neointima formation is the main cause of failure following arterial reconstructions. Vessel wall homeostasis is regulated by proinflammatory cytokines that affect smooth muscle cell proliferation, growth, migration, and death. We assessed the hypothesis that naringenin, a flavinoid possessing anti-inflammatory, antioxidant, and antiproliferative activities, reduces neointimal hyperplasia (NIH) following vascular injury.Arterial injury was created by interposition grafting of autologous right superficial epigastric vein graft into the right femoral artery (FA) in 48 male Sprague-Dawley rats. Following injury, the rats were divided into 4 groups (n = 12). Two groups were treated with naringenin (100 mg/kg intraperitoneal q daily) for 2 and 4 weeks each while 2 control groups received normal saline for the same durations. For Sham group (n = 10), the FA and vein were isolated without any additional procedure. Rats were killed at the end of treatment regimen in all groups, and FAs were harvested. Thickness of intima was measured in histologic sections, and levels of platelet derived growth factor (PDGF)-BB, TNFalpha, and Ki67 labeling index (Ki67 LI) were quantified in immunohistochemical analyses to assess the amount of NIH and mechanisms underlying its formation.Although there was no significant difference between the groups at 2 weeks, neointima thickness was lower in the naringenin treated group at 4 weeks (23.7 +/- 2.3 vs. 35.6 +/- 2.6 microm in control group; P < 0.001). The levels of PDGF-BB, and TNFalpha were lower in naringenin treated groups at both 2 weeks (PDGF-BB [0.21% +/- 0.03% versus 0.39% +/- 0.05% in control group, P < 0.001), TNFalpha (21.2% +/- 0.8% vs. 36.1% +/- 1.9% in control group, P < 0.001]) and 4 weeks (PDGF-BB [0.25% +/- 0.03% vs. 0.57% +/- 0.09% in control group, P < 0.001], TNFalpha [25.5% +/- 1.8% vs. 45.0% +/- 2.9% in control group, P < 0.001]). Ki67 LI was lower in naringenin treated groups at 2 weeks (13.9% +/- 2.8% vs. 18.7% +/- 3.7% in control group, P < 0.05), and at 4 weeks (17.5% +/- 2.6% vs. 31.1% +/- 4.7% in control group, P < 0.001), indicating a lower level of cellular proliferation.Naringenin reduces NIH following arterial reconstruction. This may be mediated by a decrease in PDGF-BB and TNFalpha levels and the resulting down-regulation of smooth muscle cells' migration and proliferation.

Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis.

The objectives of this study are to determine risk factors associated with deep sternal wound infections (DSWIs) following cardiac surgery, and to describe their impact on long-term survival. Data was obtained from a departmental database. Analysis included 7,978 consecutive patients who underwent cardiac surgery between 1997 and 2003. To identify risk factors for DSWI, regression analysis was performed. The probability scores obtained from logistic regression were used for propensity analysis of 2 groups. Kaplan-Meier analysis with log-rank test and Cox proportional hazard models were then used in survival analysis. DSWI developed in 123 of 7,978 patients (1.5%). Preoperative predictors of DSWI were body mass index >30 kg/m(2) (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1 to 2.4; P < 0.05), diabetes mellitus (OR, 2.4; 95% CI, 1.6 to 3.4; P < 0.001), urgent operation (OR, 1.7; 95% CI, 1.2 to 2.6; P < 0.05), smoking history within past year (OR, 2.7; 95% CI, 1.5 to 4.9; P < 0.001), smoking history within past 2 weeks (OR, 2.6; 95% CI, 1.5 to 4.5; P < 0.001), and a history of stroke (OR, 1.9; 95% CI, 1.1 to 3.1; P < 0.005). In addition, total length of hospital stay (OR, 1.01; 95% CI, 1.01 to 1.02; P < 0.05) and sepsis and/or endocarditis following surgery (OR, 5.1; 95% CI, 2.9 to 9.0; P < 0.001) were also predictive of DSWI. Patients with DSWI had a prolonged total length of hospital stay (40.3 days versus 16.1 days; P < 0.001), and higher 30-day mortality (1.6% versus 7.3% in DSWI group, P < 0.05). There were no differences between groups in 4-year and 8-year survival rates, with 77.2% and 61.8%, respectively, in patients with DSWI compared with 78.0% and 67.5% in patients without DSWI (P = 0.16). After adjustments for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 0.9 (95% CI, 0.6 to 1.2, P = 0.39). Though DSWIs are associated with increased early mortality, patients undergoing cardiac surgery complicated by DSWI do not experience worse long-term survival.

Sclerotherapy to a large cervicofacial vascular malformation: a case report with 24 years' follow-up.

BACKGROUND: Large craniofacial venous malformations frequently cause significant cosmetic and functional problems. Treatment of the lesions early in life helps to avoid these problems. We present a case of a large cervicofacial venous malformation. METHODS: The patient was treated with a 5% benzyl alcohol solution of sodium morrhuate. The treatment was begun when the patient was 3 months of age, with a total of 23 injections. RESULTS: The lesion had completely disappeared by age 10. No major complications were observed except a superficial tissue loss on the temporal region. It was healed by conservative treatment. There were no recurrences during the 14-year follow-up. CONCLUSIONS: It is difficult to conclude that this type of treatment is the best choice for patients with venous malformation on the basis of a single case. However, intralesional sclerotherapy should be kept in mind as a saving treatment option in cases of large venous malformations in anatomic regions that present challenges to both the surgeon and the patient. Intralesional sclerotherapy can be performed without serious complications if the sclerosing agent is selected and injected cautiously.