Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement.

OBJECTIVES: Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA. MATERIALS AND METHODS: Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT). RESULTS: A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing. CONCLUSIONS: This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.

The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Cooled radiofrequency ablation versus standard medical management for chronic sacroiliac joint pain: a multicenter, randomized comparative effectiveness study.

INTRODUCTION: Low back pain is the leading cause of disability worldwide, with sacroiliac joint pain comprising up to 30% of cases of axial lower back pain. Conservative therapies provide only modest relief. Although placebo-controlled trials show efficacy for sacral lateral branch cooled radiofrequency ablation, there are no comparative effectiveness studies. METHODS: In this randomized, multicenter comparative effectiveness study, 210 patients with clinically suspected sacroiliac joint pain who obtained short-term benefit from diagnostic sacroiliac joint injections and prognostic lateral branch blocks were randomly assigned to receive cooled radiofrequency ablation of the L5 dorsal ramus and S1-S3 lateral branches or standard medical management consisting of pharmacotherapy, injections and integrative therapies. The primary outcome measure was mean reduction in low back pain score on a 0-10 Numeric Rating Scale at 3 months. Secondary outcomes included measures of quality of life and function. RESULTS: 3 months post-treatment, the mean Numeric Rating Scale pain score for the cooled radiofrequency ablation group was 3.8±2.4 (mean reduction 2.5±2.5) compared with 5.9±1.7 (mean reduction 0.4±1.7) in the standard medical management group (p<0.0001). 52.3% of subjects in the cooled radiofrequency ablation group experienced >2 points or 30% pain relief and were deemed responders versus 4.3% of standard medical management patients (p<0.0001). Comparable improvements favoring cooled radiofrequency ablation were noted in Oswestry Disability Index score (mean 29.7±15.2 vs 41.5+13.6; p<0.0001) and quality of life (mean EuroQoL-5 score 0.68±0.22 vs 0.47±0.29; p<0.0001). CONCLUSIONS: In patients with sacroiliac joint pain, cooled radiofrequency ablation provided statistically superior improvements across the spectrum of patient outcomes compared with standard medical management. TRIAL REGISTRATION NUMBER: NCT03601949.

Educational Curriculum for Peripheral Nerve Stimulation Developed by the North American Neuromodulation Society.

BACKGROUND: Peripheral nerve stimulation (PNS) is an effective neuromodulation therapy for chronic neuropathic and nociceptive pain. Although the total number of PNS implantations has increased over the last decade, no curriculum exists to guide training and learning of this therapy. The goal of the North American Neuromodulation Society (NANS) education committee is to develop a series of competency-based curriculums for neuromodulation therapies. The PNS curriculum is the latest part of such series, following the curriculums for spinal cord stimulation and intrathecal drug delivery system. MATERIALS AND METHODS: A multidisciplinary task force (anesthesiology, physical medicine and rehabilitation, neurosurgery, preventive medicine and public health, and neurology) was created by the educational committee of NANS to develop a PNS curriculum in accordance with the Accreditation Council for Graduate Medical Education (ACGME) milestones. The curriculum was created based on the best available evidence and expert knowledge (from our task force members) of available PNS systems. The final PNS curriculum was approved by the NANS board. RESULTS: A PNS curriculum was developed by the task force. Milestones included professionalism, practice-based learning, interpersonal communication, medical knowledge, systems-based practice, procedural skills, and patient care. Each milestone was defined into three categories: early learner, advanced learner, and practitioner. CONCLUSIONS: This manuscript provides a PNS training curriculum developed by a multidisciplinary task force of the NANS educational committee in accordance with the milestones described by ACGME for basic learners, advanced learners, and practitioners. This curriculum will help provide a structured training and evaluation process for obtaining proficiency in PNS treatment(s).

Telemedicine Implementation in Pain Medicine: A Survey Evaluation of Pain Medicine Practices in Spring 2020.

BACKGROUND: The COVID-19 pandemic resulted in a novel challenge for healthcare delivery and implementation in the United States (US) in 2020 and beyond. Telemedicine arose as a significant and effective medium for safe and efficacious physician-patient interactions. Prior to the COVID-19 pandemic, telemedicine while available, had infrequently been utilized in pain medicine practices due to difficulties with reimbursement, the learning curve associated with new technology usage, and the need for new logistical systems in place to implement telemedicine effectively. Given the unique constraints on the healthcare system during the COVID-19 pandemic, the ubiquitous utilization of telemedicine among pain medicine physicians increased, giving insight into potential future roles for the technology beyond the pandemic. OBJECTIVES: To survey and understand the state of implementation of telemedicine into pain medicine practices across practice settings and geographical areas; to identify potential barriers to the implementation of telemedicine in pain medicine practice; and to identify the likelihood of telemedicine continuing beyond the pandemic in pain medicine practice. STUDY DESIGN: Online questionnaire targeting Pain Medicine physicians in the US. Participants were asked questions related to the use of telemedicine during the first peak of the COVID-19 pandemic. SETTING: Online-based questionnaire distributed to academic and private practice pain medicine physicians nationally in the United States. METHODS: A 34 web-based questionnaires were distributed by the American Society of Regional Anesthesia and Pain Medicine and the Spine Intervention Society to all active members. Data were analyzed using SAS v9.4. RESULTS: Between December 3, 2020, and February 18, 2021, 164 participants accessed the survey with a response rate of 14.3%. Overall, academic physicians were more likely to implement telemedicine than private practice physicians. Telemedicine was also more frequently utilized for follow-up appointments rather than initial visits. LIMITATIONS: Although our n = 164, the overall low response rate of 14.3% warrants further investigation into the utilization of telemedicine throughout the COVID-19 pandemic. CONCLUSIONS: Telemedicine as an emerging technology for efficient communication played a key role in mitigating the adverse effects of the COVID -19 pandemic on chronic pain patients. The utilization of telemedicine remarkably increased after the start of the pandemic within 1 to 2 weeks. Overall, private hospital-based centers were significantly less likely to implement telemedicine than academic centers, possibly due to limited access to secure telemedicine platforms and high start-up costs. Telemedicine was used more frequently for follow-up visits than initial visit encounters at most centers. In spite of the unforeseen consequences to the healthcare system and chronic pain practices in the US from COVID-19, telehealth has emerged as a unique model of care for patients with chronic pain. Although it has flaws, telehealth has the ability to increase access to care beyond the end of the pandemic. Further identification of barriers to the use of telemedicine platforms in private practices should be addressed from a policy perspective to facilitate increased care access.

Novel Technologies in Interventional Pain Management.

This article comprehensively covers 3 major novel technologies and techniques in the management of chronic lower back pain. The first 2 procedures, percutaneous interspinous spacer implantation, and minimally invasive lumbar decompression have shown significant impact in the management of lumbar spinal stenosis (LSS), especially in patients who are not great surgical candidates or are otherwise not amenable to open spinal surgery. The wealth of data for these procedures continues to increase, with up to 4 to 6-year follow-up data recently being made available. A novel solution for vertebrogenic back pain is also discussed as follow-up data emphasizes the safety and sustainability of the procedure. This article also establishes a framework for evaluating novel technologies in interventional pain management.

Establishing a Dose-Response Relationship Between Opioid Use and Hypogonadism: A Retrospective Case-Control Study.

Background: Opioid-induced androgen deficiency (OPIAD) related to chronic, long-acting opioid use can be a significant detriment to patient quality of life. The aim of this study was to investigate the association between chronic opioid use and hypogonadism. Methods: A single-center, retrospective, matched case-control analysis of 357 males (94 cases, 263 controls, aiming for 1:4 matching) was performed. Study subjects were ages 18 to 80 years and had a diagnosis of chronic opioid use. Patients with a hypogonadism diagnosis were matched to patients without a hypogonadism diagnosis by age, ethnicity, and body mass index. The maximum morphine equivalent daily dose (MEDD) was compared in each group. Results: A significant linear association between MEDD and the odds of developing hypogonadism (P<0.001) in males with chronic use of opioids was observed, with an odds ratio of 1.44 (95% CI 1.16-1.78) by 100-unit difference in maximum MEDD. Conclusion: Results showed a significant, positive linear association between chronic opioid dose and the odds of developing hypogonadism in males. This higher index of suspicion of OPIAD could lead to earlier recognition of symptoms and increase the positive predictive value of diagnostic laboratory tests.

The American Society of Pain and Neuroscience (ASPN) Practical Guidelines to Study Design and Scientific Manuscript Preparation in Neuromodulation.

BACKGROUND: Healthcare clinical and even policy decisions are progressively made based on research-based evidence. The process by which the appropriate trials are developed and well-written manuscripts by means of evidence-based medicine recommendations has resulted in unprecedented necessity in evidence-based medicine in neuromodulation. METHODS: The essential considerations in the planning of neuromodulation research are discussed in the light of available scientific literature as well as the authors' scientific expertise regarding research study design and scientific manuscript preparation. CONCLUSION: This article should enable the reader to understand how to appropriately design a clinical research study and prepare scientific manuscripts. The high-quality and well-designed studies, when performed and reported effectively, support evidence-based medicine and foster improved patient outcomes.

Outcome of Percutaneous Lumbar Synovial Cyst Rupture in Patients with Lumbar Radiculopathy.

BACKGROUND: Lumbar synovial cysts can result from spondylosis of facet joints. These cysts can encroach on adjacent nerve roots, causing symptoms of radiculopathy. Currently the only definitive treatment for these symptoms is surgery, which may involve laminectomy or laminotomy, with or without spinal fusion. Surgery has been reported to successfully relieve radicular pain in 83.5% of patients by Zhenbo et al. Little information is available concerning the efficacy and outcome of percutaneous fluoroscopic synovial cyst rupture for treatment of facet joint synovial cysts. OBJECTIVE: The goal of this investigation was to assess the efficacy of fluoroscopically guided lumbar synovial cyst rupture, in particular for its relief of radicular symptoms and its potential to reduce the need for surgical intervention. STUDY DESIGN: Retrospective evaluation of a case series. SETTING: University hospital and urban public health care system. METHODS: With approval from the Institutional Review Board of Case Western Reserve University/ MetroHealth Medical Center, we reviewed the medical charts of patients with lumbar radiculopathy who underwent percutaneous lumbar synovial cyst rupture. The 30 patients in the cohort were treated by one pain specialist between 2006 and 2013. These patients were diagnosed with moderate to severe lower back pain, radiculopathy, and ranged in age from 42 to 80 years. Patients were followed up for a minimum of 6 months and up to 24 months. Pre- and post-procedure pain assessments were reviewed by clinical chart review. In addition post-procedure pain assessments and duration of pain relief were obtained with telephone interviews. Pain had been reported by the patients using a numeric rating scale of 0 - 10 (0 = no pain; 10 = worst possible pain). Charts were reviewed to determine if surgery was eventually performed to correct radicular symptoms. RESULTS: More than 6 months of pain relief was achieved in 14/30 patients (46%) and between one and 6 months of pain relief was achieved in 7/30 patients (23.3%). Nine patients (30.0%) had recurrence of the synovial cyst requiring repeat rupture and 6 patients (20.0%) required surgical intervention for cyst removal. A Wilcoxon signed-rank test demonstrated that the difference in numeric pain rating scale scores before and after the procedure was statistically significant (P < 0.0001). The average pain reduction was 71.2%. No complications were reported. LIMITATIONS: The results are limited by the retrospective nature of the data collection and the lack of detailed information regarding patients' functional improvement. CONCLUSIONS: Rupture of percutaneous lumbar synovial cysts in patients with lumbar radiculopathy was associated with immediate relief of radicular symptoms. In 80% of the patients, synovial cyst rupture eliminated the need for surgical interventions over the measured term. This minimally invasive procedure helps relieve pain in a subset of a patient population associated with these characteristics and is useful for management of this condition. Cyst expansion and failure to rupture with possible neuronal compression are the potential complications of this procedure. This complication did not occur in the study population. KEY WORDS: Fluoroscopically guided lumbar synovial cyst rupture, lumbar synovial cyst, lumbar zygapophyseal joint cyst, nonsurgical intervention, radiculopathy, spondylosis.

Cervical Transforaminal Epidural Steroid Injections: Diagnostic and Therapeutic Value.

BACKGROUND: Cervical transforaminal epidural steroid injections (CTFESIs) may help decrease pain and restore function in patients with cervical radiculopathy. Evidence of the injections' effectiveness, however, remains controversial, and multiple case reports have identified potential complications. Such reports have led to diminished interest in including the procedure in patient care algorithms. OBJECTIVES: Our retrospective analysis aims to evaluate the CTFESI-associated pain relief and possible decreased need for spine surgery, along with its potential predictive role in determining cervical surgical outcomes. Finally, our study intends to estimate associated complications. METHODS: A pain management database registry was used to identify patients who were referred by spine surgeons for diagnostic CTFESIs in preparation for possible surgery between January 2001 and December 2009. Outcomes were defined as the incidence of cervical surgery after diagnostic injection and the associated pain relief. A Poisson distribution was used to obtain a 95% confidence interval for the incidence of complications. RESULTS: Sixty-four patients met the inclusion and exclusion criteria. After diagnostic CTFESIs, 45 (70.3%) of the observed 64 patients did not require cervical spine surgery whereas 19 (29.7%) still did. The mean pain reduction was 4.4 units on the numeric rating scale, with no observed complications. CONCLUSIONS: This retrospective analysis further demonstrates the safety, diagnostic value, and possible therapeutic role of CTFESIs. A larger, controlled, randomized study is needed to assess definitively the procedure's efficacy and safety.

Chronic intermittent hypoxia is independently associated with reduced postoperative opioid consumption in bariatric patients suffering from sleep-disordered breathing.

BACKGROUND: Evidence suggests that recurrent nocturnal hypoxemia may affect pain response and/or the sensitivity to opioid analgesia. We tested the hypothesis that nocturnal hypoxemia, quantified by sleep time spent at an arterial saturation (SaO2) < 90% and minimum nocturnal SaO2 on polysomnography, are associated with decreased pain and reduced opioid consumption during the initial 72 postoperative hours in patients having laparoscopic bariatric surgery. METHODS: With Institutional Review Board approval, we examined the records of all patients who underwent laparoscopic bariatric surgery between 2004 and 2010 and had an available nocturnal polysomnography study. We assessed the relationships between the time-weighted average of pain score and total opioid consumption during the initial 72 postoperative hours, and: (a) the percentage of total sleep time spent at SaO2 < 90%, (b) the minimum nocturnal SaO2, and (c) the number of apnea/hypopnea episodes per hour of sleep. We used multivariable regression models to adjust for both clinical and sleep-related confounders. RESULTS: Two hundred eighteen patients were included in the analysis. Percentage of total sleep time spent at SaO2 < 90% was inversely associated with total postoperative opioid consumption; a 5-%- absolute increase in the former would relatively decrease median opioid consumption by 16% (98.75% CI: 2% to 28%, P = 0.006). However, the percentage of total sleep time spent at SaO2 < 90% was not associated with pain. The minimum nocturnal SaO2 was associated neither with total postoperative opioid consumption nor with pain. In addition, neither pain nor total opioid consumption was significantly associated with the number of apnea/hypopnea episodes per hour of sleep. CONCLUSIONS: Preoperative nocturnal intermittent hypoxia may enhance sensitivity to opioids.

Relationship between chronic intermittent hypoxia and intraoperative mean arterial pressure in obstructive sleep apnea patients having laparoscopic bariatric surgery.

BACKGROUND: Recurrent nocturnal hypoxemia in obstructive sleep apnea enhances sympathetic function, decreases baroreceptor sensitivity, and weakens peripheral vascular responses to adrenergic signals. The authors hypothesized that the percentage of total sleep time spent at oxyhemoglobin saturation (SaO2) less than 90% and minimum nocturnal SaO2 on preoperative polysomnography are associated with decreased intraoperative mean arterial pressure. METHODS: The authors examined the records of all patients who had laparoscopic bariatric surgery at Cleveland Clinic between 2005 and 2009 and an available polysomnography study. The authors assessed the relationships between the percentage of total sleep time spent at SaO2 less than 90% and minimum nocturnal SaO2, and the time-weighted average of mean arterial pressure. The authors used multivariable regression models to adjust for prespecified clinical confounders. RESULTS: Two hundred eighty-one patients were included in the analysis. The average change in the time-weighted average of mean arterial pressure was -0.02 (97.5% CI, -0.08, 0.04) mmHg for each 1% absolute increase in the percentage of sleep time spent at SaO2 less than 90% (P = 0.50). The average change was -0.13 (97.5% CI, -0.27, 0.01) mmHg, for each 1% absolute decrease in the minimum SaO2 (P = 0.04 > significance criterion of 0.025, Bonferroni correction). An unplanned analysis estimated 1% absolute decrease in minimum SaO2 was associated with -0.22 (98.75% CI, -0.39, -0.04) mmHg, change in mean arterial pressure (P = 0.002) in the time period between endotracheal intubation and trocar insertion. CONCLUSION: Recurrent nocturnal hypoxemia in obstructive sleep apnea is not a risk marker for intraoperative hypotension.

Double-Opposing Z-Palatoplasty for Secondary Surgical Management of Velopharyngeal Incompetence in the Absence of a Primary Furlow Palatoplasty.

OBJECTIVE: The present study was performed to identify factors that lead to a favorable outcome of postpalatoplasty velopharyngeal incompetence using the double-opposing Z-palatoplasty. DESIGN: A retrospective analysis was performed on 23 consecutive nonsyndromic patients who underwent secondary surgical management of velopharyngeal incompetence using a double-opposing Z-palatoplasty technique following primary, non-Furlow palatoplasty for overt cleft palate. MAIN OUTCOME MEASURES: All subjects were evaluated preoperatively using a perceptual speech assessment scale, nasendoscopy, and videofluoroscopy. Inclusion criteria consisted of a velopharyngeal gap of 9 mm or less on phonation. Patients were followed with perceptual speech assessment for at least 1 year following secondary surgery. RESULTS: The perceptual speech assessment score for all patients decreased from 6.48 ± 2.26 (mean ± standard deviation; range, 3 to 11) to 1.90 ± 1.51 (range, 0 to 6) at 6 months or more postoperatively (P < .0001). Of the 21 patients with follow-up data 1 year or more post-op, 16 (76%) achieved velopharyngeal competence and five (24%) had borderline competence. Preoperative assessment factors associated with compromised outcome included a large velopharyngeal gap of 7 to 9 mm, poor lateral wall motion of 40% or less, and an elevated perceptual speech assessment score. CONCLUSION: Double-opposing Z-palatoplasty is a surgical technique that can be used successfully to correct velopharyngeal incompetence in selected secondary palatoplasty patients. This technique permits correction of velopharyngeal incompetence and restoration of the velopharyngeal mechanism irrespective of prior intravelar veloplasty and without accompanying loss in the nasal airway. Preoperative assessment can better identify those patients who are less likely to achieve velopharyngeal competence following double-opposing Z-palatoplasty alone.

An evaluation of a zero-heat-flux cutaneous thermometer in cardiac surgical patients.

BACKGROUND: Although core temperature can be measured invasively, there are currently no widely available, reliable, noninvasive thermometers for its measurement. We thus compared a prototype zero-heat-flux thermometer with simultaneous measurements from a pulmonary artery catheter. Specifically, we tested the hypothesis that zero-heat-flux temperatures are sufficiently accurate for routine clinical use. METHODS: Core temperature was measured from the thermistor of a standard pulmonary artery catheter and with a prototype zero-heat-flux deep-tissue thermometer in 105 patients having nonemergent cardiac surgery. Zero-heat-flux probes were positioned on the lateral forehead and lateral neck. Skin surface temperature probes were attached to the forehead just adjacent to the zero-heat-flux probe. Temperatures were recorded at 1-minute intervals, excluding the period of cardiopulmonary bypass, and for the first 4 postoperative hours. Zero-heat-flux and pulmonary artery temperatures were compared with bias analysis; differences exceeding 0.5°C were considered to be potentially clinically important. RESULTS: The mean duration in the operating room was 279 ± 75 minutes, and the mean cross-clamp time was 118 ± 50 minutes. All subjects were monitored for an additional 4 hours in the intensive care unit. The average overall difference between forehead zero-heat-flux and pulmonary artery temperatures (i.e., forehead minus pulmonary artery) was -0.23°C (95% limits of agreement of ±0.82); 78% of the differences were ≤0.5°C. The average intraoperative temperature difference was -0.08°C (95% limits of agreement of ±0.88); 84% of the differences were ≤0.5°C. The average postoperative difference was -0.32°C (95% limits of agreement of ±0.75); 84% of the differences were ≤0.5°C. Bias and precision values for neck site were similar to the forehead values. Uncorrected forehead skin temperature showed an increasing negative bias as core temperature decreased. CONCLUSIONS: Core temperature can be noninvasively measured using the zero-heat-flux method. Bias was small, but precision was slightly worse than our designated 0.5°C limits compared with measurements from a pulmonary artery catheter.

The frequency of surgical maneuvers during open rhinoplasty.

BACKGROUND: The improved exposure afforded by the external rhinoplasty approach has allowed for more precise surgical maneuvers and makes more consistent results possible. This study examines the frequency and array of surgical maneuvers during primary aesthetic rhinoplasty in a single surgeon's practice. METHODS: A retrospective review of 100 consecutive primary external cosmetic rhinoplasty patients with a minimum follow-up of approximately 1 year was conducted. Surgical maneuvers were reviewed and tabulated. Special attention was devoted to the number of cartilage grafts and suturing techniques used. Operative times and incidence of revision surgery were investigated. RESULTS: The mean duration of surgery was 1 hour 50 minutes. The majority of rhinoplasties involved concomitant septal surgery for deviation and airway occlusion or cartilage harvesting. Osteotomies were performed on over 95 percent of patients. The dorsal hump was removed on 84 percent of the patients. The most common grafts used included alar rim grafts in 88 percent, subdomal grafts in 77 percent, and spreader grafts in 74 percent. Sutures used to contour the cartilage included transdomal sutures in 62 percent, followed by footplate approximation sutures in 32 percent. Seventy-seven patients had interdomal sutures placed as a component of subdomal grafting. CONCLUSIONS: The senior surgeon has found that common incorporation of certain maneuvers offers more consistent, aesthetically pleasing, and superior functional outcomes. Careful review of this article may guide the reader to consider the more frequent use of some maneuvers or reduction of other maneuvers to reflect that of a streamlined and higher-volume rhinoplasty practice.

Nonviral transfection of mouse calvarial organ in vitro using Accell-modified siRNA.

BACKGROUND: Understanding the biology of cranial suture fusion and the precise role of involved molecules implicated in the process will help to identify key factors involved in regulation of suture fusion. Modulation of these key factors may serve as a tissue-engineering technique to replace the traditional surgical procedures for the correction of premature suture fusion. Modulation of gene expression by RNA interference is a widely used technique with high potential. Because there is no available report of calvarial organ transfection in vitro, the authors studied the development of a successful nonviral delivery technique of small inhibitory RNA (siRNA) to an in vitro calvarial organ culture system. METHODS: In this study, 19-day-old male CD1 mice were euthanized and parallel craniotomies made through the parietal and frontal calvaria, 2 mm to either side of the sagittal suture, with care taken to preserve the underlying dura mater. Organs grown in vitro in a defined medium were transfected with transforming growth factor-beta1-specific Accell-modified siRNA followed by RNA isolation and quantitative polymerase chain reaction analysis. RESULTS: Transfection of a calvarial organ with transforming growth factor-beta1-specific Accell-modified siRNA effectively knocks down the mRNA level. CONCLUSIONS: Observations from this study indicate that in an in vitro calvarial organ culture system, a specific, efficient, and durable RNA interference activity can be achieved when Accell-modified siRNA is used. In addition to bypassing the need for toxic lipid carriers, the modifications introduced in Accell-modified siRNAs make it more stable and less off-target. This technique can potentially be used for in vivo studies once the initial effect of gene-specific siRNA on in vitro suture fusion has been determined.

Tranquilli-Leali or Atasoy flap: an anatomical cadaveric study.

BACKGROUND: The Tranquilli-Leali and Atasoy volar V-Y advancement flaps are considered workhorse flaps in the reconstruction of fingertip amputations. However, their description in the literature in terms of surgical dissection and blood supply is often indistinct. This study describes the differences between the two flaps and highlights their unique blood supply based on a thorough cadaveric study and review of the literature. METHODS: Using 16 fresh cadaveric fingers, eight Tranquilli-Leali and eight Atasoy volar V-Y advancement flaps were dissected, mapping the arterial blood supply using an injectable blue resin. In addition, a thorough literature search on the subject was done. RESULTS: In all eight fingertips dissected as decribed by Tranquilli-Leali, the flap was supplied by the anastomotic connections between the terminal branches of the palmar digital arteries and dorsal nail-bed arcades via the fibro-osseous hiatus. In contrast, in all eight fingertips which were dissected as described by Atasoy, the flaps were perfused through the terminal branches of the palmar digital arteries. CONCLUSIONS: The Tranquilli-Leali and Atasoy volar V-Y advancement flaps, used to reconstruct fingertip amputations, are distinct from one another in several ways. The most obvious difference is their technique of flap dissection, which, in turn, dictates a unique blood supply. Through careful dissection and a review of the literature, this anatomical study has brought to light the specific vascular supply to each flap that was evaluated.