Craniofacial Trauma from Electronic Scooter Use.

BACKGROUND: In 2018, the City of Providence introduced a program in which electronic scooters were deployed for public use. We aim to characterize the burden of craniofacial injuries associated with these scooters. METHODS: A retrospective review was conducted of all patients consulted to the plastic surgery service for evaluation of craniofacial injury between September 2018 and October 2022. Data pertaining to patient sociodemographics, site and time of injury, and craniofacial trauma were recorded. RESULTS: Twenty-five patients sustaining craniofacial trauma were identified over a four-year period. Most patients required soft tissue repair (64%) and bony fractures were sustained by approximately half of all patients (52%). Admission to ICU was uncommon (16%), and there were no fatalities. CONCLUSIONS: The incidence of craniofacial injury from electronic scooter use is low. However, these injuries may involve extensive surgical reconstruction and ICU admission. We advise the City of Providence to optimize best safety practices and monitoring to minimize risk.

Short-term outcomes following open gluteus maximus transfer for the management of hip abductor tears.

Tears of the gluteus medius and minimus are an important cause of recalcitrant greater trochanteric pain syndrome. Although endoscopic and open abductor repairs have demonstrated promising outcomes, the success of these techniques is dependent on the size of the tear and the quality of the tissue. In patients presenting with abductor insufficiency and evidence of previous repair failure, large retracted tears, muscle atrophy and/or fatty infiltration, reconstruction/augmentation techniques should be considered. In the present study, we present a retrospective cohort study assessing patient outcomes following open gluteus maximus transfer for irreparable or severely retracted gluteus medius tears. Patients were included in the present study if they underwent open gluteus maximus transfer to address hip abductor tears that a senior surgeon deemed irreparable or at high risk for failure following isolated repair secondary to the following tear characteristics: large tears with >2 cm of retraction, the presence of extensive fatty infiltration (Goutallier Grade 3 or greater) and/or patients requiring revision abductor repair due to primary repair failure with associated pain and a Trendelenburg gait. Patients undergoing a concomitant, or those with a previous history of hip arthroplasty, were excluded from the study. All participants were prospectively enrolled in the study, and both pre- and post-operative patient-reported outcomes were collected at 6 months and 1 year including the modified Hip Harris Score, Visual Analog Score, Hip Outcomes Score of Activities Daily Living, Hip Outcomes Score for Sports-Related Activities and Overall Satisfaction with Hip. Pre-operative scores were compared with post-operative assessments using Student's t-test with a significance level of P < 0.05. Twenty-one patients and 22 hips were included. The average age was 69 (SD ±9.2) and 17 (81%) were females. The average body mass index was 30.0 (±6.2). The outcome scores at both 6 months and 1 year demonstrated significant improvements compared with pre-operative functional assessment. This article reports the utility of gluteus medius/minimus repair augmentation or reconstruction via gluteus maximus transfer demonstrating improvement in patient-reported outcomes at short-term follow-up.

Refining Indications for Orbital Floor Fracture Reconstruction: A Risk-Stratification Tool Predicting Symptom Development and Need for Surgery.

BACKGROUND: Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation. METHODS: The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures. RESULTS: One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02). CONCLUSIONS: The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Postnatal Sagittal Craniosynostosis: A Novel Presentation and Considerations in Diagnosis and Management.

ABSTRACT: Sagittal craniosynostosis results in scaphocephaly from abnormal fusion of the sagittal suture. Traditionally, craniosynostosis presents at birth and is diagnosed within the first year of life. The authors report a patient with development of sagittal craniosynostosis after birth, which we term postnatal sagittal craniosynostosis. This is a rare occurrence in which management considerations are critical but are not well discussed. A 3-year-old boy presented with concerns of a metopic ridge. Workup revealed metopic ridging and an open sagittal suture. The patient later developed signs of increased intracranial pressure and repeat computed tomography scan 14 months later identified a newly fused sagittal suture. The patient underwent open posterior cranial vault expansion, resulting in resolution of symptoms. Postnatal sagittal craniosynostosis is a rare condition and should be considered in otherwise unexplained increases in increased intracranial pressure among pediatric patients. Open posterior cranial vault expansion represents a safe and effective method to treat this condition.

Eosinophilic Polymyositis: A Rare Cause of Atraumatic Compartment Syndrome of the Forearm.

Background Eosinophilic polymyositis is a rare disorder in which eosinophils infiltrate muscle and supporting connective tissue structures, resembling autoimmune or immunologically mediated disease. This disorder can be associated with muscle inflammation and death, and can be a cause of atraumatic compartment syndrome. Methods This is a retrospective chart review of a case report as well as review of pertinent literature. Results This report presents a rare case of atraumatic compartment syndrome of the forearm caused by eosinophilic polymyositis. It provides a case summary and histological examination of this patient. Conclusion This is an important case to report because it highlights eosinophilic polymyositis as a unique etiology of compartment syndrome. In appropriate clinical situations where patients do not improve despite standard interventions, one should consider the rare and unusual etiology of compartment syndrome due to eosinophilic polymyositis. Furthermore, primary surgical intervention should not be delayed while waiting to ascertain a definitive diagnosis.

Quantification of Nasal Septal Deviation With Computed Tomography Data.

BACKGROUND: Despite extensive literature on the classification and management of nasal septal deviation (NSD) for preoperative planning, standardized objective measures to evaluate the NSD severity remains challenging. In this study, we quantitatively analyzed NSD to determine the most predictive two-dimensional (2D) computed tomography (CT)-landmark for overall three-dimensional (3D) septal morphology derived from nasal airway segmentation. METHODS: A retrospective study was conducted at a large academic center. One hundred four patients who underwent CT scans of the face were selected from a computer imaging database. Demographic variables were screened to ensure an equal number of men and women in different age groups. Digital Imaging and Communications in Medicine files were imported for 3D nasal cavity segmentation using 3D Slicer software. A volumetric analysis was performed to determine 3D NSD ratios. These values were compared to previously reported methods of obtaining objective 2D NSD measures using OsiriX and MATLAB software. Maximum deviation values were calculated using OsiriX, while the root mean square values were retrieved using MATLAB. Deviation area and curve to line ratios were both quantified using OsiriX and MATLAB. RESULTS: The data set consisted of 52 men and 52 women patients aged 20 to 100 years (mean = 58 years, standard deviation = 23 years). There was a strong correlation between 3D NSD ratio and maximum deviation (r = 0.789, P < 0.001) and deviation area (r = 0.775, P < 0.001). Deviation area (r = 0.563, P < 0.001), root mean square (r = 0.594, P < 0.001), and curve to line ratio (r = 0.470, P < 0.001) had a positive correlation of moderate strength. The curve to line ratio was not significant (r = 0.019, P = 0.85). CONCLUSIONS: The 2D CT-based NSD landmarks maximum deviation and deviation area were the most predictive of the severity of NSD from 3D nasal cavity segmentation. We present a robust open-source method that may be useful in predicting the severity of NSD in CT images.

A 3D printed suturing trainer for medical students.

BACKGROUND: Medical students must be able to suture competently upon graduation. To learn suturing technique, students must have access to practice materials. The purpose of this pilot study was to develop a novel suturing trainer and to evaluate its ability to provide realistic and accessible suturing practice. A cohort of senior students at one institution compared the device with standard suture-training media (porcine feet and sponges). METHODS: Using 3D printing and silicone casting, a novel suturing trainer was developed and a cohort of senior medical students trialed the device in a standardised suturing workshop. Participants evaluated the novel suturing trainer, porcine feet and sponges for simulating human tissue with regard to: (i) tissue layers; (ii) tissue texture; (iii) ability to perform interrupted suturing; (iv) running subcuticular suturing; and (v) knot tying. RESULTS: Compared with porcine feet and sponges, the suturing trainer had significantly higher mean scores (p < 0.001) for the simulation of human tissue layers and texture, as well as for the ability to facilitate the practice of interrupted suturing, running suturing and knot tying. All (n = 32) participants identified the silicone trainer as the best tool upon which to practice suturing, and 92% (n = 23) responded that their suturing skills would improve if the silicone trainer replaced porcine feet and sponges. DISCUSSION: The silicone suturing device provides a more realistic and accessible suture learning experience than porcine feet and sponges. Further validation is required to assess its long-term effectiveness in medical education.

Functional return after implant-based breast reconstruction: A prospective study of objective and patient-reported outcomes.

BACKGROUND: There is sparse literature studying the functional morbidity of subpectoral implant- based breast reconstruction. We aimed to prospectively investigate this technique's impact on objective upper extremity function and patient-reported outcomes. METHODS: Women undergoing mastectomy and immediate subpectoral tissue expander insertion with ADM sling were enrolled from November 2014 to August 2016. Preoperative evaluation of shoulder range of motion, pectoralis major strength, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Breast-Q surveys were conducted before surgery and at 1 month and 6 months postoperatively, or until return to baseline pectoralis major strength. RESULTS: Eighteen women (mean age, 51 years, SD 9.6, range 35-72 years) comprising 26 breast reconstructions completed postoperative follow-up. The average follow-up length was 9 months (range, 3 -18 months; SD, 144 days). At 1-month follow-up, there was a statistically significant decrease in lower and non dominant upper fiber pectoralis strength from preoperative baseline (p < 0.05). At final postoperative follow-up, 24 reconstructions (92.3%) recovered to at least 80% of preoperative strength in upper and lower fibers. From preoperative to final postoperative follow-up, QuickDASH scores showed a statistically significant (p = 0.008) increase from 4.1 (range 0-20.5, SD 6.1) to 18.7 (range 0-45.5, SD 13.4). Physical well-being: The chest was the only Breast-Q domain in which the average score significantly decreased (p = 0.02) between preoperative assessment and final follow-up. CONCLUSIONS: After implant-based breast reconstruction, patients achieve the return of objective upper extremity function, but patient-reported outcomes do not return to baseline as shown by increased QuickDASH scores. Thus, pectoralis-sparing reconstructive strategies such as prepectoral implant insertion should be pursued.

Gangrenous cholecystitis: A silent but potential fatal disease in patients with diabetic neuropathy. A case report.

Gangrenous cholecystitis (GC) is a severe and potentially deadly complication of acute cholecystitis. We present a 83-year-old gentleman with a past medical history of type 2 diabetes mellitus with significant associated neuropathy, presenting to a community hospital in a major metropolitan area with 10 days nausea and vomiting and a benign abdominal exam. While the patient was admitted for hyperglycemia, he was subsequently found to have severe GC requiring urgent surgical intervention.

The Use of a Magnetic Port Finder in the Retrieval of Air Rifle BBs to the Upper Extremity.

Air-powered rifles shoot ball bearings with enough kinetic energy to penetrate skin and fracture underlying bones. In addition, there are reports of these ball bearings embolizing within the vascular network, causing serious injuries such as ischemic stroke with resultant blindness. The severity of these complications warrants occasional removal of these foreign bodies; however, they can be difficult to localize. In this case report, we describe the use of a magnetic port finder, a sterilizable tool used in breast reconstruction, to localize the foreign body in situ. We believe that this tool is effective at locating ferrous foreign bodies precisely, allowing for surgical retrieval while minimizing damage to surrounding tissue.

Characterizing infections in prosthetic breast reconstruction: A validity assessment of national health databases.

INTRODUCTION: Current guidelines in the United States require reporting only the 30-day postoperative outcomes to standardized databases, including the National Surgical Quality Improvement Program (NSQIP). Thus, many breast implant-related complications go unreported in standard databases. We sought to characterize late periprosthetic infections following implant-based breast reconstruction. METHODS: We conducted a retrospective analysis of all women who underwent expander/implant reconstruction from 2005 to 2014 at two institutions. All periprosthetic infections were identified and divided into early and late cohorts (≤30 days or >30 days). Infection was defined as any episode where antibiotics were initiated or a prosthetic device was explanted because of clinical evidence of the infection. RESULTS: In the 1820 patients (2980 breasts) identified, 421 periprosthetic infections occurred (14%). Of these, 173 (41%) were early and 248 (59%) were late (mean time to infection = 66.4 ± 101.9 days). Patients with late infections were more likely to be current smokers or have diabetes than patients with early infections (p < 0.034 for both). Infections caused by gram-negative bacteria and antimicrobial-resistant strains of Staphylococcus were more common in the early infection group (p < 0.001 for both). Implant loss due to infection was more common in the late infection group (p = 0.037). DISCUSSION: Late periprosthetic infections following implant-based breast reconstruction are underestimated in national outcome databases and have unique risk factors and microbiology compared to early infections. A system-level change in reevaluating and redefining a timeline for tracking and treating implant infections is necessary, given the substantial morbidity associated with, and frequency of, late periprosthetic infections.

Pedicled Flap Closure as an Adjunct for Infected Ventricular Assist Devices.

PURPOSE: End-stage cardiac disease has resulted in an increased utilization of cardiac transplantation or long-term mechanical assistance to sustain life. Though left ventricular assist devices (LVAD) have revolutionized the treatment algorithm for these patients, these devices carry a substantial infection rate, ranging from 30% to 50%. We report our institution's experience with attempted flap salvage for infected and exposed LVADs. METHODS: A retrospective review for all LVAD-related infections treated with flaps at our institution from 2010 to 2015. RESULTS: Twenty flaps were performed in 15 patients during the study period. Average age was 54 years. There were 4 women and 11 men with average body mass index of 30.6. Surgery was indicated for LVAD motor or drive line exposure in the setting of infection in all cases. Rectus abdominus (n = 10), omentum (n = 6), pectoralis major (n = 3), and intercostal (n = 1) were used for coverage. Complications resulted in approximately 67% of cases including hematoma (n = 4), seroma (n = 3), cellulitis (n = 1), and total flap loss (n = 1). CONCLUSIONS: Left ventricular assist devices are lifesaving interventions for patients with severe cardiac disease but are associated with a high rate of infectious complications over time. Although device coverage carries a high rate of complications, no devices required exchange due to infection or failed attempts at salvage.

Tweens feel the burn: "salt and ice challenge" burns.

PURPOSE: To review our institution's experience with frostbite injury secondary to "salt and ice challenge" (SIC) participation. METHODS: We conducted a retrospective analysis of intentional freezing burns from 2012 to 2014. Demographics, depth and location of burn, total body surface area of burn, treatment, time to wound healing, length of stay, complications, and motives behind participation were analyzed. RESULTS: Five patients were seen in the emergency department for intentional freezing burns that resulted from SIC (all females; mean age: 12.3 years; range age: 10.0-13.2 years). Mean total body surface area was 0.408%. Salt and ice was in contact with skin for >10 min for two patients, >20 min for two patients, and an unknown duration for one patient. Complications included pain and burn scar dyschromia. Four patients cited peer pressure and desire to replicate SIC as seen on the Internet as their motivation in attempting the challenge. CONCLUSION: SIC has become a popular, self-harming behavior among youths. Increased public education, and provider and parent awareness of SIC are essential to address this public health concern.

Deep Venous Thrombosis in Teen With Crouzon Syndrome Post-Le Fort III Osteotomy With Rigid External Distraction.

Venous thromboembolic events are rare in pediatric patients. Risk factors associated with the development of venous thromboembolic events in pediatric patients include the use of central venous catheters, hospitalization, cancer, sepsis, trauma, surgery, and congenital prothrombotic disorders.The authors present the case of a 14-year-old man with Crouzon syndrome who required Le Fort III osteotomy with rigid external distraction for significant midface hypoplasia who presented postoperatively with an extensive deep venous thrombosis. This is the first reported case of symptomatic venous thrombosis post-Le Fort III osteotomy and rigid external distraction. Although rare, surgeons should be aware of this potential complication.

The Millard Rotation-Advancement Cleft Lip Repair: 50 Years of Modification.

Since its inception in 1955, Millard's rotation-advancement repair has been one of the most popular techniques used in the care of patients with a cleft lip. Over the past half century, Millard's repair has evolved and laid the foundation for many other repair techniques that have followed in its footsteps. This publication compares Millard's rotation-advancement technique to the various repairs used today. The purpose of this article is to lend perspective as to the impact of Millard repair over the past 50 years in the treatment of cleft lip.

Timing in the baby brain.

Ten-month-old infants and adults were tested in an auditory oddball paradigm in which 50-ms tones were separated by 1500 ms (standard interval) and occasionally 500 ms (deviant interval). Both infants and adults showed marked brain responses to the tone that followed a deviant inter-stimulus interval (ISI). Specifically, the timing-deviance event-related-potential (ERP) difference waves (deviant-ISI ERP minus standard-ISI ERP) yielded a significant, fronto-centrally distributed, mismatch negativity (MMN) in the latency range of 120-240 ms post-stimulus for infants and 110-210 ms for adults. A robust, longer latency, deviance-related positivity was also obtained for infants (330-520 ms), with a much smaller and later deviance-related positivity observed for adults (585-705 ms). These results suggest that the 10-month-old infant brain has already developed some of the same mechanisms as adults for detecting deviations in the timing of stimulus events.