Utility of the LeFort I Osteotomy in the Acute Management of Midface Trauma.

PURPOSE: Pure and isolated LeFort I, II, and III fractures are rare. Typically, they occur at different levels on each side and may be incomplete in nature, which complicates management. The LeFort I osteotomy is a well-described technique in elective management of midface deformities. However, there is minimal literature on its use in acute trauma. This study describes the use of the LeFort I osteotomy as a surgical maneuver to aid in the reduction of complex midface fractures and the re-establishment of premorbid occlusion. METHODS: A retrospective review was performed of all consecutive midface fractures managed at our center from 2008 to 2020. The inclusion criteria were adult patients who had a LeFort I osteotomy in the setting of acute fracture management. Primary outcomes were the long-term stability of fracture fixation and the re-establishment of stable, reproducible occlusion at follow-up. RESULTS: Twenty-two cases met the criteria for inclusion. The most common indication was contralateral LeFort I and ipsilateral incomplete or absent LeFort I (50%). Most remaining cases had a high LeFort (II or III) on the ipsilateral side and a high LeFort I on the contralateral side (41%). There was one case of nonunion requiring revision and bone grafting. In all remaining cases who presented for follow-up at an average of 1.5 years, stable, reproducible occlusion was achieved. CONCLUSIONS: In acute trauma, a LeFort I osteotomy is a safe and effective technique to re-establish premorbid occlusion when passive reduction of the maxilla cannot be achieved. This technique can be safely added to the armamentarium of any surgeon who manages acute craniofacial trauma.

Nerve Transfer Is Superior to Nerve Grafting for Suprascapular Nerve Reconstruction in Obstetrical Brachial Plexus Birth Injury: A Meta-Analysis.

BACKGROUND: Restoration of shoulder function in obstetrical brachial plexus injury is paramount. There remains debate as to the optimal method of upper trunk reconstruction. The purpose of this study was to test the hypothesis that spinal accessory nerve to suprascapular nerve transfer leads to improved shoulder external rotation relative to sural nerve grafting. METHODS: A systematic review of Medline, EMBASE, EBSCO CINAHL, SCOPUS, Cochrane Library, and TRIP Pro from inception was conducted. Our primary outcome was shoulder external rotation. RESULTS: Four studies were included. Nerve transfer was associated with greater shoulder external rotation relative to nerve grafting (mean difference: 0.82 AMS 95% confidence interval [CI]: 0.27-1.36, P < .005). Patients undergoing nerve grafting were more likely to undergo a secondary shoulder stabilizing procedure (odds ratio [OR]: 1.27, 95% CI: 0.8376-1.9268). CONCLUSION: In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery. LEVEL OF EVIDENCE: Level III; Therapeutic.

Revisiting Lunotriquetral Arthrodesis in Chronic Lunotriquetral Ligamentous Injuries.

Background Chronic lunotriquetral (LT) ligament tears are a source of ulnar-sided wrist pain. Left untreated, complete tears of the LT ligament may progress to a volar intercalated segment instability deformity and eventual carpal arthritis. Various treatments have been proposed, one of which is LT arthrodesis. LT arthrodesis has been criticized for high rates of nonunion frequently requiring reoperation, and therefore has largely fallen out of favor. However, our experience has been quite different from the literature. This study examines a single surgeon's experience with LT arthrodesis over a 15-year period. Methods A retrospective review of the senior author's practice over a 15-year period was performed. All adult cases of LT arthrodesis for chronic LT injuries were included. Headless compression screw and cancellous bone graft from the distal radius were used for primary arthrodesis in all cases. The primary outcome was rate of union, and secondary outcomes were time to union, secondary or salvage procedures, and range of motion. Nonparametric statistical analysis was used to calculate differences in outcomes. Results Twenty-eight patients met inclusion criteria. The median age was 45.5 (interquartile range [IQR] 35-50) years and 75% were male. The dominant hand was most commonly affected. Eighty-six percent of patients achieved union, one patient required redo arthrodesis, and one patient went on to wrist salvage. Three patients developed a pain-free pseudoarthrosis. Median time to radiographic union was 8.8 (IQR 5.9-11.9) weeks. Conclusion Despite multiple previous reports, this study demonstrates that LT arthrodesis for chronic LT injuries is a safe technique with high rates of successful union. Further comparative studies are warranted to determine the optimal treatment for chronic LT injuries.

Effect of magnification in pediatric liver transplantation: A systematic review and meta-analysis.

BACKGROUND: Hepatic artery thrombosis (HAT) represents a devastating and often fatal complication of liver transplantation. Due to the small vessel caliber in pediatric patients, the use of an operating microscope has largely become the standard for hepatic artery reconstruction to reduce the rate of HAT. Recent evidence, however, suggests that loupe magnification for anastomosis may be equally effective. We aimed to determine the effect of magnification on the rate of hepatic artery thrombosis in pediatric liver transplantation. METHODS: A systematic search of the literature was conducted. Thousand eighty-eight unique titles were assessed by two independent reviewers. Studies directly comparing rates of HAT from loupe magnification and operating microscope-assisted anastomoses were eligible for meta-analysis. RESULTS: Among primary transplants, the rate of HAT was 6.0%. Operating microscope anastomosis was associated with a 2.6% decrease in the rate of HAT compared to that of loupe magnification (4.9% and 7.4%, respectively, p < .040). When re-transplants were included, the rate of HAT was 5.8%. Operating microscope anastomosis was associated with a 1.0% decrease in the rate of HAT compared to that of loupe magnification (5.3% and 6.3%, respectively, p < .279). Meta-analysis of eligible studies demonstrated a reduction in the rate of HAT with the use of an operating microscope (p < .03). CONCLUSIONS: Anastomosis under an operating microscope may be associated with decreased rates of HAT in children undergoing primary liver transplantation. Further high-quality studies comparing the two techniques are needed.

One or two venous pedicles by anastomoses for free flaps in reconstruction of the lower extremity: A systematic review and meta-analysis.

BACKGROUND: Microsurgical free tissue transfers are a mainstay of lower extremity reconstruction. Despite being a reliable source of soft tissue, complications do arise. Venous congestion is among the most common causes of flap failure in lower extremity reconstruction, an issue that is attributed to venous stasis and impaired venous return in this region. There remains significant debate whether dual venous drainage improves outcomes. The aim of this study was thus to compare one versus two venous anastomoses in lower limb free flap reconstruction. METHODS: A systematic review of Medline, EMBASE, EBSCO CINAHL, SCOPUS, Proquest Dissertations and Theses Global, Cochrane Library, and PROSPERO from inception to May 20, 2020, was conducted. Two independent reviewers screened titles and extracted data. Our primary outcome was total free flap necrosis. Secondary outcomes were partial flap necrosis, minor complications, flap reoperation, venous thrombosis, and amputation. Methodological quality was assessed using the MINORS criteria and level of evidence. RESULTS: Three-hundred and fourteen unique titles were identified. All studies were level VI evidence and had a mean MINORS score of 16.1/24. Seven studies (comprising 1499 patients, 910 single venous anastomoses, and 579 double venous anastomoses) met criteria for inclusion. The mean (SD) patient age was 46.5 (7.1) years. Double venous anastomoses did not reduce the rate of minor complications, flap takeback, venous thrombosis, total flap necrosis, or partial flap necrosis when compared to a single vein (all p > .05). CONCLUSION: In microvascular lower extremity reconstruction, two venous anastomoses did not reduce the rate of minor or major complications.

The Transition to Microsurgical Technique for Hepatic Artery Reconstruction in Pediatric Liver Transplantation.

BACKGROUND: Hepatic artery thrombosis represents a potentially fatal complication following liver transplantation. Rates of hepatic artery thrombosis are significantly higher in children, with mortality reported up to 80 percent. Microsurgical anastomosis has been shown to decrease the rate of hepatic artery thrombosis and now represents the standard of care at the authors' institution. In this article, the authors present the largest study of its type directly comparing rates of hepatic artery thrombosis with and without microsurgical reconstruction of the hepatic artery. METHODS: All pediatric patients who underwent primary orthotopic liver transplantation between 1989 and 2018 were included. Patients were divided into two cohorts: standard anastomosis with loupes, and microsurgical anastomosis under the operating microscope. The authors' primary outcome was the rate of hepatic artery thrombosis. Secondary outcomes were graft survival, patient survival, retransplantation rate, requirement for intraoperative blood products, and length of stay. RESULTS: Two hundred thirty-one children met criteria for inclusion. One hundred eighty cases were performed with loupe magnification and 51 cases were performed under the microscope. The hepatic artery thrombosis rate was lower, but not significantly so (p = 0.114), in the microsurgical group [n = 1 (2.0 percent)] compared with the standard cohort [n = 15 (8.3 percent)]. Survival analysis revealed a significant increase in graft survival with microsurgical anastomosis (p = 0.020), but not patient survival (p = 0.196). The retransplantation rate was significantly lower with microsurgical anastomosis (p = 0.021). CONCLUSIONS: Microsurgical anastomosis was associated with a clinically important decrease in hepatic artery thrombosis compared with standard loupe anastomosis. The graft survival rate was significantly higher in the microsurgical cohort, with a reduced retransplantation rate at 1 year. On this basis, the authors recommend microsurgical hepatic artery anastomosis in cases of pediatric liver transplantation. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Demographics and clinical outcomes of adult burn patients admitted to a single provincial burn centre: A 40-year review.

INTRODUCTION: This study evaluated trends in demographics and outcomes of cutaneous burns over a forty-year period at a Canadian burn centre. METHODS: Retrospective review was performed of all consecutive adult burn admissions to the Vancouver General Hospital (VGH) between 1976 and 2015. Comparison was made to the 2016 American Burn Association - National Burn Repository. RESULTS: There were 4105 admissions during study period. Both overall admissions and admissions per 100,000 BC residents declined (p < 0.0001). Males represented three quarters of admissions. There was a decrease in large burns (p < 0.05). Flame burns were most commonly associated with larger TBSA, ICU stays, and mortality. Mortality decreased from 11.3% to 2.8% (p < 0.05). Factors found to affect mortality included: increased length of stay, age and burn size, male gender, and number of complications. Baux50 and rBaux50 increased, from 102.8 to 116.7 and 112.2 to 125.3 respectively (p < 0.05, respectively). CONCLUSIONS: This study represents the largest report on burn epidemiology in Canada. The incidence of burns has decreased significantly over the last forty years. Mortality has improved over this time frame, as evident by increases in Baux50 and rBaux50 scores. Further data is largely in concurrence with that of the National Burn Repository's amalgamation of US centres.

Tissue Expansion for Severe Foot and Ankle Deformities: A 16-Year Review.

BACKGROUND: Tissue expansion in the lower extremity is controversial, with studies reporting complication rates as high as 83%. Few studies have looked at tissue expansion prior to orthopaedic correction of severe foot and ankle deformities, and those available are restricted to clubfoot in the pediatric population. Here, we report the largest case series on the use of tissue expanders for the reconstruction of severe foot and ankle deformity and the only report in adults. METHODS: This is a retrospective chart review of the senior author's practice over a 16-year study period. All patients over 18 years of age who underwent tissue expansion prior to definitive orthopaedic correction of a severe foot and ankle deformity were included. Patient demographics, etiology of deformity, rate of expansion, and complications were recorded. Major complications were defined as those which required surgical intervention. Data were analyzed using descriptive statistics. RESULTS: Nineteen cases were performed on 16 patients. Our overall complication rate was 31.6% (6/19), with major complications occurring in 21.1% (4/19) of cases, and minor complications occurring in 10.5% (2/19) of cases. Despite this, 94.7% (18/19) of cases went on to receive definitive orthopaedic correction after tissue expansion. No demographic parameters were associated with occurrence of complications. CONCLUSIONS: This represents the largest report on lower extremity tissue expansion for severe foot and ankle deformity correction. While we observed complications in 31.6% of patients, 94.7% of cases went on to receive definitive orthopaedic correction with successful primary closure.

HISTORIQUE: L'expansion tissulaire des membres inférieurs est controversée, car des études font état d'un taux de complications atteignant les 83 %. Peu d'études ont porté sur l'expansion tissulaire avant la correction orthopédique de graves déformations du pied et de la cheville, et celles qui existent se limitent au pied bot dans la population pédiatrique. Les auteurs rendent compte de la plus grande série de cas sur l'utilisation d'expandeurs tissulaires en vue de la reconstruction de graves déformations du pied et de la cheville, la seule à être menée chez des adultes. MÉTHODOLOGIE: La présente étude rétrospective traite des dossiers de l'auteur principal sur une période de 16 ans. Tous les patients de plus de 18 ans qui ont subi une expansion tissulaire avant la correction orthopédique définitive d'une grave déformation du pied et de la cheville en ont fait partie. Les chercheurs ont consigné la démographie des patients, l'étiologie des déformations, le taux d'expansion et les complications. Ils ont défini les complications majeures comme celles qui exigent une intervention chirurgicale. Ils ont analysé les données à l'aide de statistiques descriptives. RÉSULTATS: Les chercheurs ont relevé 19 cas chez 16 patients. Le taux de complications global s'élevait à 31,6 % (six cas sur 19). Des complications majeures se sont produites dans 21,1 % des cas (quatre sur 19) et des complications, mineures, dans 10,5 % des cas (deux sur 19). Malgré tout, 94,7 % des cas (18 sur 19) ont subi une correction orthopédique définitive après l'expansion tissulaire. Aucun paramètre démographique ne laissait présager les complications. CONCLUSIONS: La présente étude est le rapport le plus vaste des expansions tissulaires pour corriger de graves déformations du pied et de la cheville. Les auteurs ont observé des complications chez 31,6 % des patients, mais 94,7 % des cas ont profité d'une correction orthopédique définitive et d'une fermeture primaire réussie.

Effects of a single bout of exercise on arterial compliance in older adults.

The effects of acute exercise on arterial compliance in older adults are unknown. Large and small arterial compliance were assessed during and 24 hours following a 30-minute bicycle ergometer test and on a nonexercise, control condition. The change in large artery compliance was similar between the exercise and nonexercise conditions (P = 0.876). Small artery compliance during the exercise day was higher than the nonexercise day at 45, 60, and 75 minutes following exercise (P < .001), was 17% higher 30 minutes postexercise than at rest (P < .001), and decreased by 20% between 30 minutes (4.5 ± 0.4 mL/mm Hg × 100) and 120 minutes (3.6 ± 0.3 mL/mm Hg × 100) after exercise (P = .027). The current study shows 30 minutes of moderate-intensity exercise transiently increases small arterial compliance 30 minutes after exercise but does not elicit more sustained increases in either large or small arterial compliance.

Association between lower-extremity function and arterial compliance in older adults.

The purpose was to identify the association between lower-extremity function and arterial compliance in older men and women. Participants included 46 healthy men (n = 18) and women (n = 28) 60 years of age or older. Lower-extremity functional performance was assessed by the summary performance score (SPS) that includes tests of 5 timed repeated chair rises, standing balance, and 4-meter walking velocity. Arterial compliance and arterial pressure were analyzed through pulsewave analysis. Small arterial compliance (3.74 +/- 2.14; mean +/- SD) was related (r = 0.34, P = .028) to SPS (11.09 +/- 1.19) after adjusting for body surface area, hyperlipidemia, and hypertension. Systolic blood pressure (138 +/- 14) also was related to SPS (r = -0.314, P = .040). These results suggest diminished lower-extremity function is associated with decreased small arterial compliance and elevated arterial pressure in older men and women.

The influence of obesity on falls and quality of life.

OBJECTIVE: To determine (1) whether obese older adults had higher prevalence of falls and ambulatory stumbling, impaired balance and lower health-related quality of life (HRQL) than their normal weight counterparts, and (2) whether the falls and balance measures were associated with HRQL in obese adults. METHODS: Subjects who had a body mass index (BMI) greater than 30 kg/m2 were classified into an obese group (n = 128) while those with BMI between 18.5 and 24.9 kg/m2 were included into a normal weight group (n = 88). Functional tests were performed to assess balance, and questionnaires were administered to assess history of falls, ambulatory stumbling, and HRQL. RESULTS: The obese group reported a higher prevalence of falls (27% vs. 15%), and ambulatory stumbling (32% vs. 14%) than the normal weight group. Furthermore, the obese group had lower HRQL, (p < or = 0.05) for physical function (63 +/- 27 vs. 75 +/- 26; mean +/- SD), role-physical (59 +/- 40 vs. 74 +/- 37), vitality (58 +/- 23 vs. 66 +/- 20), bodily pain (62 +/- 25 vs. 74 +/- 21) and general health (64 +/- 19 vs. 70 +/- 18). In the obese group, a history of falls was related (p < or = 0.05) to lower scores in 4 domains of HRQL, and ambulatory stumbling was related (p < or = 0.01) to 7 domains. CONCLUSION: In middle-aged and older adults, obesity was associated with a higher prevalence of falls and stumbling during ambulation, as well as lower values in multiple domains of HRQL. Furthermore, a history of falls and ambulatory stumbling were related to lower measures of HRQL in obese adults.

The relationship between arterial elasticity and metabolic syndrome features.

The purpose of this study was to examine the effects of metabolic syndrome (MS) features on arterial elasticity of the large and small arteries in apparently healthy adults, to examine the effect of clustered features of MS, and to determine which features are most predictive of large and small artery elasticity. The subjects for this study consisted of 126 men and women, age 45 years and older. The subjects rested supine while pulse contour analysis was measured from the radial artery by using an HDI/Pulsewave CR-2000 instrument (Hypertension Diagnostic, Inc) to assess arterial elasticity in the large and small arteries. Medical history was obtained along with body mass index, waist circumference, body surface area, and blood pressure. Large artery elasticity was lower (p = 0.002) in subjects with hypertension (12.7 -/+ 4.3 mL/mm Hg x 10) than in those with normotension (15.0 -/+ 4.2 mL/mm Hg x 10; mean -/+ SD), and small artery elasticity was lower (p = 0.001) as well (3.9 -/+2.3 mL/mm Hg x 100 vs 5.3 -/+ 2.5 mL/mm Hg x 100). Large artery elasticity was lower (p = 0.02) in obese subjects (12.2 -/+ 4.9 mL/mm Hg x 10) than in nonobese subjects (14.2 -/+ 4.5 mL/mm Hg x 10), and large artery elasticity was lower (p = 0.04) in subjects with abdominal obesity (12.2 -/+ 4.5 mL/mm Hg x 10) than in those without (14.5 -/+ 4.8 mL/mm Hg x 10). Large artery elasticity decreased as the number of features of MS increased (p < 0.01). Multiple regression showed that body mass index and the presence of hypertension were predictors of large artery elasticity (R = 0.61, R2 = 0.37, p = 0.003, SEE = 3.60 mL/mm Hg x 10), and hypertension was a predictor of small artery elasticity (R = 0.53, R2 = 0.28, p = 0.001, SEE = 2.12 mL/mm Hg x 100). Hypertension and obesity are the features of MS that are most predictive of impairment in large and small artery elasticity in apparently healthy middle-aged and older adults. Furthermore, impairment in large artery elasticity is more evident in subjects with at least three features of MS.

The influence of obesity on calf blood flow and vascular reactivity in older adults.

OBJECTIVE: To determine whether differences in vascular reactivity existed among normal weight, overweight, and obese older men and women, and to examine the association between abdominal fat distribution and vascular reactivity. METHODS: Eighty-seven individuals who were 60 years of age or older (age = 69 +/- 7 yrs; mean +/- SD) were grouped into normal weight (BMI < 25; n = 30), overweight (BMI > or = 25 and < 30; n = 28), or obese (BMI > or = 30; n = 29) categories. Calf blood flow (BF) was assessed by venous occlusion strain-gauge plethysmography at rest and post-occlusive reactive hyperemia. RESULTS: Post-occlusive reactive hyperemia BF was lower (p = 0.038) in the obese group (5.55 +/- 4.67%/min) than in the normal weight group (8.34 +/- 3.89%/min). Additionally, change in BF from rest to post-occlusion in the obese group (1.93 +/- 2.58%/min) was lower (p = 0.001) than in the normal weight group (5.21 +/- 3.59%/min), as well as the percentage change (75 +/- 98% vs. 202 +/- 190%, p = 0.006, respectively). After adjusting for age, prevalence in hypertension and calf skinfold thickness, change in BF values remained lower (p < 0.05) in obese subjects compared to the normal weight subjects. Lastly, the absolute and percentage change in BF were significantly related to BMI (r = -0.44, p < 0.001, and r = -0.37, p < 0.001, respectively) and to waist circumference (r = -0.36, p = 0.001, and r = -0.32, p = 0.002). CONCLUSION: Obesity and abdominal adiposity impair vascular reactivity in older men and women, and these deleterious effects on vascular reactivity are independent of conventional risk factors.

Physical activity is related to quality of life in older adults.

BACKGROUND: Physical activity is associated with health-related quality of life (HRQL) in clinical populations, but less is known whether this relationship exists in older men and women who are healthy. Thus, this study determined if physical activity was related to HRQL in apparently healthy, older subjects. METHODS: Measures were obtained from 112 male and female volunteers (70 +/- 8 years, mean +/- SD) recruited from media advertisements and flyers around the Norman, Oklahoma area. Data was collected using a medical history questionnaire, HRQL from the Medical Outcomes Survey short form-36 questionnaire, and physical activity level from the Johnson Space Center physical activity scale. Subjects were separated into either a higher physically active group (n = 62) or a lower physically active group (n = 50) according to the physical activity scale. RESULTS: The HRQL scores in all eight domains were significantly higher (p < 0.05) in the group reporting higher physical activity. Additionally, the more active group had fewer females (44% vs. 72%, p = 0.033), and lower prevalence of hypertension (39% vs. 60%, p = 0.041) than the low active group. After adjusting for gender and hypertension, the more active group had higher values in the following five HRQL domains: physical function (82 +/- 20 vs. 68 +/- 21, p = 0.029), role-physical (83 +/- 34 vs. 61 +/- 36, p = 0.022), bodily pain (83 +/- 22 vs. 66 +/- 23, p = 0.001), vitality (74 +/- 15 vs. 59 +/- 16, p = 0.001), and social functioning (92 +/- 18 vs. 83 +/- 19, p = 0.040). General health, role-emotional, and mental health were not significantly different (p > 0.05) between the two groups. CONCLUSION: Healthy older adults who regularly participated in physical activity of at least moderate intensity for more than one hour per week had higher HRQL measures in both physical and mental domains than those who were less physically active. Therefore, incorporating more physical activity into the lifestyles of sedentary or slightly active older individuals may improve their HRQL.