Anatomical relationship of Roos' type 3 band and the T1 nerve root.

BACKGROUND: The most common clinical presentation of thoracic outlet syndrome stems from compression of the lower trunk of the brachial plexus or ulnar nerve. A plethora of anatomical variations have been implicated in the cause of thoracic outlet syndrome. Roos' identification and classification of scalene muscle and fibrous bands have added an additional dimension to understanding its cause and subsequent treatment. Understanding the anatomy and relationship of this band with the lower trunk of the brachial plexus is of paramount importance. METHODS: As part of the authors' long-term study of the type 3 band in relation to the brachial plexus, 70 embalmed cadavers were dissected to yield 100 first thoracic ribs. Fibrous bands, when present, were studied in relation to the brachial plexus. RESULTS: A fibrous band consistent with Roos' type 3 was identified and found to occur in 35 percent of first ribs and 41 percent of cadavers. The mean size was 3.45 × 0.27 cm. Origins and insertions are described. Contrary to Roos' own description, however, the authors observed that Roos' type 3 band was anterior to the T1 nerve root, creating a tunnel through which the T1 nerve root must pass before joining the C8 nerve root. CONCLUSIONS: The authors believe that the type 3 band, when present, can create a tunnel that compresses the T1 nerve root against the first rib, potentially predisposing susceptible individuals to thoracic outlet syndrome. Clinical studies are needed to determine whether correlations between type 3 bands and thoracic outlet syndrome exist.

The use of an innovative device for wound closure after upper extremity fasciotomy.

INTRODUCTION: The purpose of this paper is to evaluate the Silver Bullet Wound Closure Device (SBWCD, Boehringer Laboratories, Norristown, PA), a new device for delayed primary closure of fasciotomy wounds. MATERIALS AND METHODS: A retrospective review was performed over a period of 36 months of all patients with an upper extremity fasciotomy that could not be closed primarily. Cases that underwent fasciotomy closure with the SBWCD were separated from the patients that had a split thickness skin graft (STSG). RESULTS: Seven patients had their wound closed with the SBWCD within 10 days (mean of 7.4 days). The seven patients that underwent STSG had their wound closed in an average of 8.4 days. The average number of days between the day of the fasciotomy incision and the date of the placement of the SBWCD was 1.9 days. STSGs were placed on the fasciotomy wounds on an average of 10.3 days after the date of the fasciotomy incision. We found that the SBWCD allowed for starting to approximate the edges of the fasciotomy wound at an earlier time when compare to STSG (2.1 vs 10.3 days). CONCLUSIONS: We feel that the SBWCD as a one-stage procedure provides a consistent and efficacious way to manage upper extremity fasciotomy wounds while minimizing the morbidity associated with STSG. Elimination of a second-stage procedure reduces hospital costs. Our findings may help to inform surgeons about an available alternative when an upper extremity fasciotomy wound is not amenable to primary closure.

Increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus in hand infections at an urban medical center.

BACKGROUND: The purpose of this article is to report the increased incidence of community-acquired methicillin-resistant S. aureus in hand infections at an urban medical center. METHODS: The authors performed a retrospective review of all patients with hand infections over a 21-month period, and all patients with culture-positive methicillin-resistant S. aureus were identified. Cases determined to be nosocomial were excluded. The study period was divided into three 7-month periods. RESULTS: A total of 343 hand infections were treated over a 21-month period. Eighty-nine patients (26 percent) with culture positive methicillin-resistant S. aureus were identified; of these, 75 were determined to be community-acquired methicillin-resistant S. aureus patients. Statistical analysis was performed using the Fisher's exact test (p < 0.0001), the chi-square test for equal proportions, the Cochran-Armitage trend test, and two-way analysis of variance. The demographics of the patients were compared using two-way analysis of variance, and patients were found to be similar in all three time periods with respect to mean age and sex. The incidence of community-acquired methicillin-resistant S. aureus increased to 40 percent during the last 7-month period compared with 14 percent during the first two periods. Overall, the incidence of methicillin-resistant S. aureus increased to 47 percent during the last 7 months compared with 16 percent and 17 percent in the first two 7-month periods, respectively. Based on their treatment approach and literature review, the authors have developed an algorithm to treat community-acquired methicillin-resistant S. aureus hand infections. CONCLUSIONS: The authors' findings at Temple University Hospital may help to alert health care providers to take necessary steps to control the spread of methicillin-resistant S. aureus in the community and in the inpatient setting. Cultures should be carefully followed and infections should be treated with appropriate antibiotics.

Recalcitrant chest wall Aspergillus fumigatus osteomyelitis after coronary artery bypass grafting: successful radical surgical and medical management.

This report describes a 62-year-old male diabetic patient with persistent chest wall osteomyelitis that developed after repeat coronary artery bypass grafting. The chronic infection was localized to the right anterior chest wall and refractory to medical and surgical treatment including long-term antiobiotics, five separate intraoperative debridements, and reconstruction with vascularized omentum over a two-year period at outside institutions. Aggressive surgical debridement with flap reconstruction resulted in definitive management. The organism isolated from multiple intraoperative bone, cartilage, and tissue cultures yielded Aspergillus fumigatus; therapy with itraconazole was utilized for 6 months. Surgical management of osteomyelitis and costochondritis is reviewed accompanied by a literature review on this uncommon cause of chronic chest wall infection.

Frontal sinus obliteration with beta-tricalcium phosphate .

Autogenous materials are considered the gold standard when indicated for frontal sinus obliteration; however, alloplastic alternatives obviate the need for a second surgical site, eliminate donor site morbidity, and reduce operating room time. A variety of different alloplastic materials have been used for this purpose, but no report to date has described the use of pure beta -tricalcium phosphate synthetic bone. This case report describes the technique and successful use of this product for frontal sinus obliteration in a severely comminuted anterior table and nasofrontal duct injury. The product warrants consideration as a viable alternative to standard autogenous and alloplastic substrates for frontal sinus obliteration.

Composite plate and wire fixation for complicated sternal closure.

Many techniques have been described to achieve closure of complicated median sternotomy wounds. The standard method of closure uses stainless steel wiring of the sternal halves; however, in complicated sternal closures, sternal cut-through and wire failure can occur. Recent literature advocates the use of fixation plates that achieve bony union, with plating across the median sternal osteotomy site as a singular method. We describe a technique of composite closure using titanium fixation plates to buttress the sternum in combination with circumferential stainless steel wires. This composite technique has been used in 6 patients with complicated sternal closures. Successful wound closure without complication was achieved in all cases. The technique and the clinical series with an illustrative example are presented. The use of plate and wire fixation represents an alternate method to conventional techniques to achieve sternal closure, stability, and uncomplicated wound healing in these difficult-to-manage cases.