Obesity and the Latissimus Dorsi Flap: A Radiologic Study.

Introduction: The increasing prevalence of obesity in patients with breast cancer has prompted a reappraisal of the role of the latissimus dorsi flap (LDF) in breast reconstruction. Although the reliability of this flap in obese patients is well-documented, it is unclear whether sufficient volume can be achieved through a purely autologous reconstruction (eg, extended harvest of the subfascial fat layer). Additionally, the traditional combined autologous and prosthetic approach (LDF + expander/implant) is subject to increased implant-related complication rates related to flap thickness in obese patients. The purpose of this study is to provide data on the thicknesses of the various components of the latissimus flap and discuss the implications for breast reconstruction in patients with increasing body mass index (BMI). Methods: Measurements of back thickness in the usual donor site area of an LDF were obtained in 518 patients undergoing prone computed tomography-guided lung biopsies. Thicknesses of the soft tissue overall and of individual layers (e.g., muscle, subfascial fat) were obtained. Patient, demographics including age, gender, and BMI were obtained. Results: A range of BMI from 15.7 to 65.7 was observed. In females, total back thickness (skin, fat, muscle) ranged from 0.6 to 9.4 cm. Every 1-point increase in BMI resulted in an increase of flap thickness by 1.11 mm (adjusted R2 of 0.682, P < .001) and an increase in the thickness of the subfascial fat layer by 0.513 mm (adjusted R2 of 0.553, P < .001). Mean total thicknesses for each weight category were 1.0, 1.7, 2.4, 3.0, 3.6, and 4.5 cm in underweight, normal weight, overweight, and class I, II, III obese individuals, respectively. The average contribution of the subfascial fat layer to flap thickness was 8.2 mm (32%) overall and 3.4 mm (21%), 6.7 mm (29%), 9.0 mm (30%), 11.1 mm (32%), and 15.6 mm (35%) in normal weight, overweight, class I, II, III obese individuals, respectively. Conclusion: The above findings demonstrate that the thickness of the LDF overall and of the subfascial layer closely correlated with BMI. The contribution of the subfascial layer to overall flap thickness tends to increase as a percentage of overall flap thickness with increasing BMI, which is favourable for extended LDF harvests. Because this layer cannot be separated from overall thickness on examination, these results are useful in estimating the amount of additional volume obtained from an extended latissimus harvest technique.

Introduction: La prévalence croissante d'obésité chez les patientes atteintes du cancer du sein a suscité une réévaluation du rôle du lambeau du grand dorsal (LGD) en reconstruction mammaire. La fiabilité de ce lambeau est bien établie en cas d'obésité, mais on ne sait pas si le volume suffit pour effectuer une reconstruction purement autologue (p. ex., prélèvement élargi de la couche adipeuse sous-aponévrotique). De plus, en cas d'obésité, la combinaison habituelle de l'approche autologue et prothétique (LGD+expanseur et implant) est liée à un taux de complications plus élevé lié aux implants à cause de l'épaisseur du lambeau. La présente étude visait à obtenir des données sur l'épaisseur des diverses parties du grand dorsal et à traiter des conséquences de la reconstruction mammaire chez les patientes ayant un IMC plus élevé. Méthodologie: Les chercheurs ont mesuré l'épaisseur du dos au siège habituel de prélèvement du LGD chez 518 patientes dans le cadre d'une biopsie pulmonaire orientée par tomodensitométrie en position couchée. Ils ont mesuré l'épaisseur globale du dos et l'épaisseur de chaque couche dans cette région. Ils ont également obtenu les données démographiques des patientes, y compris l'âge, le genre et l'IMC. Résultats: Les chercheurs ont observé une fourchette d'IMC de 15,7 à 65,7. Chez les femmes, l'épaisseur totale du dos (peau, adiposité, muscle) variait entre 0,6 et 9,4 cm. Chaque point ajouté à l'IMC est associé à une augmentation de l'épaisseur du lambeau de 1,11 mm (rapport de cote rajusté [RCR] de 0,682, p<0,001) et à une augmentation de l'épaisseur de la couche adipeuse sous-aponévrotique de 0,513 mm (RCR de 0,553, p<0,001). L'épaisseur totale moyenne pour chaque catégorie de poids correspondait à 1,0, 1,7, 2,4, 3,0, 3,6 et 4, cm chez les patientes en insuffisance pondérale, de poids normal, en surpoids et obèses de classe I, II et III, respectivement. L'apport moyen de la couche adipeuse sous-aponévrotique à l'épaisseur du lambeau était de 8,2 mm (32 %) globalement et de 3,4 mm (21 %), 6,7 mm (29 %), 9,0 mm (30 %), 11,1 (32 %) et 15,6 mm (35 %) chez les patientes de poids normal, en surpoids et obèses de classe I, II, III, respectivement. Conclusion: Les résultats précédents démontrent que l'épaisseur globale du LGD et de la couche sous-aponévrotique est étroitement liée à l'IMC. L'apport de la couche sous-aponévrotique a tendance à être proportionnel à l'IMC en pourcentage de l'épaisseur globale du lambeau, ce qui est favorable à un prélèvement étendu du LGD. Puisque cette couche ne peut pas être séparée de l'épaisseur globale à l'examen, ces résultats sont utiles pour évaluer le volume supplémentaire obtenu à partir de la technique de prélèvement élargi du grand droit.

The 5 D's to Dunk the Dog: A Retrospective Clinical Review to Prevent Dog-Ear Contour Abnormalities in Vertical Breast Reductions and Breast Lifts.

Background: In 2020, reduction mammoplasties and mastopexies comprised 34.2% of all breast surgeries performed by plastic surgeons. Various approaches for the skin incision of these procedures have been described. The vertical pattern has become an increasingly popular option due to its lower scar burden. However, it is prone to dog-ear formation along the caudal aspect of the incision. Herein, we describe 5 technical steps to eliminate the dog-ear in patients undergoing vertical mammoplasties. Methods: A retrospective chart review was performed on all patients who underwent vertical breast reduction and mastopexy between the years 2008 and 2020 performed by the senior author. The 5 steps employed in eliminating the dog-ear are delineated and depicted pictorially. Results: A total of 58 patients and 89 breasts were operated upon. A majority of 66.6% were Caucasian, 33.3% were African American, and 1 patient was of Hispanic descent. The mean age was 53.2 years (19-73 years), and average BMI was 31.5 kg/m2 (21.3-42.7 kg/m2). The average resection weights for reduction and mastopexy patients were 479 grams (100-1500 grams) and 58.1 grams (18-100 grams), respectively. Mean follow-up was 10.5 months (1-35 months). Only one patient developed a dog-ear (1.7%) in bilateral breasts (2.2%); however, the patient did not request a revision. Our revision rate over 13 years remained at 0%. Conclusions: Utilizing these 5 technical steps reduces the risk of dog-ear deformity and thereby diminishes the overall need for revisional surgery in patients undergoing short scar vertical mammoplasties.

Centralizing the Umbilicus in Abdominoplasty: Eccentric versus Concentric Fascial Plication in Addition to Medializing at the Skin.

BACKGROUND: The umbilicus is often not a midline structure. Centralization of the umbilicus during an abdominoplasty is routinely performed at the level of the skin; however, this is associated with a high rate of postoperative reversion. The authors propose using an eccentric fascial plication centered on the true midline to maintain postoperative centralization of the umbilicus in addition to correction at the skin level. METHODS: A retrospective study was conducted of all patients between 2015 and 2019 who underwent abdominoplasty with either skin only (concentric plication) or fascial (eccentric plication) umbilical centralization. The Fisher exact test and t test were used to compare the two groups and assess differences in rates of umbilical reversion. RESULTS: A total of 71 patients were included in the study; the majority of patients were women [ n = 69 (97%)] and White [ n = 50 (70%)]. There were 28 (39%) patients who underwent concentric plication, and 43 (61%) had eccentric plication. Mean body mass index in the concentric and eccentric groups was 32 kg/m 2 and 28.5 kg/m 2 , respectively. Average follow-up was 51.6 months for concentric plication and 27.8 months for eccentric plication. Of those who received concentric plication, 10 patients (36%) had their umbilicus revert to the preoperative position; none in the eccentric plication group reverted ( P < 0.0001). CONCLUSIONS: Midline placement of the umbilicus during an abdominoplasty is important in providing symmetry to optimize aesthetics. Eccentric fascial plication maintains the centralization of the umbilicus when compared with concentric fascial plication with skin-only centralization. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Early intramedullary nailing of bilateral femur fractures: who might benefit most?

INTRODUCTION: Identifying which patients can receive immediate intramedullary nailing (IMN) after bilateral femoral shaft fracture may improve health-related quality of life outcomes and decrease healthcare costs. This retrospective study evaluated the perioperative factors that guided emergency department transfer of patients to the operating room (OR) where IMN or temporizing external fixation (TEF) was performed, to the intensive care unit (ICU), or to the orthopedic ward. The hypothesis was that patients referred initially to the OR or to the ICU had more serious co-morbidities, complications, or orthopedic polytrauma, increasing the likelihood that they would benefit from "damage control orthopedics" and TEF use. METHODS: A Level I Trauma Center database (2010-2020) review identified the records of 23 patients that met study inclusion and exclusion criteria. Most sustained their injury in a motor vehicle accident (87%) and were not wearing a seatbelt. RESULTS: Patients transferred to the operating room had a greater body mass index and shorter times between admission and surgery. Those transferred to the OR or ICU had higher injury severity scores (ISS), higher arterial blood O2 partial pressure (paO2) values on the first post-surgical day, and had more red blood cell unit (RBCU) transfusions during hospitalization. Patients transferred to the ICU more often underwent TEF and had shorter initial surgical procedure duration. Those with pneumothorax, rib fractures, or with other orthopedic comorbidities were more often transferred to the OR or ICU and those with acute complications requiring exploratory laparotomy were transferred to the OR. CONCLUSIONS: Patients with higher BMI, ISS, greater RBCU transfusion needs, with pneumothorax, rib fractures, or acute complications requiring exploratory laparotomy were more likely to be initially transferred to the OR or ICU. Patients transferred to the orthopedic ward represented a more heterogenous group with greater possibility for benefitting from earlier definitive IMN.

Intramedullary nailing of concurrent ipsilateral fractures of the tibia and femur: primary synchronous nailing versus staged osteosynthesis with temporizing external fixation.

INTRODUCTION: The optimal timing to definitive osteosynthesis in the polytraumatized patient remains an unanswered question. Early total care, damage control orthopaedics, and early appropriate care have been described to manage the fractures in these patients, but there is a paucity of literature specific to ipsilateral tibial and femoral fractures. We sought the perioperative outcomes of primary simultaneous intramedullary nailing (IMN) versus temporizing external fixation (EF) of both fractures. METHODS: A chart review of all patients who sustained fractures of the ipsilateral femur and tibia that were definitively treated with (IMN) from January 2010 to December 2020 was performed. Patients who underwent initial EF and those that were primarily treated with IMNs were examined. RESULTS: IMNs and EF were the initial treatment in 23 and 16 patients, respectively. The mean (range) injury severity score (ISS) was 23.3 (33) in the EF group vs. 18.5 (34) in the IMN group, (p = 0.0686). The EF group had a higher total transfused units of packed red blood cells 7.4 vs. 2.8, the mean initial operative time was 236 vs. 282.6 (min), (p = 0.7399), a longer mean total operative time 601.78 vs. 236 (min), and longer mean length of stay 15.6 vs. 11 (days), (p < 0.5). Rates of complications were not significantly different between groups. CONCLUSION: Primary IMN is as safe as provisional EF in the adequately resuscitated patient with ipsilateral femoral and tibial fractures. This implies the fixation of both fractures into a single surgery without increasing perioperative complications, and decreasing total hospital stay in patients with sufficient preoperative resuscitation.

Restoring Breast Volume in High BMI Patients: A Single-Center Review of Breast Reconstruction Using Hyperinflated Saline Implants.

Background: Breast reconstruction in the obese patient is often fraught with poor patient satisfaction due to inadequate volume restoration. The off-label hyperinflation of saline implants is a direct yet controversial solution to this problem, with limited studies in the literature. This study sought to determine the safety and efficacy of this technique for breast reconstruction. Methods: A retrospective chart review was performed to identify all patients with a body mass index (BMI) greater than or equal to 30 kg/m2 who underwent breast reconstruction between the years 2013 to 2020 with saline implants filled beyond the manufacturer's maximum recommended volume. Results: The 21 patients identified had an average age of 49 years. The mean BMI was 39.5 kg/m2. A total of 42 implants were placed; 34 were 800 mL, 4 were 750 mL, and 4 were 700 mL. The average overfill volume was 302 mL (138%). Mean follow-up was 65.0 months. Of these, 1 (4.8%) patient with a history of chest wall radiotherapy underwent reoperation for unilateral implant exposure 27 days after the index procedure, no patient sustained spontaneous leak or rupture, and 1 patient had unilateral deflation following emergent central line and pacemaker placement 2 years after the implant was placed for an unrelated cardiovascular event. Conclusions: Hyperinflation of saline implants beyond the maximum recommended volume may be considered for volume replacement in obese patients undergoing implant-based breast reconstruction. This practice is well tolerated, has a complication rate comparable to using implants filled to the recommended volume, and has the potential to restore lost breast volume in the obese patient post mastectomy.

Posterior Interosseous Nerve Graft: Utilizing External Landmarks and Anthropometric Ratios to Predict Available Length for Digital Nerve Reconstruction in a Cadaveric Study.

Objective: In digital nerve defects that require grafting, autografts remain the efficacious option. The sensory posterior interosseous nerve (PIN) is an ideal choice as it is of similar caliber to digital nerves and leaves no donor morbidity upon resection. However, a finite length of harvestable PIN exists, and considerable variations of this length have been reported in the literature. There exists no predictive model to estimate this length. We sought to determine a method to accurately predict the available length of PIN based on individual patient anthropometry. Methods: A cadaveric dissection study was performed in a fresh tissue laboratory. The length of the sensory branch of the PIN and various anthropometric measurements were made in respect to surface anatomy of the ulna to develop a predictable ratio for available PIN donor graft. Results: A total of 16 specimens were obtained. On average the length of the PIN was 5.7 cm (range: 3.3-9. cm) and the length of the ulna was 25.7 cm (range: 23.5-30.6 cm). The ratio of PIN to ulnar length was 0.222 (r = 0.4651). Using one-fifth the length of the ulna, the mean predicted length of the PIN was 5.14 cm (range: 4.7-6.1 cm). On univariate analysis, there was no significant difference between the measured and predicted PIN length (P = .249). Conclusion: An anthropometric ratio predicated on reproducible surface anatomy of the ulna is a useful tool in predicting the sensory PIN length. Such a prediction may be a useful in guiding patient discussions concerning surgical options for digital nerve reconstruction.

Objectif: Dans les cas d'anomalies des nerfs digitaux qui exigent une greffe, les autogreffes sont les plus efficaces. Le nerf interosseux postérieur (NIP) sensitif est le choix idéal, car son calibre est semblable à celui des nerfs digitaux et qu'il ne provoque aucun problème de santé au site de résection. Cependant, la longueur du NIP pouvant être récolté est limitée, et d'énormes variations sont présentées dans les publications. Aucun modèle prédictif ne permet d'évaluer cette longueur. Les chercheurs ont entrepris d'établir une méthode pour prédire avec fiabilité la longueur disponible du NIP d'après les caractéristiques anthropométriques de chaque patient. Méthodologie: Les chercheurs ont procédé à une étude de dissection cadavérique dans un laboratoire de tissus frais. Ils ont mesuré le rameau sensitif du NIP et diverses dimensions anthropométriques d'après l'anatomie de surface de l'ulna pour établir un ratio prévisible de greffe du NIP disponible chez le donneur. Résultats: Les chercheurs ont obtenu 16 prélèvements et calculé une longueur moyenne du NIP de 5,7 cm (plage de 3,3 cm à 9,6 cm) et une longueur moyenne de l'ulna de 25,7 cm (plage de 23,5 cm à 30,6 cm). Ils ont calculé un ratio de 0,222 (r = 0,4651) entre la longueur du NIP et de l'ulna. D'après le cinquième de la longueur de l'ulna, ils ont prédit une longueur moyenne du NIP de 5,14 cm (plage de 4,7 cm à 6,1 cm). À l'analyse univariée, ils n'ont constaté aucune différence significative entre la longueur mesurée et prédite du NIP (P = 0,249). Conclusion: Le ratio anthropométrique établi d'après l'anatomie de la surface reproductive de l'ulna est un outil utile pour prédire la longueur du NIP sensitif. Une telle prédiction peut être utile pour orienter les échanges avec le patient au sujet des possibilités chirurgicales de la reconstruction du nerf digital.

3D-printed titanium cages without bone graft outperform PEEK cages with autograft in an animal model.

BACKGROUND CONTEXT: Modernization of 3D printing has allowed for the production of porous titanium interbody cages (3D-pTi) which purportedly optimize implant characteristics and increase osseointegration; however, this remains largely unstudied in vivo. PURPOSE: To compare osseointegration of three-dimensional (3D) titanium cages without bone graft and Polyether-ether-ketone (PEEK) interbody cages with autologous iliac crest bone graft (AICBG). STUDY DESIGN: Animal study utilizing an ovine in vivo model of lumbar fusion. METHODS: Interbody cages of PEEK or 3D-pTi supplied by Spineart SA (Geneva, Switzerland) were implanted in seven living sheep at L2-L3 and L4-L5, leaving the intervening disc space untreated. Both implant materials were used in each sheep and randomized to the aforementioned disc spaces. Computed tomography (CT) was obtained at 4 weeks and 8 weeks. MicroCT and histological sections were obtained to evaluate osseointegration. RESULTS: MicroCT demonstrated osseous in-growth of native cancellous bone in the trabecular architecture of the 3D-pTi interbody cages and no interaction between the PEEK cages with the surrounding native bone. Qualitative histology revealed robust osseointegration in 3D-pTi implants and negligible osseointegration with localized fibrosis in PEEK implants. Evidence of intramembranous and endochondral ossification was apparent with the 3D-pTi cages. Quantitative histometric bone implant contact demonstrated significantly more contact in the 3D-pTi implants versus PEEK (p<.001); region of interest calculations also demonstrated significantly greater osseous and cartilaginous interdigitation at the implant-native bone interface with the 3D-pTi cages (p=.008 and p=.015, respectively). CONCLUSIONS: 3D-pTi interbody cages without bone graft outperform PEEK interbody cages with AICBG in terms of osseointegration at 4 and 8 weeks postoperatively in an ovine lumbar fusion model. CLINICAL SIGNIFICANCE: 3D-pTi interbody cages demonstrated early and robust osseointegration without any bone graft or additive osteoinductive agents. This may yield early stability in anterior lumbar arthrodesis and potentially bolster the rate of successful fusion. This could be of particular advantage in patients with spinal neoplasms needing post-ablative arthrodesis, where local autograft use would be ill advised.

Three-dimensional Printing of Biomimetic Titanium Mimicking Trabecular Bone Induces Human Mesenchymal Stem Cell Proliferation: An In-vitro Analysis.

STUDY DESIGN: In vitro analysis. OBJECTIVE: The aim of this study was to assess the effect of three-dimensional (3D) printing of porous titanium on human mesenchymal stem cell (hMSC) adhesion, proliferation, and osteogenic differentiation. SUMMARY OF BACKGROUND DATA: A proprietary implant using three-dimensional porous titanium (3D-pTi) that mimics trabecu-lar bone structure, roughness, porosity, and modulus of elasticity was created (Ti-LIFE technology™, Spineart SA Switzerland). Such implants may possess osteoinductive properties augmenting fusion in addition to their structural advantages. However, the ability of 3D-pTi to affect in vitro cellular proliferation and osteogenic differentiation remains undefined. METHODS: Disks of 3D-pTi with a porosity of 70% to 75% and pore size of 0.9 mm were produced using additive manufacturing technology. 2D Ti6Al4V (2D-Ti) and 2D polyetheretherketone (2D-PEEK) disks were prepared using standard manufacturing process. Tissue culture plastic (TCP) served as the control surface. All discs were characterized using 2D-micros-copy, scanning electron microscopy (SEM), and x-ray micro-computed tomography. Forty thousand hMSCs were seeded on the disks and TCP and cultured for 42 days. hMSC morphology was assessed using environmental SEM and confocal imaging following phalloidin staining. hMSC proliferation was evaluated using DNA fluorescent assay. hMSC differentiation was assessed using RT-qPCR for genes involved in hMSC osteogenic differentiation and biochemical assays were performed for alkaline phosphatase activity (ALP) and calcium content. RESULTS: 3D-pTi lead to a higher cell number as compared to 2D-Ti and 2D-PEEK at D21, D28 and D42. ALP activity of hMSCs seeded into 3D-pTi scaffolds was as high as or higher than that of hMSCs seeded onto TCP controls over all time points and consistently higher than that of hMSCs seeded onto 2D-Ti scaffolds. However, when ALP activity was normalized to protein content, no statistical differences were found between all scaffolds tested and TCP controls. CONCLUSION: 3D-pTi provides a scaffold for bone formation that structurally mimics cancellous bone and improves hMSC adhesion and proliferation compared to 2D-Ti and PEEK.

Cannabinoids and orthopedic surgery: a systematic review of therapeutic studies.

BACKGROUND: Recent work has shed light on the potential benefits of cannabinoids for multimodal pain control following orthopedic procedures. The objective of this review was to summarize the available evidence of analgesic and opioid-sparing effects cannabinoids have in orthopedic surgery and identify adverse events associated with their use. METHODS: A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines including PubMed, EMBASE, MEDLINE, PsycINFO, and Google Scholar was performed to include all primary, therapeutic studies published on the use of cannabis, and cannabis-derived products in orthopedic surgery. RESULTS: The literature review returned 4292 citations. Thirteen publications were found to meet inclusion criteria. Four randomized controlled trials were evaluated while the remaining studies were of quasi-experimental design. CONCLUSION: Research on cannabinoids in orthopedic surgery is mostly of a quasi-experimental nature and is mainly derived from studies where orthopedics was not the primary focus. The overall results demonstrate potential usefulness of cannabinoids as adjunctive analgesics and in mitigating opioid use. However, the current evidence is far from convincing. There is a need to produce rigorous evidence with well-designed randomized controlled trials specific to orthopedic surgery to further establish these effects.

Anatomic surface landmarks to guide injection for posterior interosseous nerve block.

Proper injection of the posterior interosseous nerve (PIN) is important for both the therapeutic and diagnostic management of wrist pain. However, no anatomical study exists describing the site of injection based on individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN. Fresh frozen cadaver forearms were dissected at the University of Louisville tissue lab. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. A total of 16 cadaver forearms of equal male to female ratio were obtained. On average, the male forearm had a greater mean wrist circumference obtained at the level of Lister's tubercle compared to female forearms, 17.1 cm vs. 13.5 cm. An injection given ulnar to proximal edge of Lister's tubercle at a length of one-fourth the distance between Lister's tubercle and radial aspect of ulnar styloid resulted in 100% accurate perineural injection without intraneural injection. An anthropometric ratio of one-fourth the distance from Lister's tubercle to the ulnar styloid was able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions.

Surface Landmarks to Provide a Safe Ulnar Nerve Block in the Wrist: Anatomical Study and Literature Review.

Introduction: Use of local anesthesia in awake patients undergoing hand surgery has become increasingly popular. A thorough understanding of local anatomy, such as the distal wrist for ulnar nerve block, is required to provide safe blockade. We sought to conduct an anatomic study of the distal wrist and review cadaveric studies describing various techniques for ulnar nerve block. Methods: Dissection of fresh-frozen cadaver forearms at the University of Louisville Robert Acland Fresh Tissue Lab assessing relationships between the flexor carpi ulnaris tendon and the ulnar nerve and the ulnar artery was performed. Three cadaveric studies on ulnar nerve blockade using the ulnar, volar, and/or transtendinous technique were identified and reviewed. Results: A total of 16 cadaver forearms of equal male to female ratio were obtained. The ulnar nerve was noted to be directly posterior to the flexor carpi ulnaris tendon in 15 (93.8%) forearms, with 1 (6.3%) specimen having the nerve extend along the ulnar border of the flexor carpi ulnaris. The ulnar artery was radial to the ulnar nerve 1 cm proximal to the pisiform in all specimens. In all 3 cadaveric studies, only the ulnar technique was associated with no ulnar artery and/or ulnar nerve injury. Conclusion: Knowledge of distal wrist anatomy can help minimize risk of iatrogenic injury during local blockade. On review, the ulnar approach provides the safest method for ulnar nerve block.

Pelvic parameters directly influence ideal S2 alar-iliac (S2AI) screw trajectory.

BACKGROUND: The utilization of the S2 Alar-Iliac (S2AI) screw provides an optimal method of spinopelvic fixation. The free-hand placement of these screws obviates the use of intra-operative fluoroscopy and relies heavily on sacropelvic anatomy; variations of this anatomy could alter the ideal screw trajectory. The S2AI corridor is near several neurovascular structures, thus an accurate trajectory is critical. The reported angles of trajectory vary within the literature and a paucity of data exists on how patient morphometry influences ideal screw trajectory. We sought to examine the relationship between ideal screw trajectory and pelvic parameters. METHODS: The records of 99 consecutive patients with degenerative thoracolumbar pathology were reviewed and pelvic parameters including sacral slope, pelvic tilt, and pelvic incidence were measured with preoperative standing radiographs. Using 3-dimensional computed tomography (CT) reconstructions, an ideal S2AI trajectory was defined and anteroposterior (horizontal) and cephalocaudal (sagittal) angles were recorded. RESULTS: Pelvic tilt was found to have a moderate inverse correlation with cephalocaudal screw trajectory (r=-0.467, p-value=0.006). Pelvic incidence and sacral slope had weaker correlations with cephalocaudal screw angle. In subgroup analysis, patients with high pelvic tilt (>20°) had a significantly lower cephalocaudal screw trajectory (24.9 ± 3.7° versus 29.8 ± 2.8°, p-value=<0.001) compared to those with a normal pelvic tilt (≤20°). CONCLUSIONS: This study found an inverse relationship between pelvic tilt and cephalocaudal S2AI screw trajectory. Therefore, the sagittal angle of insertion becomes increasingly more perpendicular to the floor (less caudally orientated) as pelvic tilt increases in reference to a patient positioned prone on an operating table parallel to the floor. This may bolster safety and efficacy when utilizing the free-hand technique for placement of the S2AI screw as it allows the surgeon to plan a more ideal trajectory by accounting for pelvic parameters.

Breast Reconstruction With Local Flaps: Don't Forget Grandma.

Objective: Lateral breast defects of various causes can be reconstructed with random patterned local flaps utilizing oncoplastic techniques. These local flaps are used frequently in other areas but are infrequent in breast reconstruction despite affording excellent utility in small lateral defects. We sought to demonstrate this with a case series involving 5 patients who underwent oncoplastic breast surgery with random patterned flap reconstruction. Methods: From 2016 to 2017, 3 different varieties of random flaps were used in 5 women requiring lateral breast defect reconstruction secondary to resection of localized cancer or cutaneous lesion. The local flaps included a rhomboid flap, the bilobed flap, and a rotational flap. Patients were then evaluated in the clinic 10 to 12 months postoperatively for complications, symmetry, and satisfaction of reconstruction. Results: In 4 of 5 patients, the local flap remained fully viable and there was no incidence of seroma, infection, or further complications. One patient developed a post-operative hematoma requiring evacuation and a second patient experienced distal flap necrosis and delayed wound healing. Patients reported satisfaction with the reconstruction. Conclusions: Several random patterned local flaps exist for a variety of breast defects. They can yield excellent cosmetic results, high patient satisfaction, and bolster a low rate of complications. Our case series emphasizes the utility of random patterned flaps for lateral breast oncoplastic reconstruction.

Kickstand External Fixator for Immobilization Following Free Flap Plantar Calcaneal Reconstruction.

Objective: Management of calcaneal wounds is challenging due to a paucity of tissue, complex local anatomy, and limited vascularity. These wounds are commonly associated with lower extremity fractures, which are often treated with external fixation. Free tissue transfers are frequently employed as a means for closure of plantar heel wounds; however, postoperative management can be challenging due to their dependent location. We sought to describe how simple modification of the external fixator can help relieve direct pressure, provide joint immobilization, and optimize accessibility necessary for flap survival. Methods: Three patients requiring autologous free tissue reconstruction of hindfoot defects were immobilized using an external fixator with a "kickstand" modification. Viability of the transferred tissue and the postoperative outcomes were assessed. Results: All free flaps survived with no associated complications. The "kickstand" modification was well tolerated with minimal discomfort. All 3 patients expressed satisfaction with early return to ambulation. Conclusion: An external fixator with a "kickstand" modification provides an essential function in maintaining the viability of the transferred tissue to plantar calcaneal wounds.