3-Tesla MRI-assisted detection of compression points in ulnar neuropathy at the elbow in correlation with intraoperative findings.

INTRODUCTION: Releasing the ulnar nerve from all entrapments is the primary objective of every surgical method in ulnar neuropathy at the elbow (UNE). The aim of this retrospective diagnostic study was to validate preoperative 3-Tesla MRI results by comparing the MRI findings with the intraoperative aspects during endoscopic-assisted or open surgery. METHODS: Preoperative MRI studies were assessed by a radiologist not informed about intraoperative findings in request for the exact site of nerve compression. The localizations of compression were then correlated with the intraoperative findings obtained from the operative records. Percent agreement and Cohen's kappa (κ) values were calculated. RESULTS: From a total of 41 elbows, there was a complete agreement in 27 (65.8%) cases and a partial agreement in another 12 (29.3%) cases. Cohen's kappa showed fair-to-moderate agreement. CONCLUSION: High-resolution MRI cannot replace thorough intraoperative visualization of the ulnar nerve and its surrounding structures but may provide valuable information in ambiguous cases or relapses.

First Experiences with Incisional Negative Pressure Wound Therapy in a High-Risk Poststernotomy Patient Population treated with Pectoralis Major Muscle Flap for Deep Sternal Wound Infection.

BACKGROUND: Radical debridement and wound closure with vascularized flaps has become a standard procedure in the treatment of deep sternal wound infections. Negative pressure incision management systems have been proven to diminish wound infections after sternotomy. In this study, the utility of Prevena Incision Management System (KCI Licensing Inc.) was evaluated in obese patients who received unilateral pectoralis major flap for the treatment of deep sternal wound infections. METHODS: The outcome and wound-related complication rates of 19 obese patients (mean body mass index, 33.7) treated for deep sternal wound infection with pectoralis major muscle flap in combination with Prevena between 2011 and 2016 were compared with 28 obese patients treated with conventional wound dressing only between 2000 and 2010. RESULTS: In patients additionally treated with Prevena, significantly fewer surgical revisions due to wound-related complications were necessary as compared with patients who received conventional wound dressing (5.3 vs. 32.1%, p = 0.034). A significantly shorter ICU length of stay (median 0 vs. 3.5 days, p < 0.001) and a trend toward shorter length of hospitalization (median 14 vs. 19.5 days after pectoralis major flap) could be observed. CONCLUSION: The application of Prevena significantly reduced revision surgery rates in obese patients treated with unilateral pectoralis major flap for deep sternal wound infections.

Outcome after surgical treatment of chronic thromboembolic pulmonary hypertension: dealing with different patient subsets. A single-centre experience.

OBJECTIVES: Pulmonary endarterectomy (PEA) is the only curative treatment for patients suffering from chronic thromboembolic pulmonary hypertension (CTEPH). In patients with a pulmonary vascular resistance (PVR) higher than 1000 dynes s cm-5, this procedure is linked with an increased perioperative risk. We compare the outcomes of patients with moderate to severe versus extremely elevated PVR. METHODS: Between 1992 and 2013, 214 patients underwent PEA for CTEPH at our institution. All patient data were entered in a prospective database. We performed a retrospective analysis of our total patient collective and of subgroups defined by: PVR ≤ 800, PVR > 800 < 1200 and PVR ≥ 1200 dynes s cm-5, to assess the therapeutic success regarding pulmonary pressure reduction, functional outcome and risk factors for perioperative mortality. RESULTS: There was a significant reduction in mean pulmonary pressure (from 51 to 33 mmHg), PVR (860 to 337 dynes s cm-5) and an increase in cardiac index (CI, 2.3 to 2.8 l/min/m2) in the whole group and in each subgroup. At 1-year follow-up, 91.2% of patients were alive and haemodynamic improvements were sustained in the majority of patients. Age, a PVR of higher than 800 dynes, NYHA functional class IV and a CI lower than 2.2 l/min/m2 were significant predictors of in-hospital mortality. The median duration of surgery was 360 min, cardiopulmonary bypass 230 min, aortic cross-clamp time 150 min and circulatory arrest 34 min. In total, there were 14 in-hospital deaths (6.5%) mainly due to right heart failure (n = 7) and multiorgan failure (n = 3). Bleeding, stroke, sepsis and pneumonia led to death in 1 patient each. Mortality was significantly higher in the two groups with PVR > 800, but absolute pressure reduction was also higher in these groups. The 1-year survival rate was 91.2%. CONCLUSIONS: Despite the increased perioperative risk and mortality, PEA should not be denied to patients with extremely elevated PVR but clear indication for surgery. Keeping increased perioperative risk and mortality in mind, significant pressure reduction and improved functional outcome can be achieved in the majority of these patients.

MR neurography of ulnar nerve entrapment at the cubital tunnel: a diffusion tensor imaging study.

OBJECTIVES: MR neurography, diffusion tensor imaging (DTI) and tractography at 3 Tesla were evaluated for the assessment of patients with ulnar neuropathy at the elbow (UNE). METHODS: Axial T2-weighted and single-shot DTI sequences (16 gradient encoding directions) were acquired, covering the cubital tunnel of 46 patients with clinically and electrodiagnostically confirmed UNE and 20 healthy controls. Cross-sectional area (CSA) was measured at the retrocondylar sulcus and FA and ADC values on each section along the ulnar nerve. Three-dimensional nerve tractography and T2-weighted neurography results were independently assessed by two raters. RESULTS: Patients showed a significant reduction of ulnar nerve FA values at the retrocondylar sulcus (p = 0.002) and the deep flexor fascia (p = 0.005). At tractography, a complete or partial discontinuity of the ulnar nerve was found in 26/40 (65%) of patients. Assessment of T2 neurography was most sensitive in detecting UNE (sensitivity, 91%; specificity, 79%), followed by tractography (88%/69%). CSA and FA measurements were less effective in detecting UNE. CONCLUSION: T2-weighted neurography remains the most sensitive MR technique in the imaging evaluation of clinically manifest UNE. DTI-based neurography at 3 Tesla supports the MR imaging assessment of UNE patients by adding quantitative and 3D imaging data. KEY POINTS: • DTI and tractography support conventional MR neurography in the detection of UNE • Regionally reduced FA values and discontinuous tractography patterns indicate UNE • T2-weighted MR neurography remains the imaging gold standard in cases of UNE • DTI-based ulnar nerve tractography offers additional topographic information in 3D.

Facial synkinesia before and after surgical reanimation of the paralyzed face.

BACKGROUND: Facial synkinesia is a common sequela of facial palsy, affecting 15 to 20 percent of patients. The rate of postoperative synkinesia after facial reanimation is not clearly established. The severity and type of synkinesia determine the degree of clinical relevance. METHODS: One hundred sixty-seven patients with facial palsy were included in this retrospective cohort study. Three-dimensional video analysis of facial movements was performed preoperatively and 18 months after facial reanimation. The severity of synkinesia was rated subjectively on a four-degree severity scale. Objective three-dimensional analysis of synkinesia was performed on patients with 18-month follow-up times. RESULTS: Preoperatively, 84.4 percent of patients were not affected by synkinesia, 9 percent presented with mild synkinesia, 4.2 percent presented with moderate synkinesia, and 2.4 percent presented with severe synkinesia. Postoperatively, 51 percent of all patients presented with facial synkinesia (41.8 percent mild, 17.3 percent moderate, and 1 percent severe synkinesia; some patients had more than one type). Patients treated with territorially differentiated gracilis muscle transplantation were most frequently affected (69.8 percent), followed by patients treated with gracilis muscle transplantation in combination with temporalis muscle transposition to the eye (51.8 percent). Oculo-oral synkinesia was the most frequent form of synkinesia. CONCLUSIONS: After surgical reanimation of the paralyzed face, half of the patients presented with synkinesia. The majority of patients developed mild or moderate forms of synkinesia; therefore, the clinical relevance of synkinesia has to be seen in the context of total facial function. Because of the high prevalence of synkinesia, it should be documented and addressed in patients undergoing facial reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of three-dimensional surface-imaging systems.

BACKGROUND: In recent decades, three-dimensional (3D) surface-imaging technologies have gained popularity worldwide, but because most published articles that mention them are technical, clinicians often have difficulties gaining a proper understanding of them. This article aims to provide the reader with relevant information on 3D surface-imaging systems. In it, we compare the most recent technologies to reveal their differences. METHODS: We have accessed five international companies with the latest technologies in 3D surface-imaging systems: 3dMD, Axisthree, Canfield, Crisalix and Dimensional Imaging (Di3D; in alphabetical order). We evaluated their technical equipment, independent validation studies and corporate backgrounds. RESULTS: The fastest capturing devices are the 3dMD and Di3D systems, capable of capturing images within 1.5 and 1 ms, respectively. All companies provide software for tissue modifications. Additionally, 3dMD, Canfield and Di3D can fuse computed tomography (CT)/cone-beam computed tomography (CBCT) images into their 3D surface-imaging data. 3dMD and Di3D provide 4D capture systems, which allow capturing the movement of a 3D surface over time. Crisalix greatly differs from the other four systems as it is purely web based and realised via cloud computing. CONCLUSION: 3D surface-imaging systems are becoming important in today's plastic surgical set-ups, taking surgeons to a new level of communication with patients, surgical planning and outcome evaluation. Technologies used in 3D surface-imaging systems and their intended field of application vary within the companies evaluated. Potential users should define their requirements and assignment of 3D surface-imaging systems in their clinical as research environment before making the final decision for purchase.

Evolution of the 3-dimensional video system for facial motion analysis: ten years' experiences and recent developments.

Since the implementation of the computer-aided system for assessing facial palsy in 1999 by Frey et al (Plast Reconstr Surg. 1999;104:2032-2039), no similar system that can make an objective, three-dimensional, quantitative analysis of facial movements has been marketed. This system has been in routine use since its launch, and it has proven to be reliable, clinically applicable, and therapeutically accurate. With the cooperation of international partners, more than 200 patients were analyzed. Recent developments in computer vision--mostly in the area of generative face models, applying active--appearance models (and extensions), optical flow, and video-tracking-have been successfully incorporated to automate the prototype system. Further market-ready development and a business partner will be needed to enable the production of this system to enhance clinical methodology in diagnostic and prognostic accuracy as a personalized therapy concept, leading to better results and higher quality of life for patients with impaired facial function.

3D video analysis of facial movements.

This article presents a review of 3D video analysis for use in patients with facial paralysis. The difficulties inherent in quantifying the degree of facial paralysis and the effect of therapeutics that has led to the use of videos and computer-assisted 3D analysis are discussed, which can yield quantifiable results of treatment, allow the description and quantification of facial paralysis, and become a tool in the planning of operative procedures. The authors provide a step-by-step overview of video analysis, and present case studies from two specific techniques they have used in reconstruction surgery.

Correlation of functional recovery with the course of electrophysiological parameters after free muscle transfer for reconstruction of the smile in irreversible facial palsy.

INTRODUCTION: The aim of this study was to determine whether processes of denervation and reinnervation, as measured by electrodiagnostic methods, correlate with clinical function, as measured by three-dimensional (3D) video analysis and whether electrodiagnostic data can serve as a prognostic indicator. METHODS: Eighteen patients with facial palsy were investigated by 3D video analysis, needle electromyography, and electrical muscle testing at 6, 12, and 18 months after free muscle transplantation for smile reconstruction. RESULTS: Electrophysiological parameters determined 6 months postoperatively correlated significantly with the index of dynamic symmetry 12 and 18 months postoperatively. CONCLUSIONS: Processes of reinnervation can be detected earlier by electrophysiological analysis than by quantified clinical analysis. Pathological spontaneous activity alone and combined assessment with motor unit action potentials in the early postoperative stage are strong prognostic indicators.