Heterotopic ossification: a preventable case of gossypiboma in spinal cord injury.

OBJECTIVE: Heterotopic ossification is the formation of ectopic bone in soft tissues. It has three established aetiologies: genetic, traumatic and neurogenic. A gossypiboma is defined as a retained foreign body, such as a mass or sponge, usually after a surgical procedure. In this article, we present a unique, preventable case of a patient admitted for newly developed heterotopic ossification in the gluteus maximus muscle caused by a retained piece of foam from negative pressure wound therapy (NPWT). The heterotopic ossification lesion, together with the retained foreign body, was completely excised and reconstructed using a posterior thigh fasciocutaneous advancement flap. This is the first reported case of heterotopic ossification caused by a retained foreign body and may be helpful to better understanding of the aetiology of heterotopic ossification.

Possible Error in Reflection Pulse Oximeter Readings as a Result of Applied Pressure.

Pulse oximetry is one of the most widely used techniques in modern medicine. In pulse oximetry, photoplethysmography (PPG) signals are measured at two different wavelengths and converted into the parameter Gamma, which is used to calculate the oxygen saturation of arterial blood. Although most pulse oximetry sensors are based on transmission geometry, the reflection mode is required for different form factors such as the forehead or wrists. In reflection oximetry, local pressure is applied to the measurement surface. We investigated the relationship between applied pressure and Gamma and found that for the reflection mode, Gamma tends to increase with increasing applied pressure. To explain this, we described the PPG signal in terms of two alternative models: a volumetric model and a Scattering-Driven Model (SDM). We assumed that the application of external pressure results in a decrease in local blood flow. We showed that only SDM correctly qualitatively describes Gamma as a function of the decrease in blood flow. We concluded that both described models coexist and that the relative influence of each depends on the measurement geometry and blood perfusion in the skin.

Sensory neurotization of muscle: past, present and future considerations.

Research has shown that temporary innervation by a sensory neuron can provide trophic support to a denervated muscle and stave off muscular atrophy until motor neuron transfer is viable. This so called 'sensory protection' allows for improved outcomes when motor reinnervation able to occur. The theoretical benefit of sensory neurotization is hypothesized to maintain tissue architecture of the end organ due to tropic effects of stimulation. While the literature supports direct motor neurotization from 2 to 4 months post-injury, patient factors including the location of the injury and loss of nerve can preclude this therapeutic window. When direct neurotization is not possible, or there is a long distance to traverse for reinnervation, sensory neurotization may be beneficial. The theorized trophic stimulation enabling end organ architectural maintenance provided by sensory neurotization has been shown to allow for delayed direct motor neurotization without the irreversible sequelae of prolonged denervation. This is a review of the pathogenesis of nerve injury and a literature review of sensory neurotization. An analytical search of the literature in PubMed was performed in order to find articles pertinent to the topic of sensory neurotization, including experimental data from both animal models and case reports in humans.

Computer-Aided Surgical Simulation in Head and Neck Reconstruction: A Cost Comparison among Traditional, In-House, and Commercial Options.

BACKGROUND: Computer-aided surgical simulation (CASS) has redefined surgery, improved precision and reduced the reliance on intraoperative trial-and-error manipulations. CASS is provided by third-party services; however, it may be cost-effective for some hospitals to develop in-house programs. This study provides the first cost analysis comparison among traditional (no CASS), commercial CASS, and in-house CASS for head and neck reconstruction. METHODS: The costs of three-dimensional (3D) pre-operative planning for mandibular and maxillary reconstructions were obtained from an in-house CASS program at our large tertiary care hospital in Northern Virginia, as well as a commercial provider (Synthes, Paoli, PA). A cost comparison was performed among these modalities and extrapolated in-house CASS costs were derived. The calculations were based on estimated CASS use with cost structures similar to our institution and sunk costs were amortized over 10 years. RESULTS: Average operating room time was estimated at 10 hours, with an average of 2 hours saved with CASS. The hourly cost to the hospital for the operating room (including anesthesia and other ancillary costs) was estimated at $4,614/hour. Per case, traditional cases were $46,140, commercial CASS cases were $40,951, and in-house CASS cases were $38,212. Annual in-house CASS costs were $39,590. CONCLUSIONS: CASS reduced operating room time, likely due to improved efficiency and accuracy. Our data demonstrate that hospitals with similar cost structure as ours, performing greater than 27 cases of 3D head and neck reconstructions per year can see a financial benefit from developing an in-house CASS program.

The vastus lateralis free flap for lower extremity gustilo grade III reconstruction.

BACKGROUND: Orthopedic trauma patients with Gustilo grade III injuries to the distal third of lower extremity present challenges to optimum reconstructive management. There is no consensus on the ideal autologous tissue for transfer in large lower extremity defect reconstruction. We present a large case series utilizing the vastus lateralis (VL) free flap for lower extremity Gustilo grade III reconstruction. PATIENTS AND METHODS: This is a case series of patients who underwent VL free tissue transfer for Gustilo grade III injuries. A total of 38 free tissue transfers were performed for lower extremity reconstruction, 19 of which were VL flaps. Mean interval between injury and reconstruction was 46 days (range 7-240 days). RESULTS: The mean wound size was 11.37 cm x 11.42 cm and all cases underwent delayed reconstruction. Seven day flap viability was 100% and 30-day flap viability was 17/19 (89%). There were six complications: two hematomas requiring drainage, one flap dehiscence, one distal flap loss requiring a reverse saphenous vein graft extension, and two complete flap losses. Of the two failed flaps, one was attributed to heparin-induced thrombocytopenia and the other to venous congestion complicated by methicillin-resistant Staphylococcus aureus infection. CONCLUSIONS: The VL free flap is a reliable and versatile flap that can be tailored and tangentially thinned to match the shape and size of a defect, and the long pedicle allows the surgeon to stay away from the zone of injury. This flap should be strongly considered for lower extremity reconstruction, especially in salvage operations for large defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:212-217, 2017.

New Innovations for Deep Partial-Thickness Burn Treatment with ACell MatriStem Matrix.

Objective: Burn injuries remain a large financial burden on the healthcare system. According to CDC statistics (2010), nonfatal and hospitalized burns in the U.S. cost $1.8 billion for an annual incidence of ∼486,000 cases. To date, no technique proves to be the ideal therapy of deep partial-thickness burns. In this study, we review a trial usage of ACell (ACell, Inc.) wound matrix on deep partial-thickness burns. Approach: Burn patients were admitted through the Vanderbilt Emergency Department. Three were consented to receive ACell therapy. Each patient suffered extremity burns, to which ACell MatriStem matrix was applied. Time to epithelialization and healing was monitored up to 1 month postintervention. Results: ACell MatriStem matrix use in deep partial-thickness burns enabled healing by 29 days on average without requiring autografts. The average total body surface area (TBSA) of injury was 7.2% with average TBSA treated with ACell equal to 2.5%. All burn sites underwent re-epithelialization after 5.6 days on average (range 4-7 days). Average length of stay after ACell placement totaled 2 days. All patients fully healed without the need for subsequent grafting or contracture development. No postoperative complications were noted. Innovation: To the extent of our knowledge, this is one of the first reported series to utilize ACell MatriStem product in deep partial-thickness extremity burns. Conclusion: Despite numerous products currently available for burn reconstruction, no one product embodies all the characteristics of an ideal graft. ACell biological extracellular matrix scaffolding appears promising, allowing for healing without use of an autograft.

The biplanar oncoplastic technique case series: a 2-year review.

BACKGROUND: Oncoplastic techniques for breast reconstruction following partial mastectomy are now commonly included in the armamentarium of most reconstructive plastic surgeons. These techniques have been frequently used for women with large breast volume and less frequently used form women with small to moderate breast volume. Most women with smaller breast volumes have been typically considered for mastectomy. As an alternative to mastectomy, the biplanar technique was designed and described as an oncoplastic option. The purpose of this manuscript is to review our 2-year experience using this technique in a series of women with small to moderate breast volume. METHODS: A retrospective review of patients who underwent oncoplastic surgery from 2011-2012 by the senior authors (RM and MYN) was completed. Ten patients were identified that had the biplanar technique involving glandular tissue rearrangement in conjunction with the immediate placement of a submuscular implant or tissue expander. Patient demographics, perioperative details, and post-operative outcomes were evaluated. RESULTS: The mean age and BMI of the ten patients in the study was 56 years (range, 40-68 years) and 24.1 years (range, 20.3-28.6 years) respectively. The mean resection volume was 76.5 g (range, 25-164 g). Eight patients had placement of a permanent implant and two patients had placement of a tissue expander. The average volume of the implanted devices was 138 cc (range, 90-300 cc). In eight patients, a sheet of acellular dermal matrix was used. Immediate biplanar reconstruction was performed in seven patients and a staged-immediate biplanar reconstruction was performed in three patients. Complications included a positive margin on final pathology requiring mastectomy (n=1), infection (n=1), incisional dehiscence following radiation (n=1), and loss of nipple sensation (n=2). Follow-up ranged from 4.5-27 months (mean of 19.5 months). CONCLUSIONS: The biplanar oncoplastic technique may represent a valuable option in women with small to moderate breast volumes that choose to have breast conservation therapy (BCT). This technique has demonstrated success with minimizing contour irregularities and maintaining breast volume. Based on our early experience, patient satisfaction is favorable.

Biplanar oncoplastic surgery: a novel approach to breast conservation for small and medium sized breasts.

UNLABELLED: Biplanar oncoplastic surgery represents a novel technique with which to address partial breast reconstruction defects in small to medium sized breasts. Traditional oncoplastic volume displacement techniques may correct contour irregularities but do not address volumetric asymmetries. Volume replacement techniques classically rely on autologous tissue flaps. A biplanar approach, with a combination of glandular rearrangement techniques and volume enhancement with submuscular implants, can result in an alternative approach in select patients to achieve symmetry. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

New noninvasive index for evaluation of the vascular age of healthy and sick people.

We conducted a study on 861 healthy and sick subjects and demonstrated that some calculated parameters based on measurement of the dynamic light scattering (DLS) signal from the finger correlate highly with chronological age ranging from 1.5 to 85 years old. Measurements of DLS signals were obtained during both occlusion and nonocclusion of blood flow in the finger. For the nonocclusion case we found that the low-frequency component of the DLS signal significantly correlates with the biological age while the high-frequency component of the DLS signal resembles the arterial pulse-wave and does correlate with age. However, the most prominent correlation between the DLS characteristics and age was noted with the stasis stage measurements. We propose that the observed age-related phenomena are caused by alterations in local blood viscosity and interactions of the endothelial cells with erythrocytes. Further, a new noninvasive index based on the age-related optical characteristics was introduced. This noninvasive index may be used as a research and diagnostic tool to examine the endothelial and thrombolytic properties of the vascular system.

Early results of total hip replacement with the Metasul metal-on-metal cementless prosthesis.

BACKGROUND: The need for better durability and longevity in total hip arthroplasty in high demand patients is a constant challenge. For this purpose, a metal-on-metal prosthesis with improved tribology was developed. Our early results using this implant are presented. MATERIALS AND METHODS: A prospective analysis was performed for 56 Metasul hip arthroplasties between 1997 and 2001. There were 39 patients (43 hips) available for both clinical and radiographic evaluation at an average follow-up period of 42 months. Outcomes were measured using the Harris hip score. DISCUSSION: The average Harris hip score increased from 40.7 to 81.1. Subjectively, 87% of the primary cases were satisfied. The majority of patients had pain-free range of motion and had returned to improved daily functions. One technical intraoperative complication (false route) was resolved with immediate revision. Two patients required cerclage wiring, due to a femoral crack. There were two cases of persistent distal peroneal nerve palsy. Three cases of anterior dislocations were reduced and did not recur. A case of positive intraoperative culture was successfully treated with intravenous antibiotics. Two patients required revision to a cemented acetabular prosthesis, one due to cup loosening and the other due to a painful hip with a suspected infection. Radiolucent lines were seen in the acetabulum in one case, which underwent revision. No femoral or pelvic radiolucent lines were found. CONCLUSIONS: We have had relatively satisfactory results in the early follow-up period. It remains premature to draw conclusions as to the superiority of this system over a conventional metal-on-polyethylene bearing prosthesis. Long-term follow-up studies are needed.