Management of Posttraumatic Avascular Necrosis of the Proximal Humerus.

The etiology of avascular necrosis (AVN) of the proximal humerus can be classified as idiopathic or posttraumatic, the latter being mainly due to proximal humerus fractures. Evidence suggests that posttraumatic AVN may require surgical intervention more often than idiopathic AVN of the proximal humerus. This article provides a comprehensive review of the management of posttraumatic AVN of the proximal humerus. Early stage AVN (stages 1 to 3) is commonly treated with nonoperative intervention or core decompression of the humeral head, whereas later stage disease (stages 4 and 5) may require hemiarthroplasty or total shoulder arthroplasty to restore function. [Orthopedics. 2021;44(6):367-375.].

Quantifying the Severity of Metopic Craniosynostosis: A Pilot Study Application of Machine Learning in Craniofacial Surgery.

The standard for diagnosing metopic craniosynostosis (CS) utilizes computed tomography (CT) imaging and physical exam, but there is no standardized method for determining disease severity. Previous studies using interfrontal angles have evaluated differences in specific skull landmarks; however, these measurements are difficult to readily ascertain in clinical practice and fail to assess the complete skull contour. This pilot project employs machine learning algorithms to combine statistical shape information with expert ratings to generate a novel objective method of measuring the severity of metopic CS.Expert ratings of normal and metopic skull CT images were collected. Skull-shape analysis was conducted using ShapeWorks software. Machine-learning was used to combine the expert ratings with our shape analysis model to predict the severity of metopic CS using CT images. Our model was then compared to the gold standard using interfrontal angles.Seventeen metopic skull CT images of patients 5 to 15 months old were assigned a severity by 18 craniofacial surgeons, and 65 nonaffected controls were included with a 0 severity. Our model accurately correlated the level of skull deformity with severity (P < 0.10) and predicted the severity of metopic CS more often than models using interfrontal angles (χ = 5.46, P = 0.019).This is the first study that combines shape information with expert ratings to generate an objective measure of severity for metopic CS. This method may help clinicians easily quantify the severity and perform robust longitudinal assessments of the condition.

An Intraoperative Salvage After Transection of the Greater Palatine Artery During Cleft Palate Repair: A Case for Buccal Fat and Buccal Myomucosal Flaps.

Recently, several adjunctive procedures have gained traction to aid cleft surgeons in repairing especially challenging palatal clefts. Buccal fat flaps and buccal myomucosal flaps have demonstrated particular utility in reinforcing thin palatal flaps or tissue deficits. Although their use has not been widely accepted, they may be particularly helpful in the setting of significant scarring or vascular compromise. Here the authors describe the case of an intraoperative salvage using bilateral buccal fat flaps and a right buccal myomucosal flap after transection of the right Greater Palatine artery (GPA) during palatoplasty on a 14-month old female with Pierre Robin Sequence and a wide Veau II cleft palate. For this operative salvage, bilateral buccal fat flaps were used to reinforce the hard-soft palate junction and a 4 cm × 2 cm flap of the right-sided buccal mucosa and buccinator muscle was inset along the majority of the right-sided soft and posterior hard palate. At 2 years follow-up, the patient had no significant complications and was doing well with healthy-appearing palatal tissue and age-appropriate speech.