Functional outcomes of replantation following radiocarpal amputation.

PURPOSE: To assess the long-term functional and clinical outcomes of patients who have undergone replantation after radiocarpal amputation. METHODS: We performed a retrospective review of radiocarpal joint amputations at a level 1 trauma center over a 13-year period. Medical records of patients treated with replantation were queried for injury data, operative reports, complications, and clinical progress. Patients who met inclusion criteria were contacted for long-term follow-up. We measured total active motion of each digit, strength (grip and pinch), and 2-point discrimination. Functional outcomes were assessed with Disabilities of Arm, Shoulder, and Hand score, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. RESULTS: Six patients met the inclusion criteria. The mean age was 36 years (range, 26-50 y). Five patients were available at a mean follow-up of 3.9 years (range, 1.0-6.9 y). Compared with the contralateral uninjured extremity, total active motion of the hand was 38% (range, 26% to 59%) and grip strength was 9% (range, 0% to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (range, 8-12 mm). All mean outcome scores indicated moderate disability, including Disabilities of Arm, Shoulder, and Hand (76; range, 45-82), Mayo Wrist Score (23; range, 5-50), Patient-Rated Wrist Evaluation (86; range, 56-98), and Michigan Hand Questionnaire (27; range, 15-55). Two patients were able to return to work and 3 were permanently disabled. All patients were satisfied with the hand function. CONCLUSIONS: Successful replantation for a radiocarpal joint amputation is associated with major restriction of motion, decreased strength, and moderate disability on functional outcome assessments. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Porous polyurethaneurea (Artelon) joint spacer compared to trapezium resection and ligament reconstruction.

PURPOSE: To examine outcomes and complications of the porous polyurethaneurea (Artelon; Small Bone Innovations, Morrisville, PA) spacer compared to traditional surgical treatment of trapeziectomy with ligament reconstruction and tendon interposition (LRTI). METHODS: A retrospective chart review was undertaken of patients with carpometacarpal (CMC) arthritis who had either placement of an Artelon spacer or LRTI. Patients were brought back to clinic for interview and functional testing. Pain was graded using a visual analog scale. Grip and pinch strength, as well as range of motion at the first CMC joint, were measured. Nine-hole peg, Moberg pickup, and Jebson-Taylor tests were performed. Research and Development 36, Michigan Hand Outcomes, and Quick Disabilities of the Arm, Shoulder, and Hand questionnaires were administered. RESULTS: Thirty-eight patients received Artelon implants into the CMC joint, and 6 were lost to follow-up. Twelve of 32 patients (37%) required revision surgery with removal of implant and salvage arthroplasty. Twenty patients with nonrevised Artelon implants were compared with 10 patients who received 13 LRTI procedures. Patients with Artelon had significantly less pain improvement compared to those receiving the LRTI procedure. In addition, satisfaction was significantly decreased. There was no significant difference in any other functional or quality of life measures. CONCLUSIONS: In our practice, use of the Artelon joint spacer resulted in an explantation rate of 37%. Due to these findings, we have abandoned its use for treatment of basilar thumb osteoarthritis. In contrast to previous studies, pain and satisfaction are worse in patients with intact Artelon spacers than those who had received LRTI.

Capsular contracture rate in a low-risk population after primary augmentation mammaplasty.

BACKGROUND: The safety of augmentation mammaplasty has increased dramatically in the past 20 years. Capsular contracture (CC) is the most commonly reported complication of augmentation mammaplasty. OBJECTIVES: The authors report the incidence of CC in a low-risk patient population after primary augmentation. METHODS: The authors retrospectively reviewed the charts of 856 consecutive patients who underwent primary augmentation mammaplasty between 1999 and 2009. This series did not include patients who underwent breast augmentation-mastopexy, secondary augmentation, revision, and/or reconstruction. Data points included demographics, functional and aesthetic outcomes, complications, and revision rate/type. RESULTS: The overall incidence of CC in 856 patients was 2.8%. Average follow-up time was 14.9 months. Antibiotic irrigation decreased CC rates from 3.9% to 0.4% (P = .004). Tobacco users had higher rates of contracture than nonsmokers (5.5% vs 1.9%; P = .036). Saline implants had a higher CC rate than silicone gel (4.3% vs 1.3%; P = .032). Using multivariate logistic regression, CC was 7.89 times more likely in saline implants than in silicone gel (P = .027, 95% confidence interval, 1.26-49.00). CONCLUSIONS: Based on our findings, it is apparent that the early CC rate in primary augmentation can be less than 1%. To avoid CC, we advocate an inframmamary approach, submuscular implant placement, and antibiotic irrigation of the breast pocket. LEVEL OF EVIDENCE: 3.

Surgical treatment of superimposed, lower extremity, peripheral nerve entrapments with diabetic and idiopathic neuropathy.

BACKGROUND: Although it is recognized that people with peripheral neuropathy have an increased prevalence of chronic nerve entrapment, controversy still exists over their management. The present report details the evaluation, surgical approach, and outcome of a large cohort of people with diabetic and with idiopathic neuropathy. METHODS: A retrospective review of 158 consecutive patients, 96 with diabetic and 62 with idiopathic neuropathy, was done to analyze the results of neurolysis of multiple sites of chronic nerve compression in the lower extremity. Of these patients, 50 had a contralateral limb decompressed for a total of 208 limbs included in the study. Outcomes included visual analog scale (VAS) for pain in the 109 patients who had pain level greater than 8.0, measurement of the cutaneous pressure threshold for sensibility, self-reported change in pain medication usage, and self-reported change in balance. RESULTS: With a minimum follow-up of 1 year, 88% of patients with preoperative numbness reported improvement in sensation (P < 0.001). Of the 84 patients with impaired balance, 81% reported improvement in balance. Of those whose VAS was greater than 8, 83% reported an improvement in VAS (P < 0.001). There was a concomitant reduction in pain medication usage. There was no difference in outcomes between patients with diabetic versus idiopathic neuropathy in response to nerve decompression. CONCLUSIONS: Neurolysis of lower extremity chronic nerve compressions in patients with neuropathy and superimposed nerve compressions is an effective method for relieving pain, restoring sensation, and improving balance.

Cranial nerve seven palsy and its influence on meibomian gland function.

PURPOSE: To investigate a possible relationship between cranial nerve seven (CN VII) palsy and meibomian gland dysfunction. METHODS: A prospective case series of 16 patients with unilateral CN VII palsy was evaluated for meibomian gland function. Main outcome measures included the Sunnybrook Facial Grading System for CN VII palsy and a modified version of a noncontact, noninvasive meibomian gland evaluation by Arita et al., Unaffected contralateral eyes were used as the control group for comparison. RESULTS: Sixteen affected eyes were evaluated. The mean Sunnybrook Facial Grading System composite score was 34.19 ± 24 (score = -15 to 100; maximum function = 100). A paired samples t test between affected and unaffected eyes demonstrated a significant difference between mean values for tear break-up time, eyelid abnormality, meiboscore for upper eyelid, meiboscore for lower eyelid, combined meiboscore, and digital pressure. No significant difference was found for superficial punctate keratopathy nor Schirmer's test. A Pearson product-moment correlation coefficient found a significant negative correlation between the Sunnybrook Facial Grading System composite score and all aspects of meibomian gland function, except for the upper eyelid meiboscore, which only approached significance (p = 0.059). CONCLUSION: These findings suggest that a strong relationship exists between cranial nerve seven palsy and meibomian gland dysfunction. Clinical optimization of meibomian gland function may benefit cranial nerve seven palsy patients.

Cutaneous mucormycosis of the upper extremity in an immunocompetent host: case report.

Cutaneous mucormycosis, a relatively common infection in immunocompromised patients, remains rare in the immunocompetent patient outside the setting of major trauma. We report a case of an immunocompetent patient who developed left upper extremity Rhizopus infection following arterial puncture. Treatment included surgical debridement, liposomal amphotericin B, and hyperbaric oxygen wound therapy; the patient recovered fully. A review of the literature of cases of upper extremity Mucor infection is included for context. We feel that a high degree of suspicion for Mucor infection is warranted in patients with the described risk factors who do not respond to first-line antibiotics.

Fibromatosis of the cervical region following laminectomy: a case report and literature review.

STUDY DESIGN: A case report and a discussion of recently published data. OBJECTIVE: To highlight the occurrence of postoperative fibromatosis arising in the cervical spine. SUMMARY OF BACKGROUND DATA: Fibromatosis is a benign, locally invasive fibroblastic proliferation that can cause compressive effects on adjacent structures. Although the precise etiology of fibromatosis remains unclear, numerous studies have investigated the role of pluripotent mesenchymal stem cells in ß-catenin-regulated tumorigenesis. At present, aggressive fibromatosis is managed with wide local excision. Postoperative radiation therapy is indicated for incomplete excision. METHODS: A 48-year-old woman presented with a 2-year history of enlarging paracervical fibromatosis after undergoing extensive cervicothoracic instrumentation for excision of an extradural schwannoma. The patient underwent wide local excision of the neck mass, with right trapezius myocutaneous flap reconstruction of the subsequent defect. RESULTS: Histologically, the lesion was shown to be fibromatosis. Six months postoperatively, the patient was doing well with no recurrence. CONCLUSION: Fibromatosis is an important diagnosis to consider when evaluating locally aggressive spinal lesions at sites of prior operative repair. Molecular and genetic studies pertaining to the role of mesenchymal stem cells and ß-catenin in the pathogenesis of aggressive fibromatosis tumors could lead to possible worthwhile treatment strategies in the future.

The use of bioelectric dressings in skin graft harvest sites: a prospective case series.

Despite advances in wound care treatments for the management of acute and chronic wounds, there remains an unmet need for interventions that accelerate epithelialization. Many authors in the past have advocated the use of electric currents to accelerate wound healing. Novel wound dressings with inherent electric activity are emerging, and studies of these specific modalities are lacking. The principal aim of this study is to evaluate the impact of a bioelectric dressing on acute wound healing. Thirteen patients who underwent skin grafting were enrolled. One half of all skin graft donor sites were treated with the bioelectric dressing and semi-occlusive dressing (SOD) and the other half using solely a SOD. Epithelialization was rated by a blinded burn surgeon attending. Participants also provided a self-assessment of their scar appearance. At week 1 postprocedure, average epithelialization of 71.8% was noted on the bioelectric dressing-treated side, compared with 46.9% on the SOD side, representing an average 34.62% faster wound healing (P = .015). At 1 month, patients rated the bioelectric dressing-treated half as superior in terms of scar color (P = .198), stiffness (P = .088), thickness (P = .038), and overall quality (P = .028). These early data show promise in terms of faster healing, improved scarring, and improved patient subjective outcome with the use of the bioelectric dressing on acute wounds. With fulfillment of an extended study population, the authors hope to provide a solid foundation for extrapolating their data beyond skin graft donor sites to all areas of wound care.

Mimix hydroxyapatite cement use in the reconstruction of the craniofacial skeleton.

Reconstruction of the craniofacial skeleton has undergone a significant evolution during the past century. Initially, the use of autogenous bone grafts from various sites was the criterion standard. However, owing to donor site morbidity and lack of sufficient bone for large defects, surgeons have relied on various bone substitutes. Hydroxyapatite (HA) has served as an alternative to autogenous grafts, but questions regarding biocompatibility, risk of infection, and slow set times have hampered its acceptance. This article serves as a review of a single surgeon's experience using HA in the craniofacial skeleton. Eighteen patients receiving HA between March 2000 and November 2006 were observed. Sixteen underwent recontouring of skull-based bone defects, and 2 underwent recontouring for nasal and alveolar defects. The mean amount of HA used in each patient was 30.2 g. For large contour irregularities, the maximum thickness of HA used was 8 mm. The size of bone defects ameliorated averaged 4.8 cm(2). Complications occurred in 3 (16.7%) of 18 patients and included scalp hematoma and superficial cellulitis. In addition, 1 patient developed a facial abscess after placement along the alveolar floor, which necessitated removal. Hydroxyapatite represents a viable alternative to autogenous bone grafts when used in the correct manner. Hydroxyapatite should be used only for smaller defects or used in conjunction with absorbable plates when attempting to fill larger defects. Use of HA for nasal piriform augmentation or alveolar bone grafting should not be considered owing to problems with late infections.

Recombinant factor VIIa (NovoSeven RT) use in high risk cardiac surgery.

OBJECTIVE: The use of recombinant factor VIIa (rFVIIa) (NovoSeven RT(®)) to establish hemostasis during massive perioperative bleeding in cardiac surgery has been explored in several retrospective studies. While early results are promising, a paucity of data leaves many questions about its safety profile. We sought to further define its use and associated outcomes in a large cohort study at a single institution. METHODS: A retrospective cohort study design was used, in which 236 patients received rFVIIa for bleeding after cardiac surgery. These patients were matched with a cohort of 213 subjects, who had similar operations during the same period of time. Primary end points included thrombo-embolic events, mortality, incidence of re-operation, use of blood products, and patient disposition at 30 days. Statistical significance was assessed at p < 0.05. RESULTS: There was no statistically significant difference in the incidence of stroke (3.4%, 1.9%; p = 0.32), renal failure (8.5%, 7.0%; p = 0.57), or 30-day mortality (7.7%, 4.3%; p = 0.14) between the rFVIIa and the control groups, respectively. The rFVIIa group did experience a higher rate of re-operation for bleeding (11.0%, 1.9%; p = 0.0001) and had a two-fold increase in the use of each of the following: cryoprecipitate, fresh-frozen plasma, platelets, and packed red blood cells, relative to the control group (p < 0.00001). CONCLUSIONS: rFVIIa is an effective hemostatic agent for intractable bleeding in high-risk cardiac surgery with an acceptable safety profile. rFVIIa does not appear to be associated with increased postoperative complications, including thrombo-embolic events and death.

Prophylactic sternal plating with pectoralis advancement flaps after sternotomy in patients with a history of chest irradiation.

Deep sternal infections secondary to bony instability and malunion, can result in mediastinitis. Previous authors have described the use of prophylactic rigid plate fixation in high-risk patients. The purpose of our study is to review the use of prophylactic sternal platting with pectoralis advancement flaps in high-risk patients with a history of chest irradiation. Fourteen patients (July 2003-September 2008) with a history of chest irradiation who underwent a median sternotomy followed by prophylactic rigid plate fixation of the sternum were reviewed. Breast cancer was the most common etiology of chest irradiation (n=11, 78%). The average EuroSCORE was 24.06% with 72% of patients having a preoperative New York Heart Association (NYHA) class≥III. There were no episodes of sternal non-union, mediastinitis or death. Follow-up was 100% with a 0% 30-day and a 7.1% one-year mortality rate (non-cardiac). A comparison between mean preoperative left ventricular ejection fraction (LVEF) (49.6%) and postoperative LVEF (59.7%) was statistically significant (P<0.0001). All living patients currently maintain a NYHA class I/II. Prophylactic rigid plate fixation and pectoralis flap coverage decreases the risk of developing sternal dehiscence and postoperative wound complications and should therefore be considered in high-risk patients with a history of chest irradiation.

Safety of laparoscopic ventral hernia repair in octogenarians.

BACKGROUND AND OBJECTIVES: The recurrence rate after laparoscopic ventral hernia repair is lower than the rate of recurrence via the open approach in many series. Studies have demonstrated the safety and efficacy of this procedure but have had relatively young patient populations. We present our experience in a significantly older population. METHODS: A retrospective chart review of all patients 80 to 89 years of age undergoing a laparoscopic ventral hernia repair at our institution from May 2000 to June 2007 was performed. Data collected included demographics, number and type of previous abdominal operations, number of previous hernia repairs, defect and mesh size, postoperative complications, and follow-up. RESULTS: Twenty octogenarian patients underwent laparoscopic ventral hernia repair. Nine were men and 11 were women. The mean age was 82 years. Thirteen patients (65%) had one or more associated comorbidities at the time of surgery. Eighteen patients (90%) had undergone a mean of 1.7 prior abdominal operations. Six (30%) patients had undergone a mean of 1.1 previous open hernia repairs; 5 (83%) with mesh. Eight patients (40%) had an additional operative procedure at the time of laparoscopic hernia repair. Ten minor complications occurred in 10 patients (50%). Four major complications occurred in 4 patients (20%). One patient required reoperation for evacuation of hematoma at a trocar site. No patients complained of pain at a transabdominal suture site or persistent seromas by 6 weeks of follow-up. At mean follow-up of 3.1 months, no recurrences occurred and no patients required mesh removal in this series. No deaths occurred. CONCLUSION: Laparoscopic ventral hernia repair is becoming an accepted technique for hernia repair in the United States, with a well-documented low recurrence rate. Our series demonstrates that this approach is equally safe and effective for a significantly older segment of the population.

Laparoscopic Repair of a Chronic Iatrogenic Diaphragmatic Hernia.

We report the diagnosis and repair of a chronic, iatrogenic diaphragmatic hernia using minimally-invasive techniques. A 69-year-old man presented with intermittent abdominal and shoulder pain. He had previously undergone laparoscopic Nissen fundoplication in which a grasper-induced puncture injury to the left hemidiaphragm was noted but not repaired. Radiographs and CT imaging diagnosed a left diaphragmatic hernia, with stomach herniated into the left thoracic cavity. This was repaired successfully via an intra-abdominal laparoscopic approach. This case represents the potential importance of repairing post-traumatic diaphragmatic hernia at the time that they occur, as well as a minimally invasive means for their repair.

Identification of functionally important negatively charged residues in the carboxy end of mouse hepatitis coronavirus A59 nucleocapsid protein.

The coronavirus nucleocapsid (N) protein is a multifunctional viral gene product that encapsidates the RNA genome and also plays some as yet not fully defined role in viral RNA replication and/or transcription. A number of conserved negatively charged amino acids are located within domain III in the carboxy end of all coronavirus N proteins. Previous studies suggested that the negatively charged residues are involved in virus assembly by mediating interaction between the membrane (M) protein carboxy tail and nucleocapsids. To determine the importance of these negatively charged residues, a series of alanine and other charged-residue substitutions were introduced in place of those in the N gene within a mouse hepatitis coronavirus A59 infectious clone. Aspartic acid residues 440 and 441 were identified as functionally important. Viruses could not be isolated when both residues were replaced by positively charged amino acids. When either amino acid was replaced by a positively charged residue or both were changed to alanine, viruses were recovered that contained second-site changes within N, but not in the M or envelope protein. The compensatory role of the new changes was confirmed by the construction of new viruses. A few viruses were recovered that retained the D441-to-arginine change and no compensatory changes. These viruses exhibited a small-plaque phenotype and produced significantly less virus. Overall, results from our analysis of a large panel of plaque-purified recovered viruses indicate that the negatively charged residues at positions 440 and 441 are key residues that appear to be involved in virus assembly.