A long-term clinical and cephalometric study of cleft lip and palate patients following intraoral maxillary quadrangular le fort I osteotomy.

OBJECTIVE: To evaluate the horizontal and vertical stability of the quadrangular Le Fort I in patients with congenital cleft lip and palate. DESIGN: Prospective longitudinal study. PATIENTS: A total of 15 congenital cleft lip and palate patients treated with the maxillary quadrangular Le Fort I were enrolled. INTERVENTION: Lateral cephalometric radiographic examinations were obtained preoperatively, early postoperatively, and late postoperatively for four dental and skeletal landmarks. A questionnaire regarding patients' satisfaction with treatment and functional/cosmetic outcomes (airway, speech, mastication) was administered. MAIN OUTCOME MEASURES: Surgical horizontal and vertical movement, late postsurgical horizontal and vertical movement, and surgical and postsurgical movement in relation to age and cleft type were evaluated using Spearman correlation coefficients, Wilcoxon signed rank tests, and Mann-Whitney tests. RESULTS: Surgical horizontal movements of all measured points showed significant changes. Significant differences of postsurgical horizontal movement were observed in younger patients versus adult patients. Significant differences of postsurgical horizontal movement were observed in unilateral cleft patients versus bilateral cleft patients. A high percentage of patients showed significant functional improvement in nasal airflow, speech, mastication, temporomandibular joint function, and mouth versus nose breathing. CONCLUSIONS: The quadrangular Le Fort I is a functionally stable and a surgically predictable procedure for cleft lip and palate patients who present with midface deficiency. Patients under the age of 18 at the time of the osteotomy had a higher relapse rate than patients over 18 years of age. Younger patients who need surgery should be advised regarding the increased risk of skeletal relapse. Patients' satisfaction was high in all aesthetic- and function-related items on the questionnaire.

Tendon transfer for the restoration of thumb opposition: the effects of friction and pulley location.

BACKGROUND: The authors compared the gliding resistance among three commonly used pulley sites used for oppositional transfers. METHODS: Eight fresh-frozen cadaver forearms were studied. The ring finger's flexor digitorum superficialis was used as a donor tendon in all specimens. An oppositional transfer was created to the thumb using three pulley sites: the Royle-Thompson, the Guyon canal, and the flexor carpi ulnaris tendon loop pulleys. The flexor digitorum superficialis was inserted into the palmar radial portion of the abductor pollicis brevis in all cases. Gliding resistance was then measured and compared. Final thumb position was measured to assess the amount of thumb palmar abduction and opposition created with each pulley configuration. RESULTS: The average gliding resistance of tendons passed within the Royle-Thompson, Guyon canal, and flexor carpi ulnaris loop pulley were 1.27, 0.58, and 0.44 N, respectively. Gliding resistance for the Royle-Thompson pulley was found to be significantly higher than that for the Guyon canal or flexor carpi ulnaris loop pulley (p < 0.05). There was no significant difference between the Guyon canal and flexor carpi ulnaris loop pulleys with regard to gliding resistance. The flexor carpi ulnaris loop pulley produced the greatest amount of palmar abduction (p < 0.05), whereas the Guyon canal and Royle-Thompson pulleys produced the greatest amount of thumb opposition. CONCLUSIONS: The Guyon canal and flexor carpi ulnaris loop pulleys produced lower friction than the Royle-Thompson pulley. The Guyon canal pulley produced greater thumb opposition compared with the flexor carpi ulnaris loop pulley and represents an ideal pulley site for restoration of thumb opposition.

Surface treatment of flexor tendon autograft and allograft decreases adhesion without an effect of graft cellularity: a pilot study.

BACKGROUND: Flexor tendon grafting is often required to reconstruct a failed tendon repair. Previous reports have demonstrated flexor grafts coated with lubricants such as carbodiimide derivatized hyaluronic acid (cd-HA) decrease adhesion formation and improve digit function. However, whether this surface modification would affect graft adhesion and cellularity is unknown. QUESTIONS/PURPOSES: Adhesion score and the cellularity of the graft of untreated and cd-HA surface-modified autograft and allograft tendons were studied using a canine forepaw in vivo model. METHODS: The peroneus longus tendons (n = 6) and flexor digitorum profundus tendons (n = 8) were used as extrasynovial autograft and intrasynovial allograft, respectively. The flexor digitorum profundus (FDP) tendons in the second and fifth digits in each dog were reconstructed with one digit treated with cd-HA and the other treated with saline as a control. Six weeks after surgery, the grafted tendons were harvested for histological evaluation with hematoxylin and eosin staining. During dissection, the adhesions were observed and scored. RESULTS: The adhesion score was greatest in the extrasynovial autograft without surface modification and the least in the intrasynovial allograft with surface modification. Autograft tendons had a higher cell density than the allografts regardless of surface treatment. Cd-HA graft treatment did not affect cellularity when compared with controls. CONCLUSIONS: Our observations suggest surface modification of a tendon graft with cd-HA decreased the adhesion formation without altering the cellularity in either autologous or allograft tendon. We therefore presume this surface modification would not adversely affect graft healing.

The effect of triangular fibrocartilage complex injury on extensor carpi ulnaris function and friction.

BACKGROUND: It has been previously shown that injury to the triangular fibrocartilage complex increases the moment arm of the extensor carpi ulnaris. This will reduce the force producing capacity of the muscle in some situations, but will also increase its mechanical advantage. It is also possible that the change in the tendon path may increase tendon friction, predisposing the patient to future repetitive motion injury. It is the purpose of this study to determine the effects of triangular fibrocartilage complex injury on extensor carpi ulnaris moment producing capacity and tendon friction. METHODS: A simple simulation was used to examine muscle moment producing capacity throughout the range of motion, at varying speeds and in both injured and healthy states. Six fresh frozen human cadaveric wrists were used to determine the effect of injury on tendon friction. A custom made device was used to move the wrists through a range of motion, while a constant force was applied to the proximal tendon and force was recorded at the distal tendon. Friction was measured before and after the creation of injury. FINDINGS: The decreases in muscle force following injury were small, even in the worse case. The moment producing capacity of the muscle was increased following injury. Tendon friction during flexion-extension was decreased following injury. The friction during radial-ulnar deviation was unchanged. INTERPRETATION: When making surgical decisions about triangular fibrocartilage complex repair, it is not necessary to consider extensor carpi ulnaris moment producing capacity or tendon friction.

Free tissue transfer for lower extremity reconstruction: a study of the role of computed angiography in the planning of free tissue transfer in the posttraumatic setting.

BACKGROUND: Computed tomographic angiography can be used as a means of assessing lower leg vasculature before performing free tissue transfer, but its reliability within a trauma setting has not been evaluated. The aim of this study was to examine the findings of preoperative computed tomographic angiography and correlate these findings to flap survival and limb salvage. METHODS: Seventy-six consecutive lower extremity trauma patients underwent preoperative computed tomographic angiography before free flap reconstruction. Arterial inflow, venous outflow, and the incidence of traumatic occlusion were recorded. Flap survival rates, limb salvage, and postoperative complications were noted. RESULTS: There were no complications associated with the computed tomographic angiography procedure. Computed tomographic angiography demonstrated normal vascular anatomy in 40 patients (52.6 percent), anatomical variants in seven patients, and atherosclerotic occlusive disease in six patients. Traumatic arterial occlusion was identified in 22 patients (28.9 percent). Flap failure was seen in five patients and the limb salvage rate was 94.7 percent. All four of the limbs amputated had at least a single artery occluded on preoperative computed tomographic angiography; preoperative arterial occlusion was found to be a significant predictor of limb loss (p < 0.05). CONCLUSIONS: The incidence of single-vessel traumatic arterial occlusion within traumatized lower limbs undergoing free tissue transfer may be as high as 29 percent. Computed tomographic angiography provided excellent visualization of lower extremity vasculature, and its routine use for trauma patients is safe. Flap failure rates were low when using this technique for preoperative planning. Flap failure occurred only in patients with evidence of arterial injury. Evidence of arterial occlusion on computed tomographic angiography may be a risk factor for limb loss.

Early clinical outcomes with the use of decellularized nerve allograft for repair of sensory defects within the hand.

Nerve conduits have become an established option for repair of sensory deficits of up to 2 cm. More recently, decellularized nerve allograft has also been advocated as an option for nerve repair; however, no clinical studies have examined its efficacy for the treatment of sensory nerve defects. The aim of this study was to examine our early experience with the use of decellularized nerve allograft for repair of segmental nerve defects within the hand and fingers. From July 2007 to March 2008, seven patients who had ten nerve gaps were treated surgically using decellularized nerve allograft. Eight digital and two dorsal sensory nerves were repaired. The etiologies of the nerve defects were traumatic nerve transection in eight defects and neuroma resection and reconstruction in two defects. All of the affected nerves were pure sensory fibers. Functional recovery was evaluated by blinded hand therapist using moving and static two point discrimination tests. Implantation sites were also evaluated for any signs of infection, rejection, or graft extrusion. There were five men and two women with a mean age of 44 years (range 23-65). Mean nerve graft length was 2.23 cm with a range of 0.5-3 cm. Mean follow up time was 9 months (range 5-12). Average two point discrimination was 4.4 mm moving and 5.5 mm static at last recorded follow-up. There were no wound infections observed around the graft material and sensory improvement was observed in all of the patients despite this short-term follow-up. Re-exploration of two fingers was required for flexor tendon rupture in one and flexor tendon tenolysis in the other. In both cases, the nerve allograft was visualized and appeared well incorporated in the repair site. Decellularized nerve allografts were capable of returning adequate sensation in nerve defects ranging from 0.5 to 3 cm. There were no cases of infection or rejection. Decellularized nerve allograft may provide an option for segmental nerve gaps beyond 2 cm. Randomized comparative studies will be required to determine efficacy in comparison to collagen conduits or nerve autograft.

Simultaneous occurrence of facial fibrous dysplasia and ameloblastoma.

BACKGROUND: Both fibrous dysplasia (FD) and ameloblastoma are benign but locally aggressive tumours of the craniofacial region. In this case report, we present the unique synchronous occurrence of these two tumours in the facial skeleton. CASE REPORT: A 16-year-old woman presented with complaints of swelling of the upper right face and at the inferior border of the mandible. She was diagnosed as FD of the maxilla, temporal bone and sphenoid sinus together with ameloblastoma of the mandible after surgery and histopathological evaluation. CONCLUSION: The case that we present here is unique in that two separate pathological conditions, FD of the upper face, and ameloblastoma of the mandible coexisted. Although cases of synchronous or metachronous occurrence of FD and ameloblastoma with other pathology have been previously described, this to our knowledge, is the first reported case of true coexistence of FD and ameloblastoma.

Vacuum-assisted closure of wounds and anxiety.

The aim of this study was to investigate the degree of anxiety in patients in whom the vacuum-assisted closure (VAC) of wounds was used. Psychological evaluations were made on the day before VAC was applied and at the 10(th) day of treatment in 20 patients with traumatic wounds of the lower extremity. Anxiety was measured with the Hamilton Rating Scale for Anxiety and with the State Anxiety Inventory test. The same measurements were also made in 20 further patients with similar wounds but managed with classic treatment as controls. Both groups showed a significant increase in anxiety during the 10 days. The mean (SD) differences in the anxiety scores measured during the 10-day period were significantly higher in the group treated by VAC than in the control group, State Anxiety Inventory test (14.0 (2.3) compared with 2.6 (1.2), p<0.001) and Hamilton Rating Scale for Anxiety test (4.4 (0.6) compared with 1.3 (0.6), p<0.001). Although we think that VAC is an effective tool for treating lower extremity wounds, we have concerns about possible accompanying psychological effects.