Preoperative Prophylactic Antibiotics in Mandibular Fractures and Surgical Site Infection.

BACKGROUND: Compared with other facial fractures, mandibular fractures have the highest rate of postsurgical site infection. There is strong evidence to suggest that postoperative antibiotics do not reduce rates of surgical site infections (SSIs) regardless of duration. However, there are conflicting data in the literature regarding the role of prophylactic preoperative antibiotics in reducing rates of SSIs. This study reviews the rate of infections in patients who underwent mandibular fracture repair who received a course of preoperative prophylactic antibiotics compared with those who received no or 1 dose of perioperative antibiotics. METHODS: Adult patients who underwent mandibular fracture repair at Prisma Health Richland between 2014 and 2019 were included in the study. A retrospective cohort review was conducted to determine the rate of SSI, comparing 2 groups of patients who underwent mandibular fracture repair. Patients who received more than 1 dose of scheduled antibiotics before surgery were compared with those who did not receive any antibiotic treatment before surgery or received only a single dose of antibiotics within 1 hour of incision time (perioperative antibiotics). The primary outcome was the rate of SSI between the 2 groups of patients. RESULTS: There were 183 patients who received more than 1 dose of scheduled antibiotics before surgery and 35 patients who received a single dose of perioperative antibiotics or did not receive any antibiotics. The rate of SSI was not significantly different in the preoperative prophylactic antibiotics group (29.3%) compared with the patients who received a single perioperative dose or no antibiotics (25.0%). CONCLUSION: Extended regimens of preoperative prophylactic antibiotics beyond a single dose at time of surgery do not reduce SSIs after surgical repair in mandibular fractures.

Palmar Creases and Their Implication on Carpal Tunnel Surgery.

BACKGROUND: A thorough knowledge of normal and variant anatomy of the wrist and hand is fundamental to avoiding complications during carpal tunnel release. The purpose of this study was to document variations of the surface anatomy of the hand to identify a safe zone in which the initial carpal tunnel incision could be placed. The safe zone was identified as the distance between the radial side of hook of hamate and the ulnar edge of the origin of the motor branch of the median nerve (MBMN). METHODS: Kaplan's cardinal line and other superficial markers were used to estimate the size of the safe zone, in accordance to prior published anatomical studies. The presence of a longitudinal palmar crease (thenar, median, or ulnar creases) within the safe zone was recorded. RESULTS: Of the 150 participants (75 male, 75 female) examined, the average safe zone widths were 10.85 (right) and 10.28 (left) mm. In all the hands examined, 86.33% of the safe zones (259 of 300) contained a longitudinal palmar crease. In the White population (n = 50), the average safe zone widths were 11.49 (right) and 10.01 (left) mm; in the African American population (n = 50), the average safe zone widths were 12.27 (right) and 12.01 (left) mm; and in the Asian population (n = 50), the average safe zone widths were 8.79 (right) and 8.82 (left) mm. On overage, males had a larger safe zone width than females by 4.55 mm. CONCLUSIONS: Although there seems to be variability between race and sex with regard to safe zone width, finding 86.33% of longitudinal palmar creases within the safe zone suggests that, for most patients, the initial carpal tunnel surgery incision may be hidden within the palmar crease while minimizing the risk of motor branch of the median nerve injury. Overall, the safe zone width is on average up to 10.5 mm measured from the hook of the hamate along Kaplan's cardinal line.

The Role of Maximal Locoregional Block in Autologous Breast Reconstruction.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has become the standard of care in microsurgical breast reconstruction. The current literature provides overwhelming evidence of the benefit of ERAS pathways in improving quality of recovery, decreasing length of hospital stay, and minimizing the amount of postoperative narcotic use in these patients. However, there are limited data on the role of using maximal locoregional anesthetic blocks targeting both the abdomen and chest as an integral part of an ERAS protocol in abdominally based autologous breast reconstruction. The aim of this study is to compare the outcomes of implementing a comprehensive ERAS protocol with and without maximal locoregional nerve blocks to determine any added benefit of these blocks to the standard ERAS pathway. METHODS: Forty consecutive patients who underwent abdominally based autologous breast reconstruction in the period between July 2017 and February 2020 were included in this retrospective institutional review board-approved study. The goal was to compare patients who received combined abdominal and thoracic wall locoregional blocks as part of their ERAS pathway (study group) with those who had only transversus abdominis plane blocks. The primary end points were total hospital length of stay, overall opioids consumption, and overall postoperative complications. RESULTS: The use of supplemental thoracic wall block resulted in a shorter hospital length of stay in the study group of 3.2 days compared with 4.2 days for the control group (P < 0.01). Postoperative total morphine equivalent consumption was lower at 38 mg in the study group compared with 51 mg in the control group (P < 0.01). Complications occurred in 6 cases (15%) in the control group versus one minor complication in the thoracic block group. There was no difference between the 2 groups in demographics, comorbidities, and type of reconstruction. CONCLUSION: The maximal locoregional nerve block including a complete chest wall block confers added benefits to the standard ERAS protocol in microvascular breast reconstruction.

Traumatic Abdominal Wall Hernia Repair with Dermal Autograft within a Morel-Lavallée Lesion.

Morel-Lavallée lesions and traumatic abdominal wall hernias seldom present together and have no standardized guidelines for treatment. We present a unique case of a traumatic abdominal wall hernia present within a patient's abdominal Morel-Lavallée lesion, which was reduced and repaired with a dermal autograft. This is a novel approach to repairing a rare and unusual injury. The literature suggests that tension-free repairs with mesh should be used on delayed repairs of traumatic abdominal wall hernias. However, some advocate for primary repairs due to an up to 50% increased risk of wound infection in these injuries, even without the use of mesh. Although infection rates with the use of biologic mesh (acellular dermal matrices) in a contaminated field are lower than that of synthetic mesh, infections still occur and tend to be higher in repairs without mesh. The lack of foreign material and innate immunogenicity of the patient's own dermis may theoretically decrease the risk of infection compared with other commercially-available and biologically-derived products. The patient is a 47-year-old woman who was in a motor vehicle accident with prolonged extrication time. She was hospitalized for approximately 6 months due to extensive injuries, but had no further complications from her Morel-Lavallée lesion or repair of her traumatic abdominal wall hernia with her own dermis.

Modified Carpal Tunnel Release: A New Approach to Minimizing Pillar Pain.

INTRODUCTION: Pillar pain is a frequent postoperative complication of carpal tunnel release (CTR). The precise definition of pillar pain is lacking, but most authors describe it as diffuse aching pain and tenderness in the thenar and hypothenar area. The etiology of pillar pain is unclear. However, the most prevalent theory is the neurogenic theory, which attributes the pain to the damage of small nerve branches of palmar cutaneous branches of median nerve after surgical incision, with resulting entrapment of the nerves in the scar tissue at the incision site. We postulated that a main source of pillar pain is sensory neuromas along the incision site.In this article, we describe a simple modification of the standard CTR technique with intent to decrease neuroma formation and thus minimizing pillar pain. MATERIALS AND METHODS: This is a retrospective study comparing the incidence and duration of pillar pain between patients who underwent standard CTR (SCTR, n = 53) versus the minimizing pillar pain CTR technique (n = 55). Based on duration of pillar pain, the groups were placed into 3 subgroups (<3, 3-6, and >6 months). Presence and duration of pillar pain in each group were recorded along with return to work (RTW), complications, and patient satisfaction. RESULTS: The SCTR group had a total of 17 patients with pillar pain (32.1%), 5 of which resolved within 3 months, 7 within 3 to 6 months, and 5 in more than 6 months. The group that underwent the minimizing pillar pain technique had a total of 4 patients with pillar pain (7.2%). Three resolved within 3 months, 1 resolved within 3 to 6 months, and there were no patients with pillar pain lasting more than 6 months. Average RTW time for minimization of pillar pain CTR (MPPCTR) was 34.9 days. Average RTW time for SCTR was 54.8 days. Satisfaction was higher among patients who underwent surgery with MPPCTR. CONCLUSIONS: Based on these results, we concluded that MPPCTR compared with SCTR had equal complication rate, however, significantly lower incidence and duration of pillar pain, higher rate of satisfaction, and earlier RTW.

Temporal trends and outcome of splenectomy in adults with immune thrombocytopenia in the USA.

Splenectomy is one of the treatments of immune thrombocytopenia (ITP) with a high response rate. However, it is an irreversible procedure that can be associated with morbidity in this setting. Our aim was to study the trends of splenectomy in adults with ITP, and the factors associated with splenectomy and resource utilization during these hospitalizations. We used the National (Nationwide) Inpatient Sample (NIS) to identify hospitalizations for adult patients with a principal diagnosis of ITP between 2007 and 2017. The primary outcome was the splenectomy trend. Secondary outcomes were (1) incidence of ITP trend, (2) in-hospital mortality, length of stay, and total hospitalization costs after splenectomy trend, and (3) independent predictors of splenectomy, length of stay, and total hospitalization costs. A total of 36,141 hospitalizations for ITP were included in the study. The splenectomy rate declined over time (16% in 2007 to 8% in 2017, trend p < 0.01) and so did the in-hospital mortality after splenectomy. Of the independent predictors of splenectomy, the strongest was elective admissions (adjusted odds ratio [aOR]: 22.1, 95% confidence interval [CI]:17.8-27.3, P < 0.01), while recent hospitalization year, older age, and Black (compared to Caucasian) race were associated with lower odds of splenectomy. Splenectomy tends to occur during elective admissions in urban medical centers for patients with private insurance. Despite a stable ITP hospitalization rate over the past decade and despite listing splenectomy as a second-line option for management of ITP in major guidelines, splenectomy rates consistently declined over time.

Innervated Pedicled Gracilis Flap for Dynamic Abdominal Wall Reconstruction.

Abdominal wall reconstruction for full-thickness defects is a challenging procedure that usually requires the use of flaps. The gracilis flap is known to be used in hernia repair in which the abdominal muscles are still intact, but there are no reports in literature describing the use of an innervated gracilis for dynamic abdominal wall reconstruction after tissue loss due to severe trauma. We present a surgical technique in which the gracilis is harvested preserving the neurovascular pedicle, then tunneled underneath the adductor longus to cover the lower abdominal defect and provide it with basal muscle tone without tension on the pedicle. This results in restored integrity of the musculofascial abdominal wall and dynamic muscle function and support. The gracilis flap has been proven to be useful and versatile in reconstructive surgery with great potential in abdominal wall reconstruction having minimal donor-site morbidity and hernia recurrence risk.

Anomalous Radial Artery as an Incidental Finding During a Routine Carpal Tunnel Release.

BACKGROUND: Compression of the median nerve at the wrist, or carpal tunnel syndrome, is the most commonly recognized nerve entrapment syndrome. Carpal tunnel syndrome is usually caused by compression of the median nerve due to synovial swelling, tumor, or anomalous anatomical structure within the carpal tunnel. METHODS: During a routine carpal tunnel decompression, a large vessel was identified within the carpal tunnel. RESULTS: The large vessel was the radial artery. It ran along the radial aspect of the carpal tunnel just adjacent to the median nerve. CONCLUSIONS: The unusual presence of the radial artery within the carpal tunnel could be a contributing factor to the development of carpal tunnel syndrome. In this case, after surgical carpal tunnel release, all symptoms of carpal tunnel syndrome resolved.

Regulation of Chlamydomonas flagella and ependymal cell motile cilia by ceramide-mediated translocation of GSK3.

Cilia are important organelles formed by cell membrane protrusions; however, little is known about their regulation by membrane lipids. We characterize a novel activation mechanism for glycogen synthase kinase-3 (GSK3) by the sphingolipids phytoceramide and ceramide that is critical for ciliogenesis in Chlamydomonas and murine ependymal cells, respectively. We show for the first time that Chlamydomonas expresses serine palmitoyl transferase (SPT), the first enzyme in (phyto)ceramide biosynthesis. Inhibition of SPT in Chlamydomonas by myriocin led to loss of flagella and reduced tubulin acetylation, which was prevented by supplementation with the precursor dihydrosphingosine. Immunocytochemistry showed that (phyto)ceramide was colocalized with phospho-Tyr-216-GSK3 (pYGSK3) at the base and tip of Chlamydomonas flagella and motile cilia in ependymal cells. The (phyto)ceramide distribution was consistent with that of a bifunctional ceramide analogue UV cross-linked and visualized by click-chemistry-mediated fluorescent labeling. Ceramide depletion, by myriocin or neutral sphingomyelinase deficiency (fro/fro mouse), led to GSK3 dephosphorylation and defective flagella and cilia. Motile cilia were rescued and pYGSK3 localization restored by incubation of fro/fro ependymal cells with exogenous C24:1 ceramide, which directly bound to pYGSK3. Our findings suggest that (phyto)ceramide-mediated translocation of pYGSK into flagella and cilia is an evolutionarily conserved mechanism fundamental to the regulation of ciliogenesis.