Osteonecrosis of Trapezium Occurring in Patient with History of Recurrent Carpometacarpal Corticosteroid Injection.

Osteonecrosis affecting the carpal bones is rare and is mostly seen in the lunate (Kienböck's disease). Osteonecrosis of the scaphoid (Preiser disease) is even rarer. There are only four individual case reports published on patients presenting with trapezium necrosis, none with previous history of corticosteroid injection. This case report is the first presentation of isolated trapezial necrosis in the setting of prior corticosteroid injection for thumb basilar arthritis. Level of Evidence: Level V (Therapeutic).

The Use of Montage Bone Putty in Assisting in the Maintenance of Reduction in Comminuted Distal Radius Fractures.

Background The distal radius fracture is the most common fracture in the United States. Achieving stable reduction and fixation of complex fracture patterns can be challenging. In order to help maintain reduction of comminuted fracture to simplify plating, the calcium phosphate-based bone putty Montage has been developed. Questions/Purposes Does Montage assist in achieving stable reduction and fixation of complex distal radius fractures with an acceptable complication profile? Patient and Methods We retrospectively analyzed all patients who were treated intraoperatively with Montage bone putty along with volar plate fixation at a large-volume urban county hospital. Preoperative, intraoperative, and postoperative measurements of radiographic features were recorded at 2 and 6 months, as were any complications. Statistical analysis was then performed on these values. Results Preoperative and postoperative radiographs demonstrated significant improvement in standard distal radius fracture measurements, reflecting adequate reduction with the use of Montage intraoperatively. Critically, radiographs demonstrated maintenance of reduction compared to intraoperative fluoroscopy images at 2 months, showing short-term stability of the use of Montage in these fracture patterns as well as long-term stability at 6 months in a subset of patients. There were no major complications in this study. Conclusion In this study, we demonstrate the utility of Montage bone putty for complex distal radius fractures with short-term follow-up and limited long-term follow-up. This initial study underlines its efficacy in maintaining reduction without major complications. Level of Evidence IV, Therapeutic.

Multiple Recurrent Fibromatosis With Cranial Fasciitis Characteristics in a Pediatric Patient.

Cranial fasciitis is a rare, rapidly growing, but benign fibroblastic tumor of the skull that generally presents in childhood. Local resection or curettage of the affected bone is generally curative and the tumor is thought not to recur. Cranial fasciitis is distinguished by positive cytoplasmic and nuclear beta-catenin staining. Fibromatosis is a clonal myofibroblastic nonmalignant proliferation that generally demonstrates positive nuclear beta-catenin staining. In this report, the authors present a patient with fibromatosis with cranial fasciitis characteristics in a 2.5-month-old boy who has had 7 recurrences (total 8 resections) of this fibroblastic neoplasm over 6 years of follow-up.

A Population-Based Exploration of the Social Implications Associated with Cleft Lip and/or Palate.

BACKGROUND: Clefts of the lip and/or palate (CL/P) carry a social stigma that often causes psychosocial stress. The purpose of this study was to consider the association of cleft phenotype and age with self-reported aspects of psychosocial stress. METHODS: Children with nonsyndromic CL/P and unaffected children born between 1997 and 2003 were identified through the North Carolina Birth Defects Monitoring Program and North Carolina birth records, respectively. The psychosocial concerns of children with CL/P were assessed via a 29-question subset of a larger survey. Responses were analyzed according to school age and cleft phenotype (cleft lip with/without cleft alveolus, CL ± A; cleft palate only, CP; or cleft lip with cleft palate, CL + P). RESULTS: Surveys were returned for 176 children with CL/P and 333 unaffected children. When compared with unaffected children, responses differed for CL ± A in 4/29 questions, for CP in 7/29 questions, and for CL + P in 8/29 questions (P < 0.05). When stratified by school age, children with CL/P in elementary, middle, and high school differed from unaffected children by 1/29, 7/29, and 2/29 questions, respectively. Middle school-aged children with CL/P were more affected by aesthetic concerns, bullying, and difficulties with friendship, and social interaction. Children with CL + P reported more severe aesthetic-related concerns than children with CL ± A or CP but experienced similar speech-related distress as children with CP only. CONCLUSION: Social implications associated with CL/P are most pronounced during middle school, and less so during elementary and high school. This information identifies areas of social improvement aimed at reducing the stigma of CL/P.

Nasal Airway Dysfunction in Children with Cleft Lip and Cleft Palate: Results of a Cross-Sectional Population-Based Study, with Anatomical and Surgical Considerations.

BACKGROUND: The aesthetic aspects of the cleft lip nasal deformity have been appreciated for over a century, but the functional implications have remained largely underappreciated or misunderstood. This study describes the frequency and severity of nasal obstructive symptoms among children with cleft lip and/or cleft palate, addressing the hypotheses that age, cleft type, and severity are associated with the development of nasal obstructive symptoms. METHODS: Children with nonsyndromic cleft lip and/or cleft palate and a comparison group of unaffected children born from 1997 to 2003 were identified through the North Carolina Birth Defects Monitoring Program and birth certificates. Nasal airway obstruction was measured using the validated Nasal Obstruction Symptom Evaluation scale. RESULTS: The survey was completed by parental proxy for 176 children with cleft lip and/or cleft palate and 333 unaffected children. Nasal obstructive symptoms were more frequently reported in cleft lip with cleft palate compared with unaffected children (p < 0.0001); children who had isolated cleft lip with or without alveolus and isolated cleft palate were not statistically different from unaffected children. Patients with unilateral cleft lip with cleft palate were found to be more severely affected than bilateral cases. Nasal obstruction was observed in early childhood, although severity worsened in adolescence. CONCLUSIONS: This population-based study reports a high prevalence of nasal obstructive symptoms in children with cleft lip and/or cleft palate based on type and severity of the cleft. The authors encourage cleft teams to consider using this or similar screening methods to identify which children may benefit from functional rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, I.

Can Vascular Patterns on Preoperative Magnetic Resonance Imaging Help Predict Skin Necrosis after Nipple-Sparing Mastectomy?

BACKGROUND: Nipple-areola complex (NAC) and skin flap ischemia and necrosis can occur after nipple-sparing mastectomy (NSM). The purpose of this study was to correlate vascular findings on MRI with outcomes in patients who underwent NSM. STUDY DESIGN: Female patients at a single institution who underwent NSM and had a preoperative breast MRI between 2010 and 2014 were identified. Medical records were reviewed for patient demographics, surgical factors, and complications. Magnetic resonance images were reviewed by 2 radiologists, blinded to outcomes, for the presence of dual vs single blood supply to the breast. The association between blood supply on MRI with ischemic and necrotic complications after NSM was analyzed. RESULTS: One hundred and sixty-four NSM procedures were performed in 105 patients (mean age 45.5 years, range 25 to 69 years) who had a preoperative MRI. The majority of procedures were performed for malignancy (89 of 164 [54.3%]) or prophylaxis (73 of 164 [44.5%]). Nipple-areola complex or skin flap ischemia or necrosis occurred in 40 (24.4%) breasts. Ischemia or necrosis after NSM was less likely to occur in breasts with dual compared with single blood supply (20.8% vs 38.2%; p = 0.03). There was no association between surgical complications and age, BMI, smoking history, previous radiation therapy, indication for NSM, surgical specimen weight, surgical incision type, reconstruction approach, or operating surgeon on univariate analysis. CONCLUSIONS: Preoperative MRI characterization of breast vascularity can be considered when planning NSM. The presence of a dual blood supply to the breast on MRI is associated with a decreased risk of nipple-areola complex and skin flap ischemia and necrosis after NSM.

Evolving Trends in Autologous Breast Reconstruction: Is the Deep Inferior Epigastric Artery Perforator Flap Taking Over?

BACKGROUND: Enthusiasm for the deep inferior epigastric artery perforator (DIEP) flap for autologous breast reconstruction has grown in recent years. However, this flap is not performed at all centers or by all plastic surgeons for breast reconstruction, and it is unclear whether practice patterns have measurably changed. This study aimed to (1) evaluate changing trends in breast flap use in the United States in recent years and (2) identify how these trends have affected charges and costs associated with autologous breast reconstruction. METHODS: Patients undergoing autologous breast reconstruction [latissimus dorsi (LD), pedicled transverse rectus abdominus myocutaneous (pTRAM), free TRAM (fTRAM), and DIEP] were identified using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2009-2011). A total of 19,182 hospital discharges were reviewed. Patient demographics, hospital teaching center status, payer status, length of stay, total charges, and total costs per discharge were reviewed. Statistical analysis was performed using linear regression, t test, and analysis of variance models. RESULTS: Between 2009 and 2011, the total number of discharges did not change significantly. Patient age distribution was similar for all flap groups. For individual flaps, there was a significant increase in DIEP flaps (P = 0.03), with a decreasing trend for other abdominal-based flaps. The patients receiving DIEP flap breast reconstruction were covered by private insurance at a higher rate than all other flap procedures (P = 0.03), whereas other potential cost determinants did not differ significantly between the groups. The mean charge per flap was $40,704 for LD, $51,933 for pTRAM, $69,909 for fTRAM, and $82,320 for DIEP. The mean cost per flap was $12,017 for LD, $15,538 for pTRAM, $20,756 for fTRAM, and $23,616 for DIEP. CONCLUSIONS: Between 2009 and 2011, the total amount of autologous breast reconstruction discharges was relatively stable, but the number of DIEP flaps increased significantly. Review of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample data shows that, compared with LD, pTRAM, and fTRAM flaps, the DIEP flap is associated with higher charges and costs.

Vascular considerations in foot and ankle free tissue transfer: Analysis of 231 free flaps.

OBJECTIVE: Successful foot and ankle soft tissue reconstruction is dependent on a clear understanding of the vascular supply to the foot. The aim of this study was to identify risk factors for reconstructive failure following foot and ankle free tissue transfer. METHODS: The authors retrospectively reviewed their 17-year institutional experience with 231 foot and ankle free flaps performed in 225 patients to determine predictors of postoperative foot ischemia and flap failure. Postoperative foot ischemia was defined as ischemia resulting in tissue necrosis, separate from the reconstruction site. RESULTS: Six (3%) patients developed postoperative foot ischemia, and 28 (12%) patients experienced flap failure. Chronic ulceration (P = 0.02) and an elevated preoperative platelet count (P = 0.04) were independent predictors of foot ischemia. The presence of diabetes was predictive of flap failure (P = 0.05). Flap failure rates were higher in the setting of an abnormal preoperative angiogram (P = 0.04), although the type and number of occluded arteries did not influence outcome. Foot ischemia was more frequent following surgical revascularization in conjunction with free tissue transfer and the use of the distal arterial bypass graft for flap anastomosis (P < 0.01). Overall, no differences were observed in foot ischemia (P = 0.17) and flap failure (P = 0.75) rates when the flap anastomosis was performed to the diseased artery noted on angiography, compared with an unobstructed native tibial artery. CONCLUSIONS: Foot and ankle free tissue transfer may be performed with a low incidence of foot ischemia. Patients with diabetes, chronic ulceration, and an elevated preoperative platelet count are at higher risk for reconstructive failure. © 2015 Wiley Periodicals, Inc. Microsurgery 36:276-283, 2016.

Delayed implant augmentation of breast free flaps.

BACKGROUND: Two commonly used breast reconstruction techniques are (1) implant-based and (2) abdominal tissue-based procedures. When the two modalities are combined, the result is a unique construct that shares advantages and disadvantages of both approaches. Combining breast flaps and implants has been reported, yet the specific techniques associated with a reliable outcome remain unclear. MATERIALS AND METHODS: Between July 2010 and 2014, a review of all patients who underwent delayed implant augmentation of a breast free flap reconstruction by the senior author was performed. Data were collected on patient characteristics, implants used, timing of reconstruction, and position of implant relative to the flap. RESULTS: During the study period, 101 patients underwent breast reconstruction with 161 abdominal free flaps. Of these, 12 patients (12%) and 17 flaps (11%) had delayed implant augmentation. Of the 17 augmented flaps, 12 had expanders placed before final implant placement. Eleven implants were placed in the subflap position and 6 in the subpectoralis major position. The mean final implant size was 296.5 mL (range, 125-510 mL). At a mean follow-up of 17.1 months, there was one expander removed before complete expansion for impending extrusion and one silicone gel implant revision for malposition. CONCLUSION: The results of delayed breast flap implant augmentation can be reliable and generate results that may not be obtainable with flaps or implants alone. Admittedly, the addition of an implant to a flap reconstruction exposes the patient to implant-related complications that would otherwise have been circumvented by a pure autologous reconstruction.

An algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle.

BACKGROUND: Wound breakdown after orthopaedic foot and ankle surgery may necessitate secondary soft tissue coverage. The foot and ankle region is challenging to reconstruct for orthopaedic and plastic surgeons owing to its complex bony anatomy and unique functional demands. Therefore, identifying strategies for plastic surgery of these wounds may help guide surgeons in defining the best treatment plan. QUESTIONS/PURPOSES: We evaluated our current algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle with respect to whether (1) prophylactic or simultaneous soft tissue coverage affected wound-healing complications (secondary plastic surgery, orthopaedic hardware removal, malunion, further orthopaedic surgery, ultimate failure) and (2) postoperative referral for soft tissue management was associated with wound location, size, and orthopaedic procedure. METHODS: We retrospectively reviewed 112 patients who underwent elective orthopaedic foot or ankle surgery and required concomitant plastic surgery at our institution. Study end points included secondary plastic surgery procedures, hardware removal for infection, foot or ankle malunion, further orthopaedic surgery, and wound-healing failure as defined by a chronic nonhealing wound or need for amputation. Minimum followup was 0.6 months (mean, 24.9 months; range, 0.6-197 months). Four patients were lost to complete followup. We developed an algorithm that centers on two critical points of care: preoperative evaluation by the orthopaedic surgeon and evaluation and treatment by the plastic surgeon after referral. RESULTS: Compared with postoperative intervention, prophylactic or simultaneous soft tissue coverage did not lead to differences in frequency of secondary plastic surgery procedures (p = 0.55), hardware removal procedures (p = 0.13), malunions (p = 0.47), further orthopaedic surgery (p = 0.48), and ultimate failure (p = 0.27). Patients referred postoperatively for soft tissue management most frequently had dorsal ankle wounds (p < 0.001) of smaller size (p = 0.03), most commonly associated with total ankle arthroplasty (p = 0.004). CONCLUSIONS: Using our algorithmic approach, prophylactic or simultaneous soft tissue coverage did not improve the study end points. In addition, unexpected postoperative wound breakdown necessitating a plastic surgery consultation most commonly occurred on the dorsal ankle after total ankle arthroplasty. Our algorithm facilitates early identification of skin instability and enables prompt soft tissue coverage before or concurrently with orthopaedic procedures. The effect of prophylactic or simultaneous soft tissue coverage on postoperative wound healing requires further investigation. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Beyond the mitochondrion: cytosolic PINK1 remodels dendrites through protein kinase A.

The subcellular compartmentalization of kinase activity allows for regulation of distinct cellular processes involved in cell differentiation or survival. The PTEN-induced kinase 1 (PINK1), which is linked to Parkinson's disease, is a neuroprotective kinase localized to cytosolic and mitochondrial compartments. While mitochondrial targeting of PINK1 is important for its activities regulating mitochondrial homeostasis, the physiological role of the cytosolic pool of PINK1 remains unknown. Here, we demonstrate a novel role for cytosolic PINK1 in neuronal differentiation/neurite maintenance. Over-expression of wild-type PINK1, but not a catalytically inactive form of PINK1(K219M), promoted neurite outgrowth in SH-SY5Y cells and increased dendritic lengths in primary cortical and midbrain dopaminergic neurons. To identify the subcellular pools of PINK1 involved in promoting neurite outgrowth, we transiently transfected cells with PINK1 constructs designed to target PINK1 to the outer mitochondrial membrane (OMM-PINK1) or restrict PINK1 to the cytosol (ΔN111-PINK1). Both constructs blocked cell death associated with loss of endogenous PINK1. However, transient expression of ΔN111-PINK1, but not of OMM-PINK1 or ΔN111-PINK1(K219M), promoted dendrite outgrowth in primary neurons, and rescued the decreased dendritic arborization of PINK1-deficient neurons. Mechanistically, the cytosolic pool of PINK1 regulated neurite morphology through enhanced anterograde transport of dendritic mitochondria and amplification of protein kinase A-related signaling pathways. Our data support a novel role for PINK1 in regulating dendritic morphogenesis.