Gillies elevation and percutaneous Kirschner wire fixation in the treatment of simple zygoma fractures: long-term quantitative outcomes.

BACKGROUND: The objective of zygoma fracture repair is to restore preinjury function and appearance. The optimal surgical technique represents a balance between accurate fracture reduction and soft-tissue morbidity. METHODS: Fifty patients were eligible for review after treatment for isolated simple zygoma fractures using a combination of Gillies elevation and percutaneous Kirschner wire fixation between 1992 and 2003. Fourteen patients were available for examination at a mean follow-up of 8.7 years. Quantifiable parameters, including orbitozygomatic complex position, ocular globe projection, and infraorbital nerve function, were measured. All patients underwent qualitative assessment by independent, blinded observers. Negative soft-tissue sequelae were recorded. RESULTS: The mean differences between injured and uninjured sides of the face for malar eminence projection, height, and lateral position were 2.5, 2.7, and 2.3 mm, respectively. The mean difference in ocular globe projection was 1.23 mm. When these results were compared with those previously published for open reduction and internal fixation, no statistically significant difference was noted. The qualitative observers were able to identify the affected side 12 percent of the time. Other than a small punctate scar noted in one patient at the Kirschner wire insertion site, no other negative cutaneous or eyelid sequelae were noted. CONCLUSIONS: This study objectively shows that Gillies elevation combined with percutaneous Kirschner wire fixation provides facial contour restoration that is not significantly different from that of open reduction and internal fixation, with less soft-tissue morbidity. The technique is safe, easy to learn, and easy to perform, and should be considered in cases of isolated simple zygoma fractures.

Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach.

BACKGROUND: The elective use of low-dose epinephrine in hand surgery has allowed for the performance of simple operative procedures with tourniquet-free pure local anesthesia (the wide-awake approach). The absence of general anesthesia or sedation has, in turn, allowed for the observation of how quickly the sensorimotor cortex adapts following procedures such as tendon transfer. METHODS: Seven patients underwent a wide-awake transfer of the extensor indicis proprius to the extensor pollicis longus between February of 2002 and May of 2005 for restoration of thumb extension using local lidocaine with epinephrine alone. One of the seven patients experienced rupture of the initial transfer, necessitating transfer of the extensor carpi radialis longus to the extensor pollicis longus using the wide-awake approach. RESULTS: All seven patients were able to extend their thumbs fully by means of extensor indicis proprius intraoperatively immediately following transfer suture placement. Restoration of function was not ablated by loss of proprioception or visual feedback. At a mean follow-up of 15 months, thumb extension was restored to within normal limits in the affected thumb, with a slight decrease in grip and tripod pinch strength. CONCLUSIONS: The wide-awake approach has allowed the authors to adjust tendon transfer tension with active movement before skin closure without the risks associated with general or regional anesthesia. In addition, it has allowed them to observe immediate cortical adaptation in the context of a simple tendon transfer. The authors hypothesize that the brain's ability to immediately use extensor indicis proprius for thumb extension stems from the activation of preexisting synergistic cortical finger movement programs.

A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase.

PURPOSE: To examine prospectively the incidence of digital infarction and phentolamine rescue in a large series of patients in whom local anesthesia with adrenaline was injected electively into the hand and fingers. There continues to be a commonly held belief that epinephrine injection is contraindicated in the finger despite a lack of valid evidence to support this concept in the literature. METHODS: From 2002 to 2004 there were 9 hand surgeons in 6 cities who prospectively recorded each consecutive case of elective hand and finger epinephrine injection. They recorded each instance of skin or tissue loss and the number of times phentolamine reversal of adrenaline vasoconstriction was required. RESULTS: There were 3,110 consecutive cases of elective injection of low-dose epinephrine (1:100,000 or less) in the hand and fingers and none produced any instance of digital tissue loss. Phentolamine was not required to reverse the vasoconstriction in any patients. CONCLUSIONS: The true incidence of finger infarction in elective low-dose epinephrine injection into the hand and finger is likely to be remote, particularly with the possible rescue with phentolamine.