Simultaneous mastopexy in patients undergoing prophylactic nipple-sparing mastectomies and immediate reconstruction.

BACKGROUND: In some patients, a satisfactory aesthetic result of reconstruction following a nipple-sparing mastectomy (NSM) is limited by breast ptosis that goes uncorrected in the early phase of reconstruction. Most plastic surgeons remain hesitant to perform a mastopexy at the time of NSM due to concerns with nipple and/or skin flap loss. METHODS: From 1990 to 1995, 33 female patients underwent NSM with simultaneous mastopexy and immediate implant-based reconstruction by a single surgeon at our institution. On chart review, the following data were extracted: age, co-morbidity, indication, breast size, initial/final implant volumes, type of implant, mastopexy technique, mastectomy flap/nipple necrosis, other complications, revision surgery and follow-up. An unpaired, two-tailed t-test was performed where indicated. P-value<0.05 was considered significant. RESULTS: Wound complications occurred in 18.2% patients (10.9% breasts) without delaying tissue expansion. As many as 3% patients developed unilateral, isolated partial ischaemia of the mastectomy flap and 8% patients developed unilateral, superficial areolar loss. All resolved with conservative treatment. Only one patient developed bilateral total nipple loss. There was no correlation between preoperative breast size and postoperative complications. None of the patients developed breast cancer. Average follow-up was 11.6 years. CONCLUSION: With proper technique, simultaneous mastopexy is a safe procedure in highly selected patients undergoing NSM with reconstruction.

Comparison of distal humerus fracture fixation: a biomechanical study.

Few biomechanical studies have been done evaluating the rigidity of internal fixation constructs for distal humerus fractures. We assessed the bending and torsional stiffness of five commonly used multiple plate constructs. Plates were applied in three positions: medially, along the medial supracondylar column; laterally, along the lateral supracondylar column; or posterolaterally, extending distally to the capitellum. Each specimen was randomly assigned to one of five construct groups. All plated specimens were stiffer in the frontal plane as compared with the sagittal plane and, when compared with intact specimens, showed a disproportionate decrease in sagittal plane stiffness. Constructs 1 and 5 had significantly greater relative bending stiffness in the sagittal plane than constructs 3 and 4. Construct 4 had the lowest relative bending stiffness in the frontal plane. This reached statistical significance when compared with constructs 2 and 5. There was no significant difference in the torsional stiffness of the five constructs. We conclude that the multiple plate constructs offered significantly less bending stiffness than the intact specimens, with a particular deficiency in the sagittal plane. The triple-plated construct (construct 5) did not confer greater stiffness and was technically difficult to implant. The medial pelvic reconstruction plate combined with the posterolateral DCP (construct 1) provided the greatest sagittal plane stiffness, in addition to comparable frontal plane and torsional stiffness. We recommend its use in the treatment of fractures of the distal humerus.

Reliability of radiographic assessment of acromial morphology.

The most widely used radiographic classification system for acromial morphology identifies three distinct acromial shapes: type I (flat), type II (curved), and type III (hooked). The purpose of this study was to measure the interobserver and intraobserver reliability of determinations of acromial morphology as defined by this system. Between 1990 and 1992, one hundred twenty-six supraspinatus outlet radiographs were obtained from 126 patients by technicians from Triangle Orthopaedic Associates in Durham, N.C. Six fellowship-trained shoulder surgeons independently reviewed each radiograph and classified it as type I, II, or III on the basis of established guidelines. Two surgeons classified each film a second time in random order. Analysis of variance was performed to obtain coefficients for interobserver and intraobserver reliability. Consensus ratings were then used to classify the 126 radiographs into consensus type I, consensus type II, or consensus type III groups. Percentages of type I, II, and III individual ratings within each consensus group were determined. The intraobserver reliability coefficient was 0.888, interpreted as good to excellent reliability. The interobserver reliability coefficient was 0.516, interpreted as poor to fair reliability. Of the 126 radiographs, 26 (20.6%) were rated as consensus type I, 76 (60.3%) were rated as consensus type II, and 24 (19.1%) were rated as consensus type III. The reliability of observer ratings was lowest when delineation between acromial types II and III was required. The low interobserver reliability makes comparisons of studies by different authors difficult to interpret and obscures the true incidence of acromial morphologic types. It also questions reported correlations between acromial type and shoulder pathologic conditions. It is concluded that a system that incorporates more objective classification criteria and acknowledges the continuous nature of acromial morphologic types may improve interobserver reliability and validate the system's use in making clinical and surgical judgments.

Fracture of a supracondylar humeral myositis ossificans.

Although myositis ossificans is a well-known sequela of elbow trauma, reinjury to the affected region can also occur, resulting in acute symptoms from a fracture of the myositis ossificans. An 18-year-old man presented with localized pain, soft-tissue swelling, and a bony mass along the anterolateral distal humerus with restricted elbow range of motion after injury to his elbow during football. One year earlier he had sustained a similar crush injury to his elbow that resulted in a limited, although painless, arc of motion. Radiographs and tomograms established the diagnosis of a fractured supracondylar humeral myositis ossificans. Surgical excision of the large mature ossified fragment confirmed the diagnosis and restored a full range of motion of the elbow.

Fractures of the supracondylar process of the humerus.

The supracondylar process of the humerus is a relatively rare but well-known anatomic variant that can be associated with other anomalies. While it usually remains clinically silent, the spur can be responsible for a wide spectrum of symptoms. We present 3 patients with fractures of the supracondylar process and review 12 other cases in the literature. The supracondylar process has potential for fracture and important neurovascular sequelae.

The glenohumeral offset ratio: A radiographic study.

A systematic method of component selection for total shoulder arthroplasty is needed. The method must take into account the soft-tissue constraints of a degenerative joint and optimize joint biomechanics by placing the joint line in the best possible position. The purpose of our study was to determine radiographically the normal glenohumeral joint line position based on a ratio of distances between the joint line and fixed landmarks on the humerus and scapula. We studied modified anteroposterior radiographs of the glenohumeral joint in 86 volunteers (51 men and 35 women; ages ranging from 21 to 47 years). Two measurements were made on each radiograph: (1) the perpendicular distance from the most medial portion of the glenoid to the inferior base of the coracoid process at its attachment to the scapular blade, and (2) the perpendicular distance from the midline of the humeral shaft to the most medial point on the humeral head. The joint line position was described as the ratio of the glenoid measurement to the sum of the two measurements (i.e., the glenohumeral offset ratio). The validity and reliability of glenoid offset measurements were determined by comparing radiographic and anatomic measurements of glenoid offset in cadaveric human scapulae. Radiographs were made with rotational error to determine its effects on the measurement of humeral offset. Humeral offsets and glenoid thicknesses of five different total shoulder systems were then determined from template overlays. The mean glenohumeral offset ratio was 0.31 (range 0.18 to 0.39). We detected no significant difference in the ratio between men and women volunteers. There was close agreement between radiographie and direct (anatomic) measurements of glenoid offset in cadaveric scapulae. Values for humeral offset were not significantly affected by radiographic rotational error. The evidence indicates that a fairly constant glenohumeral offset ratio in normal shoulders can be reliably calculated from a single radiograph. In addition to the prosthesis specifications, we suggest that the glenohumeral offset ratio is a potentially useful preoperative planning tool for total shoulder arthroplasty.

Sedimentary 12-n-Propylcholestanes, Molecular Fossils Diagnostic of Marine Algae.

Certain C(30)-steranes have been used for identifying sedimentary rocks and crude oils derived from organic matter deposited in marine environments. Analysis of a C(30)-sterane from Prudhoe Bay oil indicates that these C(30)-steranes are 24-n-propylcholestanes that apparently are derived from precursor sterols 24-n-propylidene-cholesterols and 24-n-propylcholesterol. These widely occurring sterols are biochemically synthesized in modern oceans by members of an order (Sarcinochrysidales) of chrysophyte algae. These data thus imply that C(30)-sterane biomarkers in sedimentary rocks and crude oils have a marine origin. Screening of a few organic-rich sedimentary rocks and oils from throughout the Phanerozoic suggests that these C(30)-steranes first appeared and, therefore, their source algae evolved between Early Ordovician and Devonian.