Meningomyelocele Reconstruction: Comparison of Repair Methods via Systematic Review.

PURPOSE: The purpose of this article was to appraise the various methods of reconstruction for meningomyelocele (MMC) defects. METHODS: A systematic review of the literature was performed to evaluate all reconstructions for MMC. The method of reconstruction was categorized by: primary closure with and without fascial flaps, random pattern flaps, VY advancement flaps (VY), perforator flaps, and myocutaneous flaps. Perforator flaps were subsequently subcategorized based on the type of flap. RESULTS: Upon systematic review, 567 articles were screened with 104 articles assessed for eligibility. Twenty-nine articles were further reviewed and included for qualitative synthesis. Two hundred seventy patients underwent MMC repair. The lowest rates of major wound complications (MWC) were associated with myocutaneous and random pattern flaps. A majority of MWC was in the lumbrosacral/sacral region (87.5% of MWC). In this region, random patterns and perforator flaps demonstrated the lowest rate of MWC (4.5, 8.1%). CONCLUSIONS: Plastic surgery consultation should be strongly considered for MMC with defects in the lumbosacral/sacral region. Perforator flaps are excellent options for the reconstruction of these defects.

Clinical Characteristics and Treatment Patterns of Open Hand Fractures in the Pediatric Population.

BACKGROUND: Open hand fractures are one of the most common injuries in the pediatric population. These injuries are at higher risk of infection, especially in cases of frank contamination. Several studies on adult hand fractures are available in the literature; however, pediatric open hand fractures have yet to be extensively studied. This study aimed to define pediatric open hand fracture's demographics, clinical characteristics, and treatment patterns. METHODS: Using the Protected Health Information database, pediatric patients (<18 y old) with the diagnosis of open hand fracture from June 2016 to June 2018 were extracted. Demographic, treatment, and follow-up data were collected. Clinical outcomes included readmission and postoperative infection rates. RESULTS: There were a total of 4516 patients who met the inclusion criteria; the median age was 7 years (interquartile range: 3 to 11); 60% males; 60% white. Displaced fractures occurred in 74% of patients, with the right hand (52%) and middle finger (27%) predominance. The most common mechanism of injury was a crushing injury in-between objects (56%). Associated nerve injury occurred in 78 patients (4%) and vascular injury in 43 patients (2%). Open reduction and internal fixation were performed in 30% of patients. Cephalosporins were the most commonly prescribed antibiotics (73%), followed by aminopenicillins (7%). Nine patients had complications related to surgical intervention (0.2%), and postoperative infection occurred in 44 patients (1%). CONCLUSIONS: Pediatric open hand fractures most often occur during childhood and more frequently in males. These fractures tend to be more distal and displaced; reduction and fixation are required in one-third of the cases. Despite the absence of treatment guidelines and variability, this injury exhibits low complication rates. LEVEL OF EVIDENCE: Level III, retrospective study.

Fractures in the Setting of Constriction Band Syndrome: A Case Series of Three Patients with Extremity Fractures at the Site of a Constriction Band.

Constriction band syndrome (CBS) is a rare condition where fibrous bands constrict one or more parts of the fetus with varying manifestations such as autoamputation, acrosyndactyly, and neuropathy. However, isolated extremity fractures in the setting of constriction band syndrome are even more rare, with only two reported cases in the literature. There are few guidelines on the management of CBS due to small case numbers, the variability of presentation between patients, and the lack of consensus on etiology and pathogenesis. In this small case series, we describe the presentation and management of three patients at our institution with extremity fractures at the site of severe constriction bands with neurologic injuries or vascular compromise. We also review the literature on this topic to provide further context. Intramedullary stabilization of the fracture with a k-wire allowed for soft tissue healing in two of our patients.

Art and Pediatric Orthopaedics: Ribera, an Artist for the Downtrodden.

Jusepe de Ribera's most famous artistic works consisted of the bizarre such as mutilated bodies and social outcasts, with one being of a Neapolitan beggar boy with upper and lower limb joint contractures. Although the etiology of the boy's contractures in The Clubfoot has been debated, we present a case for arthrogryposis with a unilateral clubfoot as the most likely diagnosis.

Composite Anterolateral Thigh and Fascia Lata Free Flap for Abdominal and Groin Reconstruction in a Pediatric Patient.

Large abdominal wall and groin defects present complex reconstructive challenges. These defects typically require free flap reconstruction to bring in healthy vascularized tissue and recreate the complex full-thickness defect. A 6-year-old previously healthy girl presented to our trauma center after sustaining a close-range shotgun injury resulting in a full-thickness defect to the inferior hemi-abdomen and groin. A composite anterolateral thigh flap with fascia lata free flap was performed to reconstruct the myofascial, skin, and subcutaneous tissue of the abdomen and groin. We present the first composite anterolateral thigh flap with fascia lata for full-thickness abdominal wall and groin reconstruction in a pediatric patient.

Evolving indications for surgical intervention in patients with differences/disorders of sex development: Implications of deferred reconstruction.

Rare medical conditions are difficult to study due to the lack of patient volume and limited research resources, and as a result of these challenges, progress in the care of patients with these conditions is slow. Individuals born with differences of sex development (DSD) fall into this category of rare conditions and have additional social barriers due to the intimate nature of the conditions. There is also a lack of general knowledge in the medical community about this group of diverse diagnoses. Despite these limitations, progress has been made in the study of effective ways to care for patients who are born with chromosomal or anatomical differences of their internal reproductive organs or external genitalia. Advocacy groups have placed a spotlight on these topics and asked for a thoughtful approach to educate parents of newborns, medical providers, and the adolescents and young adults themselves as they mature.1 There is growing interest in the approaches to surgical reconstruction of the genitalia and the management of internal gonads, specifically the timing of procedures and the indications for those procedures.2 Advocates suggest deferring surgical procedures until the affected individual can participate in the decision-making process. This approach requires a roadmap for addressing the long-term implications of delayed surgical management. Presented here is a review of the specific issues regarding the complex management of the various categories of DSD.

Effect of a behavioral intervention on dimensions of self-regulation and physical activity among overweight and obese adults with type 2 diabetes: a pilot study.

The purpose of this pilot study was to determine the preliminary effect of a behavioral intervention on the use of self-regulation strategies and moderate-to-vigorous physical activity (MVPA) in overweight and obese adults with type 2 diabetes. 23 individuals recruited from ResearchMatc.org and campus advertisements were randomized into an intervention (n = 12) and control (n = 11) group. The intervention group received a behavioral intervention that used goal setting, time management, and self-monitoring to target dimensions of self-regulation and MVPA. The control received information regarding their PA habits. MVPA was measured via BodyMedia Armbands at pre- and post-test. The use of self-regulatory strategies for MVPA was assessed at pretest and posttest using the Self-Regulation for Exercise Scale. Cohen's d effect sizes were calculated to determine the practical impact of the intervention. The intervention had a large effect on all dimensions of self-regulation across time: including total self-regulation (3.15), self-monitoring (4.63), goal setting (3.17), social support (1.29), self-reward (1.98), time management (4.41), and overcoming barriers (2.25). The intervention had no impact on dimensions of MVPA across time. This pilot study demonstrated the ability of a behavioral intervention to improve the use of self-regulation strategies for MVPA in a sample of adults with type 2 diabetes. These findings can further inform the development of health promotion programs to promote self-regulation. Future research should focus on determining ability of improvements in self-regulation to stimulate behavior change.

The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction.

BACKGROUND: Soft-tissue defects of the distal lower extremity and foot present significant challenges to the reconstructive surgeon. The reverse superficial sural artery flap (RSSAF) is a popular option for many of these difficult wounds. Our initial experience with this flap at multiple institutions resulted in a 50% failure rate, mostly because of critical venous congestion. To overcome this, we have modified our operative technique, which has produced a more reliable flap. METHODS: All patients reconstructed with an RSSAF between May 2002 and September 2013 were retrospectively reviewed. In response to a high rate of venous congestion in an early group of patients, we adopted a uniform change in operative technique for a late group of patients. A key modification was an increase in pedicle width to at least 4 cm. Outcomes of interest included postoperative complications and limb salvage rate. RESULTS: Twenty-seven patients were reconstructed with an RSSAF (n = 12 for early group, n = 15 for late group). Salvage rate in the early group was 50% compared with 93% in the late group (P = 0.02). Postoperative complications (75% vs. 67%, P = 0.70) were similar between groups. Venous congestion that required leech therapy was 42% in the early group (n = 5) and 0% in the late group (P = 0.01). CONCLUSIONS: Venous congestion greatly impairs the survival of the RSSAF. A pedicle width of at least 4 cm is recommended to maintain venous drainage and preserve flap viability.

Anatomy of the supratrochlear nerve: implications for the surgical treatment of migraine headaches.

BACKGROUND: Migraine headaches have been linked to compression, irritation, or entrapment of peripheral nerves in the head and neck at muscular, fascial, and vascular sites. The frontal region is a trigger for many patients' symptoms, and the possibility for compression of the supratrochlear nerve by the corrugator muscle has been indirectly implied. To further delineate their relationship, a fresh tissue anatomical study was designed. METHODS: Dissection of the brow region was undertaken in 25 fresh cadaveric heads. The corrugator muscle was identified on both sides, and its relationship with the supratrochlear nerve was investigated. RESULTS: The supratrochlear nerve was found in all 50 hemifaces. Three potential points of compression were uncovered in this investigation: the nerve entrance into the brow through the frontal notch or foramen, the entrance of the nerve into the corrugator muscle, and the exit of the nerve from the corrugator muscle. The nerve generally bifurcates within the retro-orbicularis oculi fat pad, and these branches enter into one of four relationships with the corrugator muscle: both branches enter the muscle, one branch enters the muscle and one remains deep, both branches remain deep, and the branches further branch into ever smaller filaments that cannot be identified cranially. CONCLUSIONS: Some patients are nonresponders to migraine decompression techniques that address the supraorbital nerve. The supratrochlear nerve may be compressed in these patients. A standard corrugator resection that comes more medially within 1.8 cm of the midline may be beneficial. The morphology of the frontal notch/foramen must be examined and addressed if necessary.

Endoscopic management of the difficult lower eyelid: a review of 300 cases.

BACKGROUND: The senior author's (H.S.B.) endoscopic brow and midface lift technique has a series of periorbital suture points. This study evaluated the efficacy of endoscopic treatment of the difficult lower eyelid and identifies the preoperative predictive patterns for additional suture placement and ancillary procedures within this population. METHODS: Patients who underwent endoscopic brow and midface lift performed by the senior author were stratified into categories of preoperative lower eyelid morphologies, including lower eyelid retraction, negative canthal tilt, negative vector orbit, exorbitism, and a deep tear trough. Intraoperative treatment and postoperative course were recorded and postoperative photographs were evaluated objectively. The data were analyzed to determine preoperative predictive patterns of endoscopic lower eyelid treatment. RESULTS: Three hundred patients who underwent an endoscopic brow and midface lift between 1999 and 2008 were included in the study, with an average follow-up of 1 year. Most patients were treated with endoscopic orbicularis oculi repositioning combined with midface elevation. Additional suture points were used in 12 percent, with preexisting scleral show being the most common indication for additional endoscopic suture placement. There were no cases of postoperative lower eyelid retraction. Skin resurfacing and volumetric filling were the most common revision procedures. CONCLUSIONS: The difficult lower eyelid can be treated effectively with endoscopic orbicularis repositioning and midface elevation. This technique preserves the innervation and continuity of the orbicularis oculi muscle, decreasing postoperative complications. Additional suture application is needed in only a minority of patients, and ancillary lower eyelid procedures can be performed safely in the same operative setting.

Brow lift in facial rejuvenation: a systematic literature review of open versus endoscopic techniques.

BACKGROUND: Currently, there are many well-described surgical approaches to address brow aesthetics (i.e., open versus endoscopic versus combination techniques). Each technique has associated benefits and limitations. The authors' discussion in this article is intended to review current worldwide surgical approaches to brow aesthetics and to explore the following question: Are open brow lifts still pertinent in the modern era of cosmetic surgery? METHODS: A systematic review of current available literature for the dates 1992 until the present was performed using the MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and CINAWL databases. Inclusion criteria required that individual studies contain original content; provide patient outcome data, including complications; and maintain a sufficient sample size of no fewer than 20 patients. RESULTS: One hundred eighty-nine articles were reviewed from the initial keyword searches of four major databases and plastic surgery journals. Fifteen articles were included in the analysis after careful review established that the necessary criteria were met. From direct analysis of these articles, no clear evidence exists to indicate that open methods of brow surgery are inferior to endoscopic approaches. CONCLUSIONS: Brow-lift surgery has clearly evolved since the inception of endoscopic techniques in the early 1990s. However, currently there are no prospective randomized trials in the literature that compare the surgical outcomes of differing approaches. This thorough review of current worldwide English-language literature highlights the relative paucity of good comparative studies and serves as a reminder that there is still an important role for the open approach to brow aesthetic dilemmas. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Neurovascular compression of the greater occipital nerve: implications for migraine headaches.

BACKGROUND: Surgical release of the greater occipital nerve has been demonstrated to be clinically effective in eliminating or reducing chronic migraine symptoms. However, migraine symptoms in some patients continue after this procedure. It was theorized that a different relationship between the greater occipital nerve and occipital artery may exist in these patients that may be contributing to these outcomes. A cadaveric investigation was performed in an effort to further delineate the occipital artery-greater occipital nerve relationship. METHODS: Fifty sides of 25 fresh cadaveric posterior necks and scalps were dissected. The greater occipital nerve was identified within the subcutaneous tissue and its relationship with the occipital artery was delineated. A topographic map of the intersection of the two structures was created. RESULTS: The greater occipital nerve and occipital artery have an intimate relationship, and crossed each other in 27 hemiheads (54.0 percent). The relationship between these structures when they crossed varied from a single intersection to a helical intertwining. CONCLUSIONS: The greater occipital nerve and occipital artery have an anatomical intersection 54 percent of the time. There are two morphologic types of relationships between the structures: a single intersection point and a helical intertwining. Vascular pulsation may cause irritation of the nerve and is a possible explanation for migraine headaches that have the occipital region as a trigger point. Future imaging studies and clinical investigation is necessary to further examine the link between anatomy and clinical presentation.

Capsular contracture with breast implants in the cosmetic patient: saline versus silicone--a systematic review of the literature.

BACKGROUND: Capsular contracture is one of the most common and trying complications associated with the placement of breast prostheses. The authors hypothesized that silicone implants have a higher rate of capsular contracture than saline implants when used for cosmetic, nonreconstructive breast augmentation. This was based on several previous studies and the experience of the senior author (R.J.R.). The authors objectively evaluated this hypothesis using a systematic review of the literature, specifically examining the incidence of capsular contracture with saline and silicone cosmetic breast implants. METHODS: A review of the PubMed, OVID, and Cochrane databases for prospective studies using these implants and having at least 1-year follow-up on all implants was performed. Reference articles of the articles meeting these inclusion criteria were also included. Two independent reviewers performed the same systematic review with the same a priori criteria, and discrepancies were settled by the senior author. RESULTS: The systematic review was performed in March of 2009. One thousand six hundred ninety-six articles were identified as potentially inclusive based on the search term "breast augmentation." When filtered for "saline or silicone" search terms, 583 articles were found. In the end, 16 articles met inclusion criteria. CONCLUSIONS: There is a lack of current prospective data comparing saline and silicone breast implants in the literature, thereby interfering with the ability of physicians to make data-driven recommendations to patients based on the best medical evidence. The authors were unable to accept or reject their null hypothesis definitively based on this review.

The zygomaticotemporal branch of the trigeminal nerve: Part II. Anatomical variations.

BACKGROUND: Musculofascial and vascular entrapments of peripheral branches of the trigeminal nerve have been thought to be trigger points for migraine headaches. Surgical decompression of these sites has led to complete resolution in some patients. The zygomaticotemporal branch of the trigeminal nerve has been shown clinically to have sites of entrapment within the temporalis. A cadaveric study was undertaken to elucidate and delineate the location of this nerve's foramen and intramuscular course. METHODS: The periorbital and temporal regions of 50 fresh cadaveric hemiheads were dissected. The deep temporal fascia and lateral orbital wall were exposed through open dissection. The zygomaticotemporal nerve was located and followed through the temporalis muscle to its exit from the zygomatic bone. The muscular course was documented, and the nerve foramen was measured from anatomical landmarks. RESULTS: In exactly half of all specimens, the nerve had no intramuscular course (n = 25). In the other half, the nerve either had a brief intramuscular course (n = 11) or a long, tortuous route through the muscle (n = 14). The foramen was located at an average of 6.70 mm lateral to the lateral orbital rim and 7.88 mm cranial to the nasion-lateral orbital rim line, on the lateral wall of the zygomatic portion of the orbit. Two branches were sometimes seen. CONCLUSIONS: The zygomaticotemporal branch of the trigeminal nerve is a site for migraine genesis; surgical decompression or chemodenervation of the surrounding temporalis can aid in alleviating migraine headache symptoms. Advances in the understanding of the anatomy of this branch of the trigeminal nerve will aid in more effective surgical decompression.

Systems of provision and delivery of hand care, and its impact on the community.

Hand injuries are important causes of impairment in the United States. They are one of the top causes for days lost from work and they impose a great economic burden on the country. In less affluent regions of the world, the impact of hand injuries on the population is even more dire, rendering the affected to life-long disability. When one considers that 85% of the world's population lives in low to middle income countries, the global deleterious effect of hand trauma becomes apparent. This paper is a review of pertinent literature available on the provision and delivery of trauma care around the world. While specific reference to hand surgery care is sparse, we will infer trauma management in these countries, synthesised from available literature, to the provision of hand surgery care. We will also examine programs around the world that are implemented at an affordable cost to the respective countries.

Abdominal aortic aneurysm.

Most abdominal aortic aneurysms (AAAs) are asymptomatic, not detectable on physical examination, and silent until discovered during radiologic testing for other reasons. Tobacco use, hypertension, a family history of AAA, and male sex are clinical risk factors for the development of an aneurysm. Ultrasound, the preferred method of screening, is cost-effective in high-risk patients. Repair is indicated when the aneurysm becomes greater than 5.5 cm in diameter or grows more than 0.6 to 0.8 cm per year. Asymptomatic patients with an AAA should be medically optimized before repair, including institution of beta blockade. Symptomatic aneurysms present with back, abdominal, buttock, groin, testicular, or leg pain and require urgent surgical attention. Rupture of an AAA involves complete loss of aortic wall integrity and is a surgical emergency requiring immediate repair. The mortality rate approaches 90 percent if rupture occurs outside the hospital. Although open surgical repair has been performed safely, an endovascular approach is used in select patients if the aortic and iliac anatomy are amenable. Two large randomized controlled trials did not find any improvement in mortality rate or morbidity with this approach compared with conventional open surgical repair.