Secondary Reconstructive Surgery Research Articles

Usefulness of using the superficial temporal pedicle as the recipient site for microvascular anastomosis in facial reconstruction: A retrospective study of 94 cases

In cranio-cervico-facial reconstructive surgery, it is accepted that the use of free flaps is the treatment of choice. The multiple antecedents can place the surgeon in situations of vascular deserts. The aim of our study is to report and analyse our experience of the use of temporal vessels in primary and secondary reconstructive surgery. A retrospective study was conducted between 01/01/2010 and 31/03/2023. Patients who underwent cranio-cervico-facial reconstruction using free flaps, with use of the superficial temporal pedicle as the recipient site for the vascular anastomosis were included. Early and late complication and failure rates were analysed according to type of reconstruction, location and risk factors for free flap failure. A total of 94 patients underwent craniocervical-facial reconstruction using a free flap anastomosed to the superficial temporal pedicle (in primary or secondary situations). Ten patients underwent reconstruction of the upper third, 58 the middle third and 26 the lower third. With an overall complication rate of 28.7% (21.3% minor complications and 7.4% major complications). Our study proves the reliability of the superficial temporal pedicle, both in the primary situation (with a success rate of 93.9%) and in the secondary situation (with a success rate of 89.3%), as well as its versatility whatever the cranio-cervico-facial level to be reconstructed. This study demonstrates the value of preserving the superficial temporal pedicle in craniofacial reconstruction surgery. This is because it is a preferred recipient site for reconstructions of the upper and middle thirds in the primary situation or in the event of recourse.

Developing A Temporary External Fixator (TEF) for Mandibular Reconstruction using Two-Phase QFD and TRIZ Approach

A temporary external fixator (TEF) is a device used to bridge resection defects after sequestrectomy and before secondary mandibular reconstruction surgery. A well-designed TEF should be customizable and adjustable to accommodate individual patient needs. This study developed a TEF for mandibular reconstruction using the quality function deployment (QFD) and the theory of inventive problem-solving (TRIZ). Customer needs (CNs) were investigated from literature reviews and a survey. Subsequently, a questionnaire was developed, refined, and delivered to 22 experts to identify the essential principles of TEF. Afterwards, the QFD priorities were analyzed based on the acquired CNs and technical requirements (TRs), and the top priorities were found to be safety and adequate operational space. The guidelines for developing a TEF with TRIZ were established as follows: First, using carbon fiber epoxy composite and Ti-6Al-4V as the material for TEFs is recommended Second, permanent magnet should be inserted into the clamp lock bolts to prevent them from falling off during surgery. Last, replacing one Schanz screw with three Bicortical screws is recommended for the fixator pins. Additionally, it was also found that changing the screw size from 2.5–4.0 mm to 2.0–2.4 mm could reduce hole defects in the mandible.

What is the rate of definitive stoma after subtotal colectomy for inflammatory bowel disease? A nationwide study of 1860 patients.

Some patients with inflammatory bowel disease (IBD) require subtotal colectomy (STC) with ileostomy. The recent literature reports a significant number of patients who do not undergo subsequent surgery and are resigned to living with a definitive stoma. The aim of this work was to analyse the rate of definitive stoma and the cumulative incidence of secondary reconstructive surgery after STC for IBD in a large national cohort study. A national retrospective study (2013-2021) was conducted on prospectively collected data from the French Medical Information System Database (PMSI). All patients undergoing STC in France were included. The association between definitive stoma and potential risk factors was studied using univariate and multivariate analyses. A total of 1860 patients were included (age 45 ± 9 years; median follow-up 30 months). Of these, 77% (n = 1442) presented with ulcerative colitis. Mortality and morbidity at 90 days after STC were 5% (n = 100) and 47% (n = 868), respectively. Reconstructive surgery was identified in 1255 patients (67%) at a mean interval of 7 months from STC. Seveny-four per cent (n = 932) underwent a completion proctectomy with ileal pouch anal anastomosis and 26% (n = 323) an ileorectal anastomosis. Six hundred and five (33%) patients with a definitive stoma had an abdominoperineal resection (n = 114; 19%) or did not have any further surgical procedure (n = 491; 81%). Independent risk factors for definitive stoma identified in multivariate analysis were older age, Crohn's disease, colorectal neoplasia, postoperative complication after STC, laparotomy and a low-volume hospital. We found that 33% of patients undergoing STC with ileostomy for IBD had definitive stoma. Modifiable risk factors for definitive stoma were laparotomy and a low-volume hospital.

Kicking the Can in DDH: The Impact of Age on Outcomes Following Secondary Reconstructive Surgery for Residual Dysplasia

Kicking the Can in DDH: The Impact of Age on Outcomes Following Secondary Reconstructive Surgery for Residual Dysplasia

Outcomes of the Goldilocks Technique in High-Risk Breast Reconstruction Patients.

The Goldilocks technique seeks to provide a safe alternative for patients who are otherwise at risk of adverse complications during reconstruction. The technique involves deepithelializing and locally contouring mastectomy skin flaps to create a breast mound. The purpose of this study was to analyze outcomes in this cohort of patients. A review was performed on a prospective database of all patients who underwent postmastectomy Goldilocks reconstruction between June of 2017 and January of 2021 at a tertiary care center. Data queried included patient demographics, comorbidities, complications, outcomes, and subsequent secondary reconstructive surgery. This series included 58 patients (83 breasts) who underwent Goldilocks reconstruction. Mean age at reconstruction was 56 years (range, 34 to 78 years), and 82% (48 patients) were obese (average body mass index, 36.8). When analyzed by individual breast, the overall complication rate was 18%. Most complications ( n = 9), such as infection, skin necrosis, and seroma, were treated in the office. Six breasts experienced major complications (ie, hematoma and skin necrosis) requiring additional surgery. At the time of follow-up, 35% ( n = 29) of breasts had a secondary reconstruction, consisting of 17 implants (59%), two expanders (7%), three fat grafts (10%), and seven autologous reconstructions (24%). The complication rate for secondary reconstruction was 14%. The Goldilocks breast reconstruction technique is safe and effective for high-risk breast reconstruction patients. Although early postoperative complications are limited, patients should be counseled on the likelihood of a subsequent secondary reconstruction procedure to achieve their desired aesthetic outcome. Therapeutic, IV.

QUALITY OF LIFE OUTCOMES AFTER SURGICAL TREATMENT FOR MANDIBULAR AMELOBLASTOMAS

Objective To evaluate Quality of Life (QoL) scores in patients who underwent surgical treatment of mandibular ameloblastomas without secondary reconstructive surgery. Study Design This is a single-center cross-sectional study conducted at a tertiary care Brazilian hospital. QoL was assessed using University of Washington Quality of Life Questionnaire for patients with Head and Neck Cancer (UW-QOL) and Oral Health Impact Profile (OHIP-14) questionnaire. Mann-Whitney and independent t-test were used to assess the association of QoL scores with predictive variables. Results Twenty individuals were enrolled, most of whom were male (70%), with a mean age of 29.55±13.28 years. Ten individuals (50%) underwent at least one radical surgical resection. Most of the participants reported an impairment in 'Appearance', 'Chewing', 'Speech' and 'Anxiety' domains of UW-QOL. Mean OHIP-14 score was 4.75±3.36. Worst OHIP-14 scores were associated with anterior tooth loss due to the tumor (p = 0.013). The overall and health-related QoL was rated as 'Good' in 65% and 45% of the cases, respectively. Conclusion Surgical treatment for mandibular ameloblastomas has a significative functional and esthetic impairment in patients' QoL. However, surgical modality and tumor recurrence did not seem to affect QoL. Only anterior tooth loss was a significant predictive factor of worst QoL scores. To evaluate Quality of Life (QoL) scores in patients who underwent surgical treatment of mandibular ameloblastomas without secondary reconstructive surgery. This is a single-center cross-sectional study conducted at a tertiary care Brazilian hospital. QoL was assessed using University of Washington Quality of Life Questionnaire for patients with Head and Neck Cancer (UW-QOL) and Oral Health Impact Profile (OHIP-14) questionnaire. Mann-Whitney and independent t-test were used to assess the association of QoL scores with predictive variables. Twenty individuals were enrolled, most of whom were male (70%), with a mean age of 29.55±13.28 years. Ten individuals (50%) underwent at least one radical surgical resection. Most of the participants reported an impairment in 'Appearance', 'Chewing', 'Speech' and 'Anxiety' domains of UW-QOL. Mean OHIP-14 score was 4.75±3.36. Worst OHIP-14 scores were associated with anterior tooth loss due to the tumor (p = 0.013). The overall and health-related QoL was rated as 'Good' in 65% and 45% of the cases, respectively. Surgical treatment for mandibular ameloblastomas has a significative functional and esthetic impairment in patients' QoL. However, surgical modality and tumor recurrence did not seem to affect QoL. Only anterior tooth loss was a significant predictive factor of worst QoL scores.

Graft failure and revision rate after ACL repair with dynamic intraligamentary stabilization. One-year results of a prospective case series of 155 patients

PurposeThe aim of this study was to assess graft failure, revision rate, and functional outcomes after treatment of acute ACL rupture with dynamic intraligamentary stabilization (DIS) Ligamys device one year post surgery. Additionally, differences in functional outcome between patients with and without anteroposterior laxity were assessed. It was hypothesized that the failure rate of DIS was non-inferior to that of previously reported ACL reconstruction (10%).MethodsIn this prospectively designed multicenter study, including patients with an acute ACL rupture, DIS was performed within 21 days after rupture. Primary outcome was failure of the graft at 1 year post surgery, defined as 1) re-rupture of the graft, 2) revision of DIS, or 3) a > 3 mm side-to-side difference in anterior tibial translation compared to the non-operated knee (∆ATT), measured by the KT1000 device. Additional analysis was performed using a 5 mm threshold. The subjective International Knee Documentation Committee Score (IKDC) and Numerical Rating Scales (NRS) for pain and confidence were used to evaluate functional outcome.ResultsA total of 155 patients were included with a mean age at surgery of 27.8 years (SD 9.4). The mean interval from rupture to DIS was 16.4 days (SD 5.2). At a median follow-up of 13 months (IQR 12–18) the failure rate of the graft was 30.2% (95%CI:22.0–39.4); 11 patients (7%) required secondary reconstructive surgery and of the 105 patients who attended ATT measurement, 24 patients (23%) had an ∆ATT > 3 mm. Secondary analysis, based on a 5 mm threshold, revealed a failure rate of 22.4% (95%CI: 15.2; 31.1). A total of 39 patients (25%) reported at least one complication, comprising mainly arthrofibrosis, traumatic re-rupture and pain. In these patients, removal of the monoblock was performed in 21 cases (13.5%). At follow-up no significant differences in functional outcomes between patients with ∆ATT > 3 mm and stable ATT were observed.ConclusionThis prospective multicenter study found a high failure rate at one year follow-up of 30% (7% revision surgery and 23% > 3 mm side-to-side difference in anterior tibial translation) in patients treated by primary repair of the ACL with DIS, and did therefore not demonstrate non-inferiority to ACL reconstruction. For patients who did not require secondary reconstructive surgery, this study found good functional outcomes, also in case of persistent anteroposterior knee laxity (∆ATT > 3 mm).Level of evidenceLevel IV.

Winter sports injuries to the elbow joint

Elbow injuries occur quite often when practicing winter sports. Due to the high sports dynamics and risk of fall the elbow joint is prone to injuries. Hereby, the most common injury is the dislocation of the elbow. Isolated ligamentous instabilities can usually be treated non-operatively when the joint is centered on post-reduction imaging. In the case of persistent symptomatic instability, secondary ligament reconstruction surgery is associated with reliable and good results. Most fractures of the elbow involve the radial head in terms of postero-lateral rotation instability, whereas distal humerus and olecranon fractures are more likely to occur in high-energy or direct trauma. Indication for surgical treatment is given according to common guidelines, including involvement of the joint line, fragment dislocation and instability with risk of secondary fracture dislocation. Minimally invasive techniques for the radial head as well as anatomic preformed locking plate systems seem to have reached a wide acceptance.

Secondary Mandible Reconstruction with Computer-Assisted-Surgical Simulation and Patient-Specific Pre-Bent Plates: The Algorithm of Virtual Planning and Limitations Revisited

Despite the known advantages of virtual surgical planning and three-dimensional (3D) printing, translation of virtual planning to actual operation is a challenge, especially in secondary mandibular reconstruction. Patients who underwent secondary microvascular mandibular reconstruction were retrospectively reviewed and categorized into three categories as follows: (i) defect not crossing the midline (category I); (ii) defects crossing the midline with availability of previous imaging data (category II) and; (iii) defects crossing the midline with unavailability of previous imaging data (category III). The resulting 3D printed models were used as an effective guide for plate bending during secondary reconstruction surgery. Accuracy of the reconstruction was evaluated by superimposing post-operative images over virtual plan. Out of eleven patients, five were category I, three were category II, and three were category III. The mean linear discrepancy between the planned and post-operative position was measured. A Mann-Whitney U test was conducted to compare mean discrepancy among the groups showed no significant difference between group I and group II (p > 0.05) whereas comparison of groups I and II with group III showed a significant difference (p < 0.01). The proposed algorithm for the generation of defect template for manual plate bending during secondary reconstruction of mandibular defects is valid with acceptable accuracy in various defect configurations.

The Clinical Significance of Infolded Limbus on Postreduction Arthrogram in Developmental Dysplasia of the Hip.

The purpose of this study was to investigate whether presence of an infolded limbus on hip arthrogram at index closed reduction was associated with increased residual dysplasia or secondary surgery. We retrospectively reviewed all patients who underwent closed reduction for dysplasia of the hip with a minimum 2-year follow-up between 1980 and 2016. Demographic data was obtained including the age at reduction and severity of dislocation based on the International Hip Dysplasia Institute (IHDI) classification. Arthrograms performed at time of closed reduction were separately reviewed by 3 fellowship-trained pediatric orthopaedic surgeons to evaluate for an infolded limbus. The primary radiographic outcome was acetabular indices at 2 and 4 years postreduction. We also assessed the presence of avascular necrosis and rate of secondary reconstructive surgery for residual dysplasia. A total of 182 hips in 165 patients underwent closed reduction at a mean age of 9.8±4.5 mo and were followed a mean of 9.0±4.9 y. An infolded limbus was identified in 20.3% (37/182) hips with substantial agreement among the 3 graders (Fleiss κ=0.75). The frequency of labral infolding increased with the severity of dislocation (8.8%% of IHDI II, 26.7% IHDI III, and 25.0% of IHDI IV hips; P=0.03). Hips with infolded limbus were older at reduction (12.4±5.3 vs. 9.2±5.8 mo, P=0.001). The mean acetabular index was higher in hips with infolded limbus than hips without at 2 years postreduction (34.8±4.8 vs. 32.6±5.8 degrees, respectively; P=0.04). However, multivariate analysis revealed that only the severity of dislocation predicted dysplasia at 2 years postreduction. No significant difference in acetabular index was seen at 4 years postreduction (27.2±7.4 vs. 25.4±6.5 degrees, P=0.24). There was no difference in avascular necrosis between groups (P=0.74). There was no difference in rate of secondary surgery between hips with labral infolding and those without (35% vs. 30%, respectively; P=0.52). An infolded limbus was more common in older patients with more severe dislocations. However, it is not associated with increased residual dysplasia or secondary surgery and may have limited utility in decision-making during closed reduction. Level II-prognostic study.

Therapeutic principles in upper limb trauma

Upper limb trauma cases vary from simple to high energy impactful injuries, with different etiologies; situations which frequently require unique, demanding and challenging endeavors in order to obtain the most favorable outcome. Experience, good decision-making and knowledge of functional goals are mandatory in order to elaborate a therapeutic plan and execute it accordingly. Although cases differ in nature and prognosis, respecting a set of therapeutic principles whilst dealing with either simple or complex cases, will enhance patient outcome and give the surgeon the confidence to tackle any kind of upper limb trauma. After clearing out vital threat, the emergency surgery represents the first threshold in achieving and restoring normal function and biomechanics, mostly in young and labor active patients, with the mindset to salvage as much tissue as possible, with a thorough debridement and step-by-step approach to different types of tissues. Secondary surgery and reconstructive surgery can be planned timely, with prior discussion with both the therapist and the patient in order to enhance patient’s upper limb function and aesthetic and ensure social reintegration.

Impact of coronavirus disease 2019 on the clinical diagnosis and treatment of breast cancer in China.

Impact of coronavirus disease 2019 on the clinical diagnosis and treatment of breast cancer in China.

Secondary Surgery and Residual Dysplasia Following Late Closed or Open Reduction of Developmental Dysplasia of the Hip.

Outcomes studies following successful closed reduction of late-detected developmental dysplasia of the hip (DDH) reveal high rates of secondary reconstructive surgery with limited comparative data demonstrating lower rates of residual dysplasia with open reduction. The purpose of this study was to compare long-term outcomes, with regard to radiographic evidence of residual dysplasia and secondary reconstructive procedures, between late closed and late open reduction for DDH in patients 6 to 24 months of age at reduction. We identified all patients between 6 and 24 months of age who underwent closed or open reduction for DDH between 1980 and 2008 and were followed until at least 10 years of age. Outcomes included radiographic measurement of acetabular dysplasia after triradiate cartilage closure, development of osteonecrosis, and the need for secondary procedures for residual dysplasia. One hundred and four hips underwent index closed reduction and 54 hips underwent index open reduction. There was no significant difference in the age at reduction (p = 0.07). Among the 116 hips for which initial anteroposterior pelvic radiographs were available, most closed reductions (55%) were performed in International Hip Dysplasia Institute (IHDI) grade-III hips whereas most open reductions (71%) were performed in IHDI grade-IV hips. Analysis of the hips that did not undergo a secondary procedure showed that those with an index open reduction had a greater lateral center-edge angle (mean and standard deviation, 27.2° ± 10.0° versus 22.4° ± 6.8° in the closed reduction cohort; p = 0.02), lower femoral head extrusion index (22.2% ± 8.9% versus 26.0% ± 6.2%; p = 0.04), and lower Sharp angle (43.3° ± 6.0° versus 46.6° ± 3.1°; p = 0.002) at triradiate closure. There was no difference in the prevalence of osteonecrosis (Bucholz-Ogden grades II, III, and IV) between the closed and open reduction cohorts (22% versus 19%, respectively; p = 0.60). Secondary procedures were performed more frequently after closed reduction than after open reduction (47% versus 30%, respectively; p = 0.03). In patients with late reduction of DDH, closed reduction was associated with increased residual dysplasia and it was associated with a higher rate of secondary surgery in those >12 months old despite a decreased severity of displacement based on the IHDI classification. Additional, prospective studies with assessment of functional outcomes are needed to validate these findings. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of Practice Diversification in the Growth of a Burn Center Network

Practices within the Burn and Reconstructive Centers of America network have been organized to provide immediate and secondary reconstructive plastic surgery to burn patients. These reconstructive surgery abilities have been further engaged to expand these practices with non-burn-related surgical cases.Seven Burn and Reconstructive Centers of America practices were analyzed to quantitate the effects of nonburn reconstructive cases on practice growth over a 4-year period (2015-2018).All surgical cases were performed during the study period and were analyzed to identify burn-related procedures and procedures not related to burn injuries. Fifty-two percent of the cases were burn-related, whereas 48% were not burn-related. Over the 4-year period, burn cases increased by 46%, whereas nonburn cases increased by 84%. The overall percentage of nonburn cases increased from 43% in 2015 to 50% and 49% in 2017 and 2018.Nonburn cases contributed effectively to practice growth over this period. This practice model successfully engages broad reconstructive surgery skill sets to expand practice volumes.

Guided Growth Improves Coxa Valga and Hip Subluxation in Children with Cerebral Palsy.

Spastic hip subluxation or dislocation that is associated with an excessive coxa valga deformity is a common pathologic condition in children with cerebral palsy (CP) that is often treated with large bone reconstructive procedures. Guided growth techniques (such as stapling, plate, or transphyseal screw) have been widely used to alter the growth axis in patients with a lower-limb deformity but only a few reports have described their use in patients with coxa valga deformities. (1) Does guided growth surgery using a transphyseal screw combined with adductor tenotomy prevent progressive coxa valga deformity and lateral hip subluxation in children with CP? (2) What factors influence the correction of coxa valga deformity and the success of hip stabilization? (3) What complications were associated with this operation and how often did children treated with it undergo reoperation? From 2012 to 2016, at our institution, three authors (H-CH, KNK, K-WW) retrospectively studied data on children with CP who underwent guided growth of the hip for progressive bilateral hip subluxation associated with coxa valga deformities. A single percutaneous screw was inserted across the inferomedial portion of proximal femoral physis in an AP view and centered along femoral neck in lateral view under fluoroscopy guidance. During the period, we treated 25 consecutive children with CP who had progressive hip subluxation with coxa valga deformities. The indications for surgery were migration percentage > 30% and head-shaft angle > 155° with at least 2 years growth remaining. Of those, 13 patients underwent guided growth alone, and 48% (12) underwent a combination of guided growth and adductor tenotomy. Of the 25 patients treated with this approach, 96% (24) were available for follow-up with complete data at a minimum of 2 years follow-up (mean 50 months; range 25 to 72). All children (17 boys and seven girls; 48 hips) underwent surgery at a mean age of 8 years (range 5 to 12). With regard to the gross motor function classification system, three patients were Level 1, four patients were Level II, seven patients were Level III, seven were Level IV, and three were Level V. Radiographic parameters including the head-shaft angle, Hilgenreiner's epiphyseal angle, acetabular index, and Reimer's migration percentage were assessed before surgery and at the latest follow-up examination by one author (H-CH). Complications and reoperations were assessed by chart review. During the period in question, we generally offered secondary reconstructive surgery to patients who underwent a guided growth procedure once their subluxation progressed. With the data available, the coxa valga and lateral hip subluxation improved in terms of the reduction of head-shaft angle by a mean of 13° ± 7° (95% CI 11 to 15; p < 0.001) and the reduction of the migration percentage by 10% ± 11% (95% CI 7 to 13; p < 0.001). After controlling for potentially confounding variables like gender, gross motor function classification system, Hilgenreiner's epiphyseal angle and acetabular index, we found that longer follow-up duration (r = 0.234; p < 0.001) and a smaller preoperative migration percentage (r = -0.258; p = 0.004) were associated with larger changes in the head-shaft angle. In terms of complications, we found that the proximal femoral physis grew off the screw tip in 44% (21 of 48 hips) at a mean of 28 months. Among these, 31% of hips (15 of 48) in 33% of patients (eight of 24) underwent replacement with a longer screw. Among the 17% of hips (eight of 48) in 21% of patients (five of 24) who had progressive lateral subluxation and underwent secondary reconstructive surgery, we found that their preoperative acetabular index was higher (mean 29° versus 21°; p < 0.001), as was their head-shaft angle (mean 166° versus 162°; p = 0.045), and migration percentage (mean 54% versus 36 %; p < 0.001). Although guided growth with single transphyseal screw did not create as large a degree of varus as proximal femoral osteotomy, it did stabilize the hip in children with cerebral palsy with migration percentage less than 50% in our series. It is a simple procedure that can be of benefit to children with cerebral palsy with unstable hip. Reoperation in patients where the physis has grown off the screw tip can be a problem; fortunately, it is a rather minor procedure to replace with a longer screw. Level III, therapeutic study.

Recovery of ACL function after dynamic intraligamentary stabilization is resultant to restoration of ACL integrity and scar tissue formation.

Dynamic intraligamentary stabilization (DIS) is recognized as a ligament preserving technique for the treatment of acute anterior cruciate ligament (ACL) injuries. The aim of this study was to assess the integrity and morphology of the recovered ACL after DIS repair. The cohort comprised 47 patients with an acute proximal ACL rupture undergoing DIS repair. All patients underwent diagnostic arthroscopy after a minimum postoperative interval of 6 months for semi-quantitative evaluation of ACL integrity, function and scar tissue formation. Tegner, Lysholmand International Knee Documentation Committee (IKDC) scores as well as objectiveanteroposterior (ap) translation were assessed at 6weeks, 3-, 6- and 12months postoperatively. Full restoration of the ACL volume was affirmed in 30 (63.8%)patients and two-third restoration in 13 (27.7%). Hypertrophic scar formation was observed in 23 (48.9%) patients. Forty-four patients (93.6%) demonstrated sufficient ACL tensioning intraoperatively upon anterior stress. At final follow-up, the median Tegner activity level was 5.5 (3-10), Lysholm and IKDC scores were 100 (64-100) and 94 (55-100)points, respectively. The mean ap-translation differed from the normal knee by 2.1±2.2mm. Deficient ACL recovery was noted in four patients (8.5%), none of which required secondary reconstructive surgery. The results demonstrate that clinical recovery of ACL function after DIS repair is resultant to both restoration of ACL volume and scar tissue formation. Factors influencing the degree of scar tissue formation need further investigation to enable future attempts of guiding a balanced biological healing response. IV.

Acellular Dermal Matrix for the Treatment and Prevention of Implant-Associated Breast Deformities

Background Acellular dermal matrix has been increasingly accepted in prosthetic breast reconstruction. Observed benefits include improved control and support of implant position, better implant coverage, and the suggestion of a decreased capsular contracture rate. Based on this positive experience, it is not surprising that acellular dermal matrix would be applied to other challenging implant-related problems. This study investigates the use of acellular dermal matrix for correction or prevention of implant-associated breast deformities. Methods Patients who underwent primary aesthetic breast surgery or secondary aesthetic or reconstructive breast surgery using acellular dermal matrix and implants between November of 2003 and October of 2009 were reviewed retrospectively. Patient demographics, indications for acellular dermal matrix, and acellular dermal matrix type and inset pattern were identified. Preoperative and postoperative photographs, success or failure of the procedure, complications, and need for related or unrelated revision surgery were recorded. Results Fifty-two patients had acellular dermal matrix placed alongside 77 breast prostheses, with a mean follow-up of 8.6 months (range, 0.4 to 30.4 months). Indications included prevention of implant bottoming-out (n = 6), treatment of malposition (n = 32), rippling (n = 20), capsular contracture (n = 16), and skin flap deficiency (n = 16). Seventy-four breasts (96.1 percent) were managed successfully with acellular dermal matrix. Three failures consisted of one breast with bottoming-out following treatment of capsular contracture, one breast with major infection requiring device explantation, and one breast with recurrent rippling. There was a 9.1 percent total complication rate, consisting of three mild infections, one major infection necessitating explantation, one hematoma, and one seroma. Conclusion Based on this experience in 77 breasts, acellular dermal matrix has shown promise in treating and preventing capsular contracture, rippling, implant malposition, and soft-tissue thinning.

A novel semi-automatic segmentation protocol for volumetric assessment of alveolar cleft grafting procedures

A novel protocol for volumetric assessment of alveolar cleft grafting procedures is presented. Eleven cone-beam computed tomography (CBCT) datasets of patients who underwent secondary alveolar cleft reconstructive surgery for a unilateral alveolar cleft were evaluated by two investigators. Residual bone volumes 1 year after surgery were analysed using a semi-automated technique in which preoperative CBCT datasets were superimposed on the postoperative scans using voxel-based registration. To define the correct boundaries of the alveolar cleft defect in the preoperative CBCT dataset, a mirror image of the preoperative CBCT dataset was superimposed on the preoperative CBCT dataset. For the difference in residual bone volume between the two observers, an intraclass correlation of 0.98 and a Dice coefficient of 0.89 were found. This study describes a reliable segmentation protocol for volumetric analysis of the alveolar cleft defect in patients with a unilateral alveolar cleft.

Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections.

Local release of antibiotic has advantages in the treatment of chronic osteomyelitis and infected fractures. The adequacy of surgical debridement is still key to successful clearance of infection but local antibiotic carriers seem to afford greater success rates by targeting the residual organisms present after debridement and delivering much higher local antibiotic concentrations compared with systemic antibiotics alone. Biodegradable ceramic carriers can be used to fill osseous defects, which reduces the dead space and provides the potential for subsequent repair of the osseous defect as they dissolve away. A dissolving ceramic antibiotic carrier also raises the possibility of single stage surgery with definitive closure and avoids the need for subsequent surgery for spacer removal.In this article we provide an overview of the properties of various biodegradable ceramics, including calcium sulphate, the calcium orthophosphate ceramics, calcium phosphate cement and polyphasic carriers. We summarise the antibiotic elution properties as investigated in previous animal studies as well as the clinical outcomes from clinical research investigating their use in the surgical management of chronic osteomyelitis.Calcium sulphate pellets have been shown to be effective in treating local infection, although newer polyphasic carriers may support greater osseous repair and reduce the risk of further fracture or the need for secondary reconstructive surgery. The use of ceramic biocomposites to deliver antibiotics together with BMPs, bisphosphonates, growth factors or living cells is under investigation and merits further study.We propose a treatment protocol, based on the Cierny-Mader classification, to help guide the appropriate selection of a suitable ceramic antibiotic carrier in the surgical treatment of chronic osteomyelitis.

Heterotopic Digital Replantation in Mutilating Hand Injuries

Objective: Reconstruction of the mutilated hand is one of the most difficult challenges for hand surgeons. When multiple digits are amputated, orthotopic digital replantation of the available remnants may not adequately restore hand function. In such cases, heterotopic digital replantation may provide a more functional reconstruction. Patients and Methods: Between 1997 and 2008, 29 patients with mutilating hand injuries were treated with heterotopic digital replantation at our institution. A retrospective chart review was conducted to determine the details of the injury, indications for heterotopic digital replantation, and functional outcomes. Results: In total, 100 digits were amputated from 29 patients’ hands. Thirty-nine digits underwent heterotopic digital replantation, 20 digits had orthotopic digital replantation, and 41 stumps were terminalized. The survival rate of digits treated by heterotopic digital replantation and orthotopic digital replantation was 87.2% (34/39) and 95% (19/20), respectively. Tripod pinch was achieved in 82.8% (24/29) of patients following replantation and any secondary reconstructive surgery that was required. Conclusions: Heterotopic digital replantation is a practical and reliable method for achieving optimal hand function following mutilating hand injuries. It is particularly indicated when orthotopic digital replantation of the available amputated parts would yield a suboptimal result. The principles are to restore a functional thumb in the first instance, followed by at least 2 adjacent fingers against which the thumb can oppose.