Faculty Bibliography

PURPOSE: De Quervain syndrome or tenosynovitis is a common wrist pathology caused by stenosing tenosynovitis of the first dorsal compartment. Multiple studies have demonstrated significant anatomic variation within the first extensor compartment. METHODS: The terms "De Quervain's tenosynovitis" and "first extensor compartment anatomy" were comprehensively searched using the PubMed, MEDLINE, and Cochrane database. The presence of a septum within the first dorsal compartment, the number of APL (abductor pollicis longus), and EPB (extensor pollicis brevis) tendon slips were identified. RESULTS: A total of 574 articles were identified on initial search, of which 21 met inclusion criteria. There were 1901 normal cadaver specimens and 470 surgically treated De Quervain disease patients, whose data were available. A septum was present in 43.7% of normal cadavers versus 62.2% De Quervain patients with 58.5% (327 of 559) of the septi characterized as incomplete. There was a difference in the number of APL tendons with a single APL tendon slip noted in 18.3% of normal cadavers (200/1096) versus 27.2% of De Quervain patients (87/230). There was a difference in the number of EPB tendons between the normal cadavers and De Quervain's wrists with 2 or more EPB tendinous slips observed in 5.9% of normal cadavers compared with 2.9% of De Quervain patients. CONCLUSION: Significant anatomic variability exists within the first extensor compartment. Patients with De Quervain disease were more likely to have a septum dividing the compartment and a single slip of APL. These variations are clinically relevant in the pathophysiology and treatment of De Quervain's tenosynovitis. TYPE OF STUDY: Prognostic studies. LEVEL OF EVIDENCE: Level III.

BACKGROUND: In microvascular breast reconstruction, the internal mammary and thoracodorsal vessels are commonly used recipients. However, these vessels are sometimes compromised or unavailable. We hypothesize that a transverse infraclavicular (TIC) incision may provide efficient and reliable exposure to perform free flap anastomosis to the thoracoacromial (TAC) vessels for breast reconstruction. METHODS: The authors present their results from a cadaveric feasibility study and a retrospective case series of 4 consecutive breast reconstruction patients in which the TIC-TAC approach was used. RESULTS: The cadaveric dissection demonstrated a 5.5-cm pedicle length and a 3.75-mm diameter on the left side. On the right, the pedicle measured 5 cm in length and 4 mm in diameter. The dissection time was 10 minutes on the left side and 13 minutes on the right side. Five free flap breast reconstructions were performed in 4 patients using the TIC approach to the TAC artery which served as the primary recipient. The average pedicle length was 6.25 cm with a diameter of 3.55 mm. The pedicle was isolated and delivered through the infraclavicular incision in an average of 16.3 minutes on the left (n = 2) and 12.6 minutes on the right (n = 3). There were no complications, such as flap compromise or reoperation. CONCLUSIONS: The TIC-TAC approach is feasible for microvascular breast reconstruction and can be considered for use by microvascular breast surgeons.

This study evaluated the reliability of implant-supported crowns repaired with resin composites. Fifty-four titanium abutments were divided in three groups (n = 18 each) to support resin nanoceramic molar crowns, as follows: (LU) (Lava Ultimate, 3M ESPE); LU repaired with either a direct or an indirect resin composite. Samples were subjected to mouth-motion accelerated-life testing in water (n = 18). Cumulative damage with a use stress of 300 N was used to plot Weibull curves for group comparison. Reliability was calculated for a mission of 100,000 cycles at 400 N load. Beta values were 0.83 for LU, 0.31 and 0.27 for LU repaired with Filtek and Ceramage, respectively. Weibull modulus for LU was 9.5 and eta = 1047 N, m = 6.85, and eta = 1002 N for LU repaired with Ceramage, and m = 4.65 and eta = 766 N for LU repaired with Filtek (p < 0.10 between LU and LU repaired with Filtek). Reliability at 400 N was 100% for both LU and LU repaired with Ceramage which were significantly higher than LU Filtek repair (32%). LU restored crowns failed cohesively. Fractures were confined within the restored material, and detailed fractography is presented. The performance of resin nanoceramic material repaired with an indirect composite was maintained after accelerated-life testing compared to unrepaired controls. (c) 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2016.

BACKGROUND: Postoperative wound complications after posterior spinal fusion are difficult to manage. The incidence in the nonidiopathic patient population is significantly higher than the adolescent idiopathic population. A comparison of wound complications after posterior spinal fusion for nonidiopathic scoliosis between the utilization of the orthopaedic surgical team at the time of closure performing a nonstandardized wound closure versus a plastic surgeon with a plastic multilayered closure technique and rotational flap coverage when needed had not previously been evaluated. The purpose of this study was to compare the complication rate between nonstandardized and plastic multilayered closure of the surgical incision in patients undergoing posterior spinal fusion for nonidiopathic scoliosis. METHODS: The charts of 76 patients with a primary diagnosis of scoliosis associated with a syndrome or neuromuscular disease and who underwent a posterior spinal fusion were reviewed. Forty-two patients had their incisions closed using the nonstandardized technique and 34 using the plastic multilayered technique. These 2 groups were compared for age, sex, primary diagnosis, number of levels fused, estimated blood loss, number of units transfused, operating room time, wound complication, and return to operating room. RESULTS: The wound complication rate in the nonstandardized closure group was 19% (8/42) compared with 0% (0/34) in the plastic multilayered closure group (P=0.007). The unanticipated return to the operating room rate was 11.9% (5/42) for the nonstandardized closure patients versus 0% (0/34) for the plastic multilayered closure patients (P=0.061). CONCLUSIONS: The use of the plastic multilayered closure technique in this patient population is important in an effort to decrease postoperative wound complications. The ability of the surgical team to decrease the infection rate of nonidiopathic scoliosis cannot be overstated. The method of wound closure plays a major role in lowering this incidence. LEVEL OF EVIDENCE: Level III-therapeutic.

BACKGROUND:Postoperative airway obstruction is a feared complication following cleft palate repair. The aim of this study was to evaluate the effectiveness of tongue stitches and nasal trumpets that have been used in an attempt to prevent this complication. METHODS:An 8-year (2005 to 2013) retrospective review of palatoplasties performed at a tertiary care center was conducted. Patients were divided into three groups: those with no airway protective measure, those with a tongue stitch only, and a group with nasal trumpet and tongue stitch. Recorded variables included sex, age, Veau classification, and comorbidities. Primary outcomes measured were postoperative respiratory distress, readmission, and reoperation rates. RESULTS:Fifty-eight patients underwent palatoplasties with no airway protective measure, 252 patients had tongue stitch only, and 87 had tongue stitch and nasal trumpet. There were no significant differences between groups with respect to comorbidities except that cleft lip was more prevalent in the no-airway protection group than in the other two groups (p = 0.04). There was no significant difference in the incidence of reintubation, intensive care unit transfer, surgery-related readmissions, or reoperation. Respiratory complications were significantly increased in the nasal trumpet group even after adjusting for age and weight. Length of stay was also significantly (p < 0.01) shortened when comparing no airway protection to those who underwent both nasal trumpet and tongue suture placement. CONCLUSIONS:The use of a tongue stitch, with or without nasal trumpet, did not correlate with improved safety and outcomes. Patients without these airway protective measures had a shorter hospital stay. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

BACKGROUND:This study reviewed a single center's 14-year experience with surgical treatment of chronic, severe hidradenitis suppurativa (HS) through wide excision technique and healing by secondary intention. METHODS:All patients who underwent wide excision of HS between 2000 and 2014 and allowed to heal by secondary intention were included. Wound care consisted of topical antimicrobials and hydrotherapy. Physical therapy was initiated for joint contracture prevention. Patients were followed until complete wound closure. RESULTS:Seventeen patients underwent 23 separate surgical encounters, five with excision of multiple areas. Seventeen excisional procedures were conducted on the upper half of the body (axillary, breast) and 11 on the lower half (inguinal, perineum, perianus, and abdomen). Two patients developed HS recurrence adjacent to the surgical site (one requiring reexcision and the other treated with topical therapy), whereas two developed HS flares at distant nonsurgical sites managed medically. The mean follow-up was 1.02 years with a median of 6 months ranging from 1.2 months to 5.25 years. Complete wound healing ranged from 8 weeks to 16 months, with limited range of motion (ROM) in two patients. CONCLUSIONS:Attempts at removing all tissue affected by HS through wide surgical excision are the mainstay intervention for achieving complete local cure, particularly in the most severe cases of the disease. Our experience with wide excision of disease and healing by secondary intent demonstrated clinically satisfactory functional and excellent aesthetic results in multiple anatomic areas and even for large defects. This healing modality requires strict adherence to the wound healing protocol, which is often tolerated only by patients who have endured symptoms of severe HS for an extended length of time.

Forequarter amputation is a radical operation performed for treatment of malignant neoplasms of the shoulder girdle not amenable to limb salvage. Traditional approaches involve bone and soft tissue resection, followed by ligation of the axillary vessels. We describe a technique to minimize blood loss whereby control of the subclavian vessels is performed before amputation of a large tumor associated with extensive venous congestion. A 34-year-old man presented with proximal humeral osteosarcoma. Surgery involved claviculectomy to facilitate vascular control of the subclavian vessels, followed by guillotine amputation at the proximal upper arm level and completion of the amputation as conventionally described.