Faculty Bibliography

INTRODUCTION: Injuries to the ulnar collateral ligament (UCL) are relatively common and are best treated in the acute setting. The acute version of this injury can often be repaired primarily but in the chronic setting the ligamentous remnants are often retracted making this method of repair difficult. We present a novel alternative approach for UCL repair after chronic injuries or difficult acute injuries. METHODS: We describe the procedure and postoperative results. A standard S-shaped incision over the dorsal ulnar aspect of the thumb is used. The adductor aponeurosis is identified and separated from the joint capsule. A proximally based and distally based rectangular flap containing the UCL remnants is elevated exposing the metacarpophalangeal joint. A burr is used to shave the condyles on the ulnar aspect of the metacarpal and proximal phalanx. The joint is stabilized with a Kirschner wire. A suture anchor is used to secure the proximally based flap. The distal flap is secured on top of this using the same sutures from the anchor. The repaired ligament is secured to the volar plate on the palmar aspect using a 4-0 Ethibond. RESULTS: This surgical technique has been used extensively by the senior authors; we present a representative case. At 3 months the patient had a grip strength of 85 lbs, tripod pinch of 12 lbs, lateral pinch of 5 lbs, 2-point pinch of 6 lbs, active range of motion at metacarpophalangeal joint of 0 to 70 and passive range of motion at the metacarpophalangeal joint MP of 0 to 85. CONCLUSION: Despite a number of options for ligament reconstruction many of the described methods of repair are relatively complex and involve derangement of local tissues. We offer a novel adjunct to current methods of UCL reconstruction in which condylar shaving makes repair much more simple and avoids the use of a tendon graft. This approach provides a shorter course for the retracted UCL remnants allowing primary repair in the chronic setting and in the difficult acute repair

Peripheral nerve defects are common. The surgeon faced with these problems must provide the best functional recovery for the patient with the tools provided. The ideal nerve reconstruction would create a tensionless repair with direct coaptation. However, this is not always possible and other techniques must be employed. The alternatives to direct coaptation include nerve autografts, nerve conduits, and tissue-engineered constructs. This article reviews commonly used autogenous nerve grafts and conduits. Autogenous nerve grafts have been utilized in various techniques which include the trunk graft, cable graft, interfascicular graft, and vascularized graft. The nerve conduits reviewed fall into the category of autogenous biological conduits, nonautogenous biological conduits, and nonbiological conduits. New technologies are being developed to enhance peripheral nerve regeneration with the concept that conduits can be enriched and manipulated in the laboratory to promote regeneration of the peripheral nerve. Further clinical studies hold the promise of successful alternatives for treating peripheral nerve injuries

BACKGROUND: Frontobasal injury is a classic craniomaxillofacial fracture affecting the anterior cranial base. No data exist regarding the degree of frontobasal injury and associated midfacial fractures. The authors propose a classification of frontobasal and midface fractures involving the cranial base based on cadaveric experiments and comprehensive clinical experience. METHODS: An institutional review board-approved retrospective review was conducted on patients with frontobasal fractures from 1995 to 2005. Fractures were categorized by pattern, location, midfacial involvement (impure), and complications compiled. One hundred five cadaveric heads underwent blunt impact to the frontal bone and upper midface. Calvarial vault, cranial base, and midface fracture patterns were categorized. RESULTS: Three frontobasal fracture patterns were identified. Isolated linear cranial base fractures constitute type I. Vertical-linear fractures of the skull vault (frontal bone) occur in combination with base fractures, representing type II (vault and base). Comminution of the frontolateral skull vault and orbital roof in association with a linear base fracture constitute type III. Two hundred ninety patients were identified with 49 complications (cerebrospinal fistula, 24; and infectious 25). Type III (n = 159) had the highest complication rate (impure, 29 percent; pure, 17 percent), followed by type II (impure, 19 percent; pure, 5 percent). There is essentially no extension of midface fractures to the cranial vault. CONCLUSIONS: Frontobasal fractures have three unique and reproducible patterns based on vector, location, and force. This new classification scheme, paired with known patterns of midfacial injuries, assists in fully understanding frontofaciobasal injury and its complications. Overwhelmingly, impure type II and any type III fractures are associated with a high rate of complications and must be carefully managed.

BACKGROUND:: The authors assessed the safety and efficacy of a novel cleft rhinoplasty procedure that combines an open rhinoplasty with the Dibbell and Tajima techniques. METHODS:: A single-surgeon, 10-year, retrospective review was conducted of all unilateral cleft lip rhinoplasties (n = 157). Nonsyndromic patients undergoing a combined open incision/Dibbell/Tajima procedure and who had follow-up of greater than 8 months were included. Thirty-five patients were identified. Standardized patient photographs were studied in 18 patients who had both preoperative and 1-year postoperative photographs. Farkas normal values were applied to the medial canthal distance; from this value, metric measurements of changes in alar base width, columellar height, and nostril apex height were derived. RESULTS:: There were no complications secondary to skin envelope ischemia or cartilage graft infection. The revision rate was 11 percent for alar base position, 3 percent for depressed lower lateral cartilage, and 3 percent for nostril apex overhang. After the procedure, there was a statistically significant decrease in alar base width (19.9 mm versus 18.2 mm; p < 0.01) and an increase in columellar height (8.37 mm versus 9.59 mm; p = 0.02) and nostril apex height (4.70 mm versus 5.44 mm; p = 0.02) on the affected side. The differences in alar base width, columellar height, and nostril apex height between the affected and nonaffected sides all decreased significantly postoperatively. CONCLUSIONS:: The combined open rhinoplasty/Dibbell/Tajima procedure is safe, has a low revision rate, and is associated with a statistically significant decrease in alar base width, an increase in columellar height and nostril apex height, and a greater symmetry of nasal form