Angelo B. Lipira

Helmet Versus Active Repositioning for Plagiocephaly: A Three-Dimensional Analysis

BACKGROUND AND PURPOSE: Orthotic helmets and active repositioning are the most common treatments for deformational plagiocephaly (DP). Existing evidence is not sufficient to objectively inform decisions between these options. A three-dimensional (3D), whole-head asymmetry analysis was used to rigorously compare outcomes of these 2 treatment methods. PATIENTS AND METHODS: Whole-head 3D surface scans of 70 infants with DP were captured before and after treatment by using stereophotogrammetric imaging technology. Helmeted (n = 35) and nonhelmeted/actively repositioned (n = 35) infants were matched for severity of initial deformity. Surfaces were spatially registered to a symmetric template, which was deformed to achieve detailed right-to-left point correspondence for every point on the head surface. A ratiometric asymmetry value was calculated for each point relative to its contralateral counterpart. Maximum and mean asymmetry values were determined. Change in mean and maximum asymmetry with treatment was the basis for group comparison. RESULTS: The helmeted group had a larger reduction than the repositioned group in both maximum (4.0% vs 2.5%; P = .02) and mean asymmetry (0.9% vs 0.5%; P = .02). The greatest difference was localized to the occipital region. CONCLUSIONS: Whole-head 3D asymmetry analysis is capable of rigorously quantifying the relative efficacy of the 2 common treatments of DP. Orthotic helmets provide statistically superior improvement in head symmetry compared with active repositioning immediately after therapy. Additional studies are needed to (1) establish the clinical significance of these quantitative differences in outcome, (2) define what constitutes pathologic head asymmetry, and (3) determine whether superiority of orthotic treatment lasts as the child matures.

Videofluoroscopic and Nasendoscopic Correlates of Speech in Velopharyngeal Dysfunction

Objective To compare videonasendoscopy, lateral videofluoroscopy, and perceptual speech examination in the assessment of velopharyngeal dysfunction. Design Retrospective observational. Setting Multidisciplinary cleft palate team at a tertiary academic institution. Patients, Participants Patients who had undergone videonasendoscopy and lateral videofluoroscopy for suspected velopharyngeal dysfunction at our center were evaluated. Inclusion required that videonasendoscopy, lateral videofluoroscopy, and the perceptual speech exam were performed on the same day. A total of 88 patients were analyzed. Main outcome Measure(s) Primary outcome measures included percent closure on videonasendoscopy, percent closure on lateral videofluoroscopy, and quantitative scores for hypernasal resonance, nasal emission, and facial grimace. Additional outcome measures included linear and angular anatomic measurements obtained from lateral videofluoroscopy. Results Moderately strong correlation was found between closure estimates of videonasendoscopy and lateral videofluoroscopy (ρ = .583; p < .001). Lateral videofluoroscopy estimates of closure averaged 11.7% higher than videonasendoscopy. Closure correlated moderately with overall speech severity (ρ = .304; p = .005); whereas, a stronger correlation was seen with hypernasal resonance (ρ = –.479; p < .001). Patients exhibiting grimace had worse closure than those without (79.1% versus 70.7%; ρ = .035). Movement angle of the velum and change in genu angle correlated significantly with closure function (ρ = –.304; p = .034 and ρ = –.395; p < .001, respectively). Conclusions Videonasendoscopy and lateral videofluoroscopy closure estimates correlated moderately. Lateral videofluoroscopy tended to give smaller gap estimates. Hypernasal resonance and facial grimace are useful clinical indicators of large gap size. Velar movement angle and change in genu angle were identified as anatomical correlates of closure function.

Complications Within 30 Days of Hand Surgery: An Analysis of 10,646 Patients

PURPOSEnThe American College of Surgeons Surgical Quality Improvement Program database collects detailed and validated data on demographics, comorbidities, and 30-day postoperative outcomes of patients undergoing operations in most subspecialties. This dataset has been previously used to quantify complications and identify risk factors in other surgical subspecialties. We sought to determine the incidence of postoperative complications following hand surgery and to identify factors associated with increased risk of complications in order to focus preventive strategies.nnnMETHODSnNational Surgical Quality Improvement Program data from 2006 to 2011 were queried using 302 hand-specific Current Procedural Technology codes. Descriptive statistics were calculated for the population, and potential risk factors and patient characteristics were analyzed for their association with complications in the 30-day postoperative period using both univariate and multivariate analyses.nnnRESULTSnThere were 208 hand-specific Current Procedural Technology codes represented in the data, and of these, 84 were associated with at least 1 complication. The overall incidence of complications within 30 days of hand surgery was 2.5% (95% confidence interval, 2.2%-2.8%). In univariate analysis, older age, diabetes, chronic obstructive pulmonary disease, congestive heart failure, atherosclerosis, steroids, bleeding disorder, increasing American Society of Anesthesiologists class, increasing wound class, emergency procedure, longer operative time, and preoperative transfusion were associated with significantly higher risk of complications, and local anesthesia and outpatient surgery were associated with lower risk. In the multivariate model, male sex, increasing American Society of Anesthesiologists class, wound class 4, and preoperative transfusion were associated with significantly higher risk, andxa0outpatient surgery was associated with significantly lower risk. The most common complication was surgical-site infection (1.2%).nnnCONCLUSIONSnThe incidence of complications was low, with overall health status being more important than specific comorbidities in predicting complication risk. This information may be valuable in counseling patients before surgery and in identifying patients at higher risk for complications following hand surgery.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic III.

Intraneural synovial sarcoma of the median nerve

Synovial sarcomas are soft-tissue malignancies with a poor prognosis and propensity for distant metastases. Although originally believed to arise from the synovium, these tumors have been found to occur anywhere in the body. We report a rare case of synovial sarcoma arising from the median nerve. To our knowledge, this is the twelfth reported case of intraneural synovial sarcoma, and only the fourth arising from the median nerve. Because the diagnosis may not be apparent until after pathological examination of the surgical specimen, synovial sarcoma should be kept in mind when dealing with what may seem like a benign nerve tumor.

Nerve Transfers for the Restoration of Wrist, Finger, and Thumb Extension After High Radial Nerve Injury

High radial nerve injury is a common pattern of peripheral nerve injury most often associated with orthopedic trauma. Nerve transfers to the wrist and finger extensors, often from the median nerve, offer several advantages when compared to nerve repair or grafting and tendon transfer. In this article, we discuss the forearm anatomy pertinent to performing these nerve transfers and review the literature surrounding nerve transfers for wrist, finger, and thumb extension. A suggested algorithm for management of acute traumatic high radial nerve palsy is offered, and our preferred surgical technique for treatment of high radial nerve palsy is provided.

Axillary arterial catheter use associated with hand ischemia in a multi-trauma patient: case report and literature review

A case of hand ischemia associated with use of an axillary arterial catheter in a multi-trauma patient is presented. Despite removal of the arterial catheter and limb salvage procedures, distal hand gangrene developed. Simple measures such as minimizing dressings, use of distal continuous pulse oximetry, placement of invasive arterial catheters in the nondominant extremity, and avoiding their use whenever possible may prevent complications and minimize morbidity.

Titanium mesh reconstruction to maintain scalp contour after temporalis musculofascial flap reconstruction of the floor of the middle cranial fossa: a technical note and report of two cases.

OBJECTIVEnTemporalis musculofascial rotational flaps can provide excellent tissue for reconstruction of defects in the floor of the middle cranial fossa. This technique can, however, result in cosmetic deformity of the temporal fossa with an asymmetric contour of the head. We report a technique that uses titanium mesh and autologous abdominal adipose to maintain a normal scalp contour.nnnCLINICAL PRESENTATIONnTwo patients, one with a large middle cranial fossa and infratemporal schwannoma, and another with penetrating trauma secondary to a rifle accident, required surgical repair of defects of the floor of the middle cranial fossa.nnnINTERVENTIONnThe repair was achieved in both cases using a temporalis musculofascial rotational flap. Normal contour of the scalp was maintained with titanium mesh and autologous abdominal adipose reconstruction.nnnCONCLUSIONnThe temporalis musculofascial flap, combined with titanium mesh and autologous adipose reconstruction, provided excellent closure of defects of the floor of the middle cranial fossa while preserving normal cosmetic scalp contour.

Automated quantification and analysis of facial asymmetry in children with arthritis in the temporomandibular joint

We present an automated method of spatially detailed 3D asymmetry quantification of face surfaces obtained in a stereophotogrammetric system, and the method was applied to a population of children with juvenile idiopathic arthritis (JIA) who have involvement of one temporomandibular joint (TMJ). Non-rigid registration of a patient face surface to a mirrored version of the same face surface provided a spatially dense map of left-right point correspondences that were used in the asymmetry calculation. For inter-patient comparison and modeling, detailed point correspondence was obtained by non-rigid registration of a symmetric atlas surface to a symmetric version of the patient surface. The method was validated by comparison to a landmark based method of asymmetry quantification, and the two methods were seen to provide similar results. The method was seen to be able to quantify typical patterns of asymmetry in JIA subjects with affected TMJ and compare them to a control population.

Severe soft tissue injuries of the upper extremity in motor vehicle crashes involving partial ejection: the protective role of side curtain airbags

INTRODUCTIONnPartial ejection (PE) of the upper extremity (UE) can occur in a motor vehicle crash (MVC) resulting in complex and severe soft tissue injuries (SSTI). This study evaluated the relationship between partial ejection and UE injuries, notably SSTIs, in MVCs focusing on crash types and characteristics, and further examined the role of side curtain airbags (SCABs) in the prevention of partial ejection and reducing SSTI of the UE.nnnMETHODSnWeighted data was analyzed from the National Automotive Sampling System Crashworthiness Data System (NASS-CDS) from 1993 to 2012. Logistic regression models were used to assess the relationship of PE with SSTI of the UE and the effect of SCABs in both nearside impacts and rollover collisions. Crash Injury Research and Engineering Network (CIREN) case studies illustrated PE involving SSTI of the UE, and long term treatment.nnnRESULTSnRollover and nearside impact collisions had the highest percentages of partial ejection, with over half occurring in rollover collisions. Annually over 800 SSTIs of the UE occurred in all MVCs. For nearside lateral force impacts, a multivariable analysis adjusting for belt use and delta V showed a 15 times (OR 15.35, 95% CI 4.30, 54.79) greater odds of PE for occupants without SCABs compared to those with a SCAB deployment. No occupants (0 of 51,000) sustained a SSTI of the UE when a SCAB deployed in nearside impacts, compared to 0.01% (114 of 430,000) when SCABs were unavailable or did not deploy. In rollover collisions, a multivariable analysis adjusted for number of quarter turns and belt use showed 3 times the odds (OR 3.02, 95% CI 1.22, 7.47) of PE for occupants without SCABs compared to those with a SCAB deployment. Just 0.17% (32 of 19,000) of the occupants sustained a SSTI of the UE in rollovers with a SCAB deployment, compared to 0.53% (2294 of 431,000) of the occupants when SCABs were unavailable or did not deploy. CIREN case studies illustrated the injury causation of SSTI of the UE due to partial ejection, and the long term treatment and medical costs associated with a SSTI to the UE.nnnCONCLUSIONSnThe majority of severe soft tissue injuries (SSTI) of the upper extremity (UE) involved partial ejection out the nearside window of outboard seated occupants in nearside impacts and rollover collisions. Real world case studies showed that SSTIs of the upper extremity require extensive treatment, extended hospitalization and are costly. Occupants without a side curtain airbag (SCAB) deployment had an increase in the odds of partial ejection. SCAB deployments provided protection against partial ejection and prevented SSTIs of the UE, with none occurring in nearside impacts, and a small percentage and reduction occurring in rollover collisions compared to those where SCABs were unavailable or did not deploy.