Devra B. Becker

Extraosseous blood supply of the tibia and the effects of different plating techniques: A human cadaveric study

Objective To describe the extraosseous blood supply of the tibia and how the blood supply of the distal tibia is influenced by different plating techniques. Design Microdissection of cadaveric adult hip disarticulation specimens following sequential arterial injections of india ink and Wards Blue Latex was performed. Readily identifiable arterioles measured approximately 0.5 mm in diameter. Their artery of origin was identified, and their position along the medial, lateral, and posterior aspects of the tibia was documented relative to the tibial plafond. Additionally, six matched pairs of limbs were used to assess the effects of different plating techniques on the extraosseous blood supply along the medial aspect of the distal tibia. Setting University anatomy laboratory. Patients/Participants Nine matched pairs (n = 18) of randomly obtained, adult cadaveric hip disarticulation specimens. Intervention India ink followed by Wards Blue Latex was injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system. The skin, subcutaneous tissue, and muscles were dissected from the leg, exposing the arterial system and the extraosseous vessels of the tibia. Mean Outcome Measurements The extraosseous blood supply of each aspect of the tibial diaphysis was determined. Each extraosseous arteriole was identified, and the locations of each documented relative to the tibial plafond. Changes in the filling of these vessels along the medial aspect of the distal tibia were documented in a separate group of specimens (n = 12), which had undergone two different plating techniques. Results The proximal metaphysis of the tibia was found to have a rich extraosseous blood supply provided primarily from vessels from the popliteal artery, the anterior tibial artery (ATA) laterally, and the posterior tibial artery (PTA) medially. In comparison, the tibial diaphysis was found to have relatively few extraosseous vessels and a considerably hypovascular region, posteriorly. Branches of the ATA were found to supply the posterior aspect of the diaphysis with these branches passing through the interosseous membrane. The diaphysis also received a variable contribution from the PTA. The lateral aspect of the diaphysis was supplied by branches of the ATA. An anastomotic network of arteries from the ATA and PTA formed the rich extraosseous blood supply of the medial distal aspect of the tibia. Open plating of the medial aspect of the distal tibia caused a statistically significant (p < 0.05) greater disruption of the extraosseous blood supply of the metaphyseal region than did percutaneously applied plates. In each specimen, open plating prevented filling of each periosteal vessel in the region as opposed to percutaneous plates, which permitted filling of the extraosseous vessels up to the edge of the plate. Conclusions The proximal and distal metaphyseal areas of the tibia have a rich extraosseous blood supply provided primarily by branches of the ATA and the PTA. Open plating of the medial aspect of the distal tibia caused a greater disruption of this extraosseous blood supply than did percutaneously applied plates. Disruption of these extraosseous vessels following fracture and subsequent operative stabilization may slow healing and increase the risk of delayed union and nonunion. These findings support current efforts to develop less invasive methods and implants for operative stabilization of distal tibia fractures.

Speech, cognitive, and behavioral outcomes in nonsyndromic craniosynostosis

Background: The neuropsychological morbidity of nonsyndromic craniosynostosis is incompletely understood. The purpose of this study was to establish the prevalence of speech-language, cognitive, and behavioral abnormalities in this population and to stratify the findings on the basis of the affected suture and age of diagnosis with speech-language or psychological abnormalities. Methods: Charts of all patients with nonsyndromic craniosynostosis evaluated between 1978 and 2000 were reviewed, noting diagnoses of speech-language, cognitive, or behavioral abnormalities. Findings were statistically analyzed for variance with regard to affected suture and diagnosis of abnormalities. Results: Two hundred fourteen patients with nonsyndromic craniosynostosis had documented follow-up evaluations with an average age of 6 years 4 months at last visit. Speech, cognitive, and/or behavioral abnormalities were manifest in 49 percent of the patients with specific rates for each suture as follows: right unilateral coronal, 61 percent; bilateral coronal, 55 percent; multiple, 47 percent; metopic, 57 percent; left unilateral coronal, 52 percent; lambdoid, 44 percent; and sagittal, 39 percent. This prevalence of abnormalities was a statistically significant increase from the general population. Logistic regression demonstrated that as patient age increased, the percentage of abnormal diagnoses also increased. Conclusions: Nonsyndromic craniosynostosis is often associated with cognitive, speech, and/or behavioral abnormalities. The etiopathology of this association is unknown. Furthermore, the proportion of children diagnosed with cognitive and behavioral dysfunction increases with age. Therefore, longitudinal cognitive, behavioral, and speech assessment and treatment are integral to the care of these patients.

Neurologic findings in infants with deformational plagiocephaly

This study evaluates the neurologic profiles of infants with deformational plagiocephaly. Forty-nine infants with deformational plagiocephaly between the ages of 4 and 13 months (mean age, 8.1 months) are evaluated, along with 50 age-matched control subjects (mean age, 8.1 months). A modified version of the Hammersmith infant neurologic assessment was performed on each infant. A caregiver completed a questionnaire regarding the infants prematurity, development, and health to date. Results are analyzed using t test. There is a statistically significant difference in overall neurologic assessment scores of infants with deformational plagiocephaly vs their healthy peers (P = .002). This difference is predominately in tone, whereby infants with deformational plagiocephaly have significantly more abnormal tone than nonplagiocephalic infants (P = .003). This abnormality is not one of decreased tone but one of variable tone, deflecting abnormally high and low tone. Infants with deformational plagiocephaly are more likely to have altered tone but not exclusively decreased tone.

Long-term osseous morphologic outcome of surgically treated unilateral coronal craniosynostosis

Background: Unilateral coronal craniosynostosis has characteristic osseous dysmorphology that persists into adulthood if untreated. Knowledge of the long-term in vivo osseous morphologic outcome of surgically treated unilateral coronal craniosynostosis patients is limited. The purpose of this study was to define the osseous morphology of adolescent patients who underwent surgery for unilateral coronal craniosynostosis in infancy, compared with both their 1-year postoperative morphology and the morphology of other individuals with untreated unilateral coronal craniosynostosis. Methods: Three populations of unilateral coronal craniosynostosis were studied: group 1, patients with surgical treatment of unilateral coronal craniosynostosis in infancy who had reached dentoskeletal maturity, ranging in age from 13.5 to 32.7 years (n= 9); group 2, individuals with untreated unilateral coronal craniosynostosis, ranging in age from 1.1 to 21 years (n= 11); and group 3, a subset of group 1 patients 1 year after surgical correction of unilateral coronal craniosynostosis, ranging in age from 1.2 to 2.6 years (n= 6). Data from high-resolution, thin-slice computed tomographic scans of the head were analyzed. Thirty-five reproducible osseous landmarks were recorded as three-dimensional coordinates using ETDIPS imaging software. Nonmidline landmarks were designated as either ipsilateral or contralateral to the synostosis. One researcher performed all landmarking with high intrarater reliability (average error, <2 mm). Data from the three groups were analyzed for asymmetry using Euclidean distance matrix analysis techniques. Results: Euclidean distance matrix analysis asymmetry analysis demonstrated more statistically significant ipsilateral-contralateral asymmetric pairs in group 1 (68 of 135) than in group 3 (25 of 135), but fewer statistically significant ipsilateral-contralateral asymmetric pairs than in group 2 (93 of 135). Conclusions: Surgical treatment of unilateral coronal craniosynostosis in infancy results in a less asymmetric craniofacial skeleton in adolescence than nontreatment. However, patients who have been followed to dentoskeletal maturity have a greater degree of asymmetry than those evaluated at 1 year postoperatively. These results support the conclusion that with time there is a partial reversion to the untreated phenotype.

Coronal ring involvement in patients treated for unilateral coronal craniosynostosis.

The etiopathology of the clinical entity normally referred to as unilateral coronal synostosis is commonly used to connote unilateral fusion of the frontoparietal suture. However, other sutures in the coronal ring may exhibit synostosis concomitant with or independent from frontoparietal synostosis and give rise to similar clinical phenotypes. This study retrospectively analyzes high-resolution computed tomographic data sets to determine patency of sutures within the coronal ring. Computed tomographic scan digital data from 33 infants who subsequently underwent surgical correction of unilateral coronal synostosis were assessed for sutural patency using Analyze imaging software. The frontosphenoidal suture was subdivided into intraorbital frontosphenoidal and extraorbital frontosphenoidal portions, and the patency of the frontoethmoidal suture was also assessed. Patients were sorted into two groups on the basis of the status of their frontosphenoidal sutures: group 1 had patent frontosphenoidal but synostotic frontoparietal sutures (n = 21) and group 2 had both frontosphenoidal and frontoparietal synostoses. Observer reproducibility was tested. The vertical and horizontal dimensions of the bony orbit and the endocranial base deflection angle were measured with the observer blinded with regard to sutural status group. Frontoethmoidal synostosis was not noted in any patients in either group. Two patients had no frontoparietal suture synostosis with isolated intraorbital frontosphenoidal and extraorbital frontosphenoidal suture closures. Suture diagnosis reproducibility was 99 percent. In group 1, the ipsilateral-to-contralateral vertical orbit dimension ratio averaged 1.11, whereas in group 2 it averaged 1.04 (p < 0.05). The ratio of horizontal orbit measurements was not significantly different between groups. In both groups, the endocranial base was deflected ipsilateral to the synostotic frontoparietal suture, with an average angle of 12 degrees in group 1 and 17 degrees in group 2 (p < 0.005). The extent of synostosis along the coronal sutural ring contributes to the dysmorphology of the orbit and the endocranial base deflection in patients whose clinical phenotypic diagnosis is unilateral coronal synostosis.

The effect of timing of surgery for velopharyngeal dysfunction on speech.

The timing of surgery for velopharyngeal dysfunction has been based on assumptions about the relation between age, speech development, and velopharyngeal dysfunction. Cleft palate teams often counsel parents to have an intervention for velopharyngeal dysfunction performed earlier rather than later, believing that earlier interventions result in more rapid or better normalization of speech. The objective of this retrospective chart review study is to determine whether the age at surgical intervention for velopharyngeal dysfunction has an effect on the subsequent length of speech therapy. Of 174 patients included in the study database, 36 had velopharyngeal dysfunction for which further velopharyngeal management was required. Of the 36 patients who received surgical velopharyngeal dysfunction management, 27 had verifiable speech therapy records. These 27 patients represent the study population. The outcome measure was the total length of subsequent speech therapy until speech normalization. The data suggest that there is no relation between the age at velopharyngeal dysfunction surgical management and the amount of speech therapy needed to achieve normalization of the speech impairments secondary to velopharyngeal dysfunction after that management. In conclusion, 1) the age at surgical velopharyngeal dysfunction management (pharyngeal flap or sphincter pharyngoplasty) does not have an effect on subsequent normalization of speech as measured by the duration of speech therapy necessary to achieve normalization of the speech impairments secondary to velopharyngeal dysfunction after that management, and 2) the age at surgical velopharyngeal dysfunction management does not affect the likelihood of subsequent surgical velopharyngeal dysfunction management procedures.

Preoperative osseous dysmorphology in unilateral complete cleft lip and palate: A quantitative analysis of computed tomography data

Background: The purpose of this study was to quantitate preoperative osseous dysmorphology in a homogeneous group of 3-month-old infants with unilateral complete cleft lip and palate. Methods: High-resolution computed tomography scans of 28 infants with unilateral complete cleft lip and palate were the basis for study. Coordinate data from 43 landmarks on the skull were collected using surface-rendered reconstructions of scan data. Euclidean distance matrix analysis was used to assess the degree of asymmetry between the cleft and noncleft sides of the craniofacial skeleton. Results: Linear distances involving primary and secondary landmarks (those that are located on or within the bony cleft and those that are near the cleft in the adjacent oronasal area, respectively) were highly asymmetric, with significantly greater distances on the cleft side. In addition, small (1 to 5 percent) but statistically significant asymmetries in linear distances were found involving tertiary landmarks (those that are not directly associated with the cleft or adjacent oronasal area). Most linear distances involving the nasion, zygomaxillare superius, and frontozygomatic junction were significantly greater on the cleft side, and certain linear distances in and around the middle cranial fossa were significantly smaller on the cleft side. Conclusions: The extreme asymmetry of primary and secondary landmarks is explained by the cleft itself and the obvious displacement of the premaxilla toward the noncleft side. The subtler, statistically significant asymmetry of the tertiary landmarks supports the idea that the unilateral cleft affects development of the entire face and possibly the cranial base. Euclidean distance matrix analysis of computed tomography landmark data is a useful methodology for the quantitative morphometry of children with untreated unilateral cleft lip and palate.

Comparative osseous and soft tissue morphology following cleft lip repair.

Objective: To quantify comparative improvement between osseous and soft tissue asymmetry following primary lip repair. Design: Retrospective analysis of preoperative and postoperative computed tomography scans of infants with unilateral cleft lip and palate. Sixteen soft tissue landmarks were placed using an exploratory two-/three-dimensional image processing system and compared for asymmetry. Patients: Computed tomography scans were obtained on 26 patients (13 boys, 13 girls) of Chinese ethnicity (mean age  =  0.25 years) prior to Millard lip repair. Nineteen of these contributed to follow-up comparative studies prior to palatoplasty at a mean age of 0.92 years. There were 18 left-sided and eight right-sided clefts. Main Outcome Measure: Euclidean distance matrix asymmetry analysis was used to determine the amount of soft tissue asymmetry pre- and postlip repair. Similar analyses of the same scans were performed for 41 osseous landmarks. Results: Soft tissue landmarks had 36/39 (92%) preoperative and 13/39 (33%) postoperative asymmetric pairs. Osseous distances demonstrated 77/125 (61%) asymmetric pairs preoperatively and 60/125 (48%) postoperatively. Soft tissue and osseous distances of the lip region demonstrated 32% and 39% postoperative asymmetry, respectively. Soft tissue and osseous distances of the nasal region demonstrated 52% and 72% postoperative asymmetry, respectively. Soft tissue and osseous distances of the facial landmarks demonstrated 24% and 34% postoperative asymmetry, respectively. Conclusions: Primary lip repair appears to effect gains in symmetry in soft tissue and provides sufficient molding forces to cause correlating symmetry changes in underlying osseous structures.

Accuracy in identification of patients with 22q11.2 deletion by likely care providers using facial photographs

Numerous facial characteristics are associated with velocardiofacial syndrome. Care providers may use these facial characteristics to identify patients who may benefit from fluorescence in situ hybridization genetic testing to determine the presence of the 22q11.2 deletion. The purpose of this study was to test the hypothesis that experienced care providers were able to correctly diagnose the 22q11.2 deletion on the basis of studying frontal facial photographs. After approval was obtained from the human studies committee, patients who had undergone fluorescence in situ hybridization genetics testing for the presence of a 22q11.2 deletion were asked to submit two frontal photographs: one at infancy and one beyond the second birthday. These photographs were randomized, made anonymous, and then placed on a secure Web site. Specialists in the fields of plastic surgery, otolaryngology, genetics, and speech pathology were asked to evaluate their experience and confidence levels in diagnosing a 22q11.2 deletion and were then asked to rate the photographs by likelihood of deletion using a five-point Likert scale. Thirty-two specialists (10 surgeons, nine geneticists, and 13 speech pathologists) participated in the study. On the basis of clear responses, respondents predicted the presence (sensitivity) and absence (specificity) of the 22q11.2 deletion at chance levels. Of the remaining responses, 20 to 25 percent were unsure and 20 to 25 percent were clearly wrong. When an unsure response was treated as a weak positive, the results favored sensitivity slightly, with a sensitivity of 70 percent and a specificity of 50 percent. Sensitivity improved somewhat with experience, as measured by the number of patients seen per year. The prediction of the presence or absence of the 22q11.2 deletion at chance levels suggests that the ability to diagnose on the basis of appearance alone is not a sufficient diagnostic tool. Although the ability does increase with experience, it is of statistical but not clinical significance.

Treatment of giant omphalocele with intraabdominal tissue expansion

Giant omphaloceles challenge the surgeon. These abdominal wall defects range in severity from minor umbilical hernias to complete defects of the abdominal wall. Giant omphaloceles have a fascial defect greater than 6 cm and an extraperitoneal liver. Small defects may be closed primarily or with an absorbable mesh patch. However, giant omphaloceles require gradual reduction of the extraperitoneal viscera using preformed silos.1–5 In patients with severe abdominovisceral disproportion, the silo may tear free of the fascia under the stress of the reduction. Alternatives such as delayed repair and staged repair are suboptimal, as the patient may develop skin ulceration or damage to intraperitoneal organs. The fundamental problem that requires correction in giant omphaloceles is the abdominovisceral disproportion. We propose a method of intraperitoneal tissue expansion with volumetric computed tomographic analysis for operative planning. Two cases treated in this manner are presented.