Hyuma A. Leland

Optimizing Outcomes following Total and Subtotal Tongue Reconstruction: A Systematic Review of the Contemporary Literature

Background More than 45,000 Americans are diagnosed with oropharyngeal cancer annually and multimodal treatment often requires wide excision, lymphadenectomy, chemotherapy, and radiation. Total and subtotal lingual resection severely impairs speech, swallow, and quality of life (QoL). This study investigates functional outcomes and QoL following subtotal and total tongue resection with free tissue transfer reconstruction. Materials and Methods A systematic review of the English language literature was performed using PubMed, Ovid, Embase, and Cochrane databases based on predetermined inclusion/exclusion criteria. Included studies were reviewed for surgical technique, adjuvant treatment, surgical and functional outcomes, and QoL. Results From an initial search yield of 1,467 articles, 22 studies were included for final analysis. Speech intelligibility was correlated with the volume and degree of protuberance of the neotongue. Adjuvant therapy (radiation) and large tumor size were associated with worse speech and swallow recovery. At 1 year follow‐up, despite 14 to 20% rates of silent aspiration, 82 to 97% of patients resumed oral feeding. Neurotized flaps have been demonstrated to improve flap sensation but have not yet demonstrated any significant impact on speech or swallow recovery. Finally, many patients continue to experience pain after surgery, but patient motivation, family support with physician, and speech therapist follow‐up are associated with improved QoL scores. Conclusion Tongue reconstruction is dictated by the amount of soft tissue resection. Taking into consideration the most common factors involved after tongue resection and reconstruction, further studies should focus on more objective measurements to offer solutions and maximize final outcomes.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps

Background Extracranial‐intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow‐through flaps for cerebral revascularization as an additional tool to provide direct and indirect revascularization and/or soft tissue coverage. Methods A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect revascularization and/or soft tissue reconstruction were performed. Results Indications for arterial bypass included intracranial aneurysm (n = 2) and moyamoya disease (n = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect cerebral revascularization (eight). Four flow‐through flaps and five pedicled flaps were used including a flow‐through radial forearm fasciocutaneous flap (one), flow‐through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor‐site complications. In one case of flow‐through TPF flap, the direct graft failed, but the indirect flap remained vascularized. Conclusion Local and flow‐through flaps can improve combined direct and indirect revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long‐term results remain under investigation for these combined neurosurgery and plastic surgery procedures. Level of Evidence The level of evidence is IV.

Abdominal Bulge After Retroperitoneal Dissection: The Definitive Management Using Bone Anchored Mesh.

BackgroundAbdominal bulge after retroperitoneal dissection occurs at a rate of 1% to 56%. Injury to the T11 and T12 nerves is thought to result in abdominal musculature denervation, laxity, and symptomatic abdominal bulge. This complication has become more prevalent because the retroperitoneal approach for spinal surgery has become the preferred approach in specific lumbar and thoracic cases. Current repair techniques fail to address the etiology of abdominal wall laxity, and outcomes are poorly reported. Recurrence rates in lateral abdominal bulge repair are reported between 0% and 100%, and the complication rate is nearly 25%. We present a method of bone anchored fixation of mesh for abdominal wall reinforcement after the imbrication of the atrophied musculature, resulting in the definitive treatment of abdominal bulge after retroperitoneal dissection. MethodsA retrospective review of 4 consecutive patients who underwent bony fixation of mesh using Mitek suture anchors (De Puy, Raynham, MA) for abdominal bulge after retroperitoneal dissection between February 2013 and September 2014 was performed. The preoperative, intraoperative, and postoperative records of 4 patients were reviewed and compared. ResultsThere were no reported early recurrences and no perioperative morbidity or mortality related to the operation. Average follow-up was 12.8 months (range, 6–26 months); operative time, 157 minutes; postoperative length of stay, 3.5 days; and estimated blood loss was 50 mL. ConclusionsReinforcement of the myofascial repair using bone anchored fixation of mesh represents a novel approach for the treatment of abdominal bulge after retroperitoneal dissection. Results demonstrate safety and no early recurrence.

Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma

Tibial fracture management may be complicated by infection of internal fixation hardware (iIFH) resulting in increased morbidity and amputation rate. When iIFH removal is not possible, salvage of the lower extremity is attempted through debridement, antibiotics, and vascularized soft tissue coverage. This study investigates lower extremity salvage with retention of iIFH.

Investigation Into the Optimal Number of Intercostal Nerve Transfers for Musculocutaneous Nerve Reinnervation: A Systematic Review

Background: The purpose of this study was to systematically review outcomes following intercostal nerve (ICN) transfer for restoration of elbow flexion, with a focus on identifying the optimal number of nerve transfers. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify studies describing ICN transfers to the musculocutaneous nerve (MCN) for traumatic brachial plexus injuries in patients 16 years or older. Demographics were recorded, including age, time to operation, and level of brachial plexus injury. Muscle strength was scored based upon the British Medical Research Council scale. Results: Twelve studies met inclusion criteria for a total of 196 patients. Either 2 (n = 113), 3 (n = 69), or 4 (n = 11) ICNs were transferred to the MCN in each patient. The groups were similar with regard to patient demographics. Elbow flexion ≥M3 was achieved in 71.3% (95% confidence interval [CI], 61.1%-79.7%) of patients with 2 ICNs, 67.7% (95% CI, 55.3%-78.0%) of patients with 3 ICNs, and 77.0% (95% CI, 44.9%-93.2%) of patients with 4 ICNs (P = .79). Elbow flexion ≥M4 was achieved in 51.1% (95% CI, 37.4%-64.6%) of patients with 2 ICNs, 42.1% (95% CI, 29.5%-55.9%) of patients with 3 ICNs, and 48.4% (95% CI, 19.2%-78.8%) of patients with 4 ICNs (P = .66). Conclusions: Previous reports have described 2.5 times increased morbidity with each additional ICN harvest. Based on the equivalent strength of elbow flexion irrespective of the number of nerves transferred, 2 ICNs are recommended to the MCN to avoid further donor-site morbidity.

Peripheral nerve injury with Nexplanon removal: case report and review of the literature

BackgroundImplantable devices offer convenient, long-acting, and reversible contraception. Injury to the peripheral nerves and blood vessels have been reported as rare complications of implantation and extraction.Case presentationWe present a case of ulnar nerve injury in a 21-year-old woman from attempted in-office removal of a deeply implanted Nexplanon® device. The injury resulted in an ulnar nerve palsy requiring surgical exploration, neuroma excision, and sural nerve cable grafting.ConclusionsIn-office attempts to remove contraceptive implants that are deep or have migrated can cause iatrogenic nerve injury. Devices that are non-palpable, deep, or migrated should be imaged before formal surgical exploration and removal. Any patient with neurologic symptoms after placement or after attempted removal requires prompt diagnosis and referral to a peripheral nerve surgeon.

Abstract 107: Extracranial to Intracranial Flow through Flaps

PURPOSE: Venous compromise is the most common reason for perioperative free flap complications. The dependent nature of the lower extremity likely increases this risk, especially following significant lower extremity trauma with superficial or deep venous injury and immobilization of the soleal muscle venous pump. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction and warrants further investigation.

Abstract: Functional Recovery after Traumatic Lower Extremity Salvage

CONCLUSION: Our findings show that there is considerable measurement error between perometry and perimetry when measuring the absolute or relative volumes of the arms and that their results should be compared with caution. Furthermore, we observed an increasingly relevant measurement error as outcomes are derived from arm volumes originally measured in error. Our findings suggest that the lymphedema surgery community should concentrate efforts to validate more precise and reliable outcomes to assess the effect of surgical treatment.

A Critical Appraisal of Vascularized Bone Grafting for Scaphoid Nonunion

Background Vascularized bone grafting (VBG) has the potential to yield reliable results in scaphoid nonunion; however, results across studies have been highly variable. This study critically evaluates surgical techniques, fracture location, and patient selection in relation to radiographic, clinical, and patient‐centered outcomes after VBG for scaphoid nonunion. Methods We conducted a systematic review of the literature for the use of VBG in scaphoid nonunion. Physical examination, radiographic, and patient‐centered outcomes were assessed. Four substratifications were performed: the location of scaphoid nonunion, pedicled versus free technique, Kirschner wire (K‐wire) versus screw fixation, and VBG done as a primary versus revision procedure. Results A total of 41 publications were included in final analysis. VBG had an 84.7% union rate at 13 weeks after surgery. On an average, 89% of patients returned to preinjury activity levels by 18 weeks after surgery and 91% of patients reported satisfaction with the procedure. Proximal pole nonunions demonstrated similar union rates but lower functionality scores compared with nonunions across all regions of the scaphoid. Pedicled techniques demonstrated slightly improved range of motion compared with free technique. K‐wire versus screw fixation demonstrated significantly higher union rates and faster union times. There were no differences in outcomes for VBG done as a primary versus revision procedure. Conclusion VBG serves as a viable option for the treatment of scaphoid nonunion, with consistent union rates in addition to significantly improved postoperative patient functionality. The fixation of these vascularized bone grafts with K‐wires versus screw fixation may result in superior radiologic outcomes. Level of Evidence Therapeutic, Level III, systematic review.

Vascularized Bone Grafting in Scaphoid Nonunion: A Review of Patient-Centered Outcomes

Background: The radiographic and clinical outcomes following vascularized bone grafting (VBG) for scaphoid nonunion have previously been reported in the literature; however, few studies report on patient-derived outcomes. The purpose of this study was to determine the effect of VBG for scaphoid nonunion on patient-derived outcomes. Methods: The MEDLINE and PubMed databases were queried for the use of VBG in scaphoid nonunion. We included studies that reported on patient-derived outcomes. We excluded studies with less than 10 patients or less than 6 months of follow-up. The primary outcomes assessed included functionality, percent and time to return to preinjury activity, postoperative pain, and patient satisfaction. Results: Twenty-six articles described the outcomes of 520 patients with an average of 19.3 patients per study. Functionality was most commonly assessed by the Mayo Modified Wrist Score and Disabilities of the Arm, Shoulder and Hand scores, which improved by 53.1% and 81.7% postoperatively, respectively. Within 16 weeks, 90.3% of patients returned to their previous occupation or sporting activity. Pain was most commonly reported using a 0 to 10 visual analog scale and improved 4-fold postoperatively. Complete satisfaction was reported by 92% of patients. The most common complications were superficial infections (1.56%), neuropathic pain (1.56%), and complex regional pain syndrome (1.25%). Conclusions: VBG for scaphoid nonunion results in the improvement of patient-derived outcomes, and high rates of return to preinjury activity levels and patient satisfaction. Multiple metrics of patient-derived outcomes were utilized by the studies in our review without a clear consensus as to which metric is most responsive and accurate.