Michael R. Bykowski

Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: A single-center, retrospective review of 8,850 cases

PURPOSE Prophylactic antibiotics have been shown to prevent surgical site infection (SSI) after some gastrointestinal, orthopedic, and plastic surgical procedures, but their efficacy in clean, elective hand surgery is unclear. Our aims were to assess the efficacy of preoperative antibiotics in preventing SSI after clean, elective hand surgery, and to identify potential risk factors for SSI. METHODS We queried the database from an outpatient surgical center by Current Procedural Terminology code to identify patients who underwent elective hand surgery. For each medical record, we collected patient demographics and characteristics along with preoperative, intraoperative, and postoperative management details. The primary outcome of this study was SSI, and secondary outcomes were wound dehiscence and suture granuloma. RESULTS From October 2000 through October 2008, 8,850 patient records met our inclusion criteria. The overall SSI rate was 0.35%, with an average patient follow-up duration of 79 days. The SSI rates did not significantly differ between patients receiving antibiotics (0.54%; 2,755 patients) and those who did not (0.26%; 6,095 patients). Surgical site infection was associated with smoking status, diabetes mellitus, and longer procedure length irrespective of antibiotic use. Subgroup analysis revealed that prophylactic antibiotics did not prevent SSI in male patients, smokers, or diabetics, or for procedure length less than 30 minutes, 30 to 60 minutes, and greater than 60 minutes. CONCLUSIONS Prophylactic antibiotic administration does not reduce the incidence of SSI after clean, elective hand surgery in an outpatient population. Moreover, subgroup analysis revealed that prophylactic antibiotics did not reduce the frequency of SSI among patients who were found to be at higher risk in this study. We identified 3 factors associated with the development of SSI in our study: diabetes mellitus status, procedure length, and smoking status. Given the potential harmful complications associated with antibiotic use and the lack of evidence that prophylactic antibiotics prevent SSIs, we conclude that antibiotics should not be routinely administered to patients who undergo clean, elective hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients.

Background: Pediatric craniofacial fractures are anatomically distinct from their adult counterparts and must be managed with respect for future growth and development. These injuries must be approached as entities fundamentally different from adult craniofacial fractures. Here, the authors aim to provide context for practitioners managing pediatric facial fractures by augmenting presently available demographic, diagnostic, and treatment data. Methods: This is a retrospective review of demographics, diagnosis, and treatment of patients under 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with facial fractures. Patients were included regardless of treating specialty, treatment modality, or inpatient status. Results: A total of 772 consecutive patients met inclusion criteria. A significant majority (p < 0.001) of patients (68.9 percent) were male; older children were significantly more likely to sustain a facial fracture (p < 0.001). Fracture pattern, level of care, and cause of injury varied by age; 55.6 percent of patients had severe associated injuries. Male subjects, older patients, and patients of lower socioeconomic status were significantly more likely to sustain facial fractures secondary to violence (p ⩽ 0.001). Conclusions: Pediatric facial fractures may be associated with severe concomitant injuries. Injury patterns are significantly correlated with socioeconomic metrics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

215 mandible fractures in 120 children: Demographics, treatment, outcomes, and early growth data

Background: Optimal management of pediatric mandible fractures demands that the practitioner balance reduction and fixation with preservation of growth potential and function. The ideal synthesis of these goals has not yet been defined. The authors catalogue their experience with pediatric mandible fractures at a major pediatric teaching hospital with reference to demographics, injury type, treatment, and outcomes to inform future management of these injuries. Methods: Demographics, management, and outcomes of pediatric mandible fractures presenting over 10 years at a pediatric trauma center were assessed. Cephalometric analysis was conducted. Relationships among demographics, fracture type, management, outcomes, and growth were explored. Results: Two hundred fifteen mandible fractures in 120 patients younger than 18 years were analyzed (average follow-up, 19.5 months). The condylar head and neck were fractured most frequently. Operative management was significantly more likely for children older than 12 years (p < 0.05). Operative management and multiple fractures were significantly associated with a higher rate of adverse outcomes (p < 0.05), but no adverse outcomes were considered to significantly affect mandibular function by patient or surgeon. No significant growth differences existed on cephalometric analysis between our cohort and age- and sex-matched controls (p > 0.05). Conclusions: This study reports the demographics, treatment, and early follow-up of a sizable cohort of pediatric mandible fractures. Management principles for these injuries are outlined. Although definitive recommendations must be withheld until longer follow-up is available, the data presented here show that the treatment protocols used at the authors’ center have yielded largely uncompromised mandibular function and growth thus far.

Postoperative hyponatremia following calvarial vault remodeling in craniosynostosis.

Background:  The incidence, severity, and risk factors for the development of hyponatremia in patients undergoing craniosynostosis surgery are not well known.

Regulation of NaCl solution intake and gastric emptying in adrenalectomized rats

Adrenalectomized (adrex) rats adaptively increase NaCl intake to compensate for the uncontrolled loss of Na(+) in urine due to the absence of aldosterone. After a period of NaCl deprivation, they ingest saline avidly but stop drinking before hyponatremia is repaired. The present experiments determined whether pre-systemic signals inhibit further NaCl intake, and whether gastric emptying of Na(+) is modulated according to the concentration of ingested NaCl solution. After overnight deprivation, adrex rats consumed 0.05 M and 0.15 M NaCl at a maximally fast rate ( approximately 1.7 ml/min) and emptied ingested fluid from the stomach at a slower but maximally fast rate ( approximately 1.1 ml/min). When 0.30 M NaCl was consumed instead, fluid intake still was maximally fast but gastric emptying slowed in proportion to concentration so that the emptying of Na(+) was comparable to that observed when 0.15 M NaCl was ingested ( approximately 0.13 meq/min). When 0.50 M NaCl was consumed, intake slowed proportionately so that Na(+) consumption was comparable to that observed when 0.30 M NaCl was ingested ( approximately 0.5 meq/min). NaCl intake appeared to be inhibited both by the concentration of saline emptied from the stomach and by the volume of ingested fluid in the stomach and small intestine. Gastric emptying also slowed proportionately when 0.50 M NaCl was consumed, as if the rats were regulating the delivery of Na(+) to the small intestine. These results suggest that adrex rats can detect the volume and concentration of ingested NaCl solution presystematically and integrate these two variables, and thereby modulate the rates of Na(+) intake and gastric emptying.

Direct comparison of progenitor cells derived from adipose, muscle, and bone marrow from wild-type or craniosynostotic rabbits

Background: Reports have identified cells capable of osteogenic differentiation in bone marrow, muscle, and adipose tissues, but there are few direct comparisons of these different cell types. Also, few have investigated the potential connection between a tissue-specific abnormality and cells derived from seemingly unrelated tissues. In this article, the authors compare cells isolated from wild-type rabbits or rabbits with nonsyndromic craniosynostosis, defined as the premature fusion of one or more of the cranial sutures. Methods: Cells were derived from bone marrow, adipose, and muscle of 10-day-old wild-type rabbits (n = 17) or from age-matched rabbits with familial nonsyndromic craniosynostosis (n = 18). Cells were stimulated with bone morphogenetic protein-4 (BMP4), and alkaline phosphatase expression and cell proliferation were assessed. Results: In wild-type rabbits, cells derived from muscle had more alkaline phosphatase activity than cells derived from either adipose or bone marrow. The cells derived from craniosynostotic rabbit bone marrow and muscle were significantly more osteogenic than those derived from wild-type rabbits. Adipose-derived cells demonstrated no significant differences. Although muscle-derived cells were most osteogenic in wild-type rabbits, bone marrow-derived cells were most osteogenic in craniosynostotic rabbits. Conclusions: These results suggest that cells from different tissues have different potentials for differentiation. Furthermore, cells derived from rabbits with craniosynostosis were different from cells from wild-type rabbits. Interestingly, cells derived from the craniosynostotic rabbits were not uniformly more responsive compared with wild-type cells, suggesting that specific tissue-derived cells may react differently in individuals with craniosynostosis.

BMP-2-regenerated calvarial bone: a biomechanical appraisal in a large animal model.

AbstractRecombinant human bone morphogenetic protein-2 (rhBMP-2) is gaining popularity in craniofacial applications. Calvarial defects are, under normal circumstances, subjected to only minimal levels of the biomechanical stresses known to play an important role in osteogenesis, yet regenerated calvarial bone must be capable of withstanding traumatic forces such that the underlying neurocapsule is protected. The aim of this study is to, for the first time, assess the biomechanical properties of calvarial bone regenerated with derivations of a commercially available rhBMP-2–based system. Standardized calvarial defects were created in 23 adult male canines. These defects were treated with rhBMP-2 on one of several carriers. After 24 weeks, the biomechanical properties of the rhBMP-2–generated bone were compared to those of controls with a modified punch-out test (Bluehill 2; Instron, Norwood, Mass) and compared using a paired nonparametric analyses (SPSS, 17.0, Chicago, Ill). In a previously published report, defects across all the rhBMP-2 therapy groups were observed to have a mean rate of 99.5% radio-opacity at 24 weeks indicating nearly full bony coverage of the calvarial defect (compared to 32.7% in surgical controls). For ultimate load, ultimate energy, and first peak energy, there were significant differences (P < 0.05) with the control native bone having more robust biomechanical properties than the rhBMP-2–generated bone. We conclude from these findings that rhBMP-2–generated calvarial bone is significantly less protective against trauma than native bone at 6 months. Further investigation is required to assess the efficacy of rhBMP-2 in healing calvarial defects in the longer term.

Gastric Emptying and Intestinal Absorption of Ingested Water and Saline by Hypovolemic Rats

Recent experiments showed that in a one-bottle test conducted 16h after sc injection of polyethylene glycol (PEG) solution, hypovolemic rats consumed water or 0.30 M NaCl in an initial drinking episode but did not empty the ingested fluid from the stomach or absorb it from the small intestine very rapidly, certainly not as rapidly as when 0.15M NaCl was consumed (Smith et al., Am J Physiol 292: R2089-R2099, 2007). The present experiments examined the patterns of water and 0.30 M NaCl ingestion and the movement of consumed fluid through the gastrointestinal tract when PEG-treated rats were given a two-bottle delayed-access test. We found that both fluids always were consumed in the first drinking episode, that the fluid mixture ingested was equivalent to 0.10-0.15M NaCl, and that gastric emptying rate and net fluid absorption from the small intestine usually were much faster than when PEG-treated rats drank either water or hypertonic saline alone. Thus, ingestion of water and 0.30 M NaCl by hypovolemic rats in the same episode adaptively facilitated the movement into the circulation of a near-isotonic fluid that is ideal for restoring plasma volume deficits.

The safe and efficacious use of arch bars in patients during primary and mixed dentition: a challenge to conventional teaching.

Background: Erich arch bars facilitate intermaxillary fixation, and traditional teaching questions and often argues against the use of arch bars in patients during primary and mixed dentition. Dental anatomy, risk of tooth avulsion, and potential disruption of developing permanent dentition are reasons cited. This study provides the only outcome data on the use of arch bars in children during primary and mixed dentition. Methods: Patients in primary and mixed dentition presenting with mandible fractures treated with arch bars from 2000 to 2010 were reviewed. Elements collected included demographics, medical history, fracture management, adverse outcomes, and dental health as determined by a pediatric dentist at follow-up. Results: A total of 154 mandible fractures in 79 patients were identified, with 23 patients (48 fractures) meeting inclusion criteria. Average age at injury was 9.10 years (range, 2.70 to 13.49 years), and average follow-up was 32.35 months (range, 0.43 to 131.84 months). Fracture types included condylar head (n = 9), condylar neck (n = 12), angle (n = 10), body (n = 4), and parasymphysis (n = 13) fractures. There were no periodontal defects, tooth avulsions, or disturbances to permanent dentition noted with regard to arch bar use. Conclusions: These data demonstrate that arch bars can be safely used in children during primary and mixed dentition with no periodontal defects, tooth avulsions, or disturbances to permanent dentition. Despite traditional teaching, the authors demonstrate arch bar use to be efficacious and safe in children during primary or mixed dentition. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Impact of Abdominal Contouring with Monsplasty on Sexual Function and Urogenital Distress in Women Following Massive Weight Loss

Background Monsplasty treats massive weight loss (MWL) patients with redundant tissues in the mons region. Monsplasty, however, is not a routine component of abdominal contouring. Objectives The goal of this study was to evaluate the changes in urinary and sexual functioning in patients who undergo abdominal contouring with monsplasty vs non-operated controls. Methods A prospective study was performed of patients who underwent abdominal contouring + monsplasty or no surgery. The Urogenital Distress Inventory Short Form (UDI-6) and the Female Sexual Function Index (FSFI) questionnaires were administered to both groups at baseline and then three months later. Results The surgical (n = 20) and nonsurgical groups (n = 20) were similar related to patient demographics, body mass index after MWL, parity, relationship status, hormonal status, and baseline UDI-6/FSFI scores (all P values >0.05). After three months, there was a statistically significant decrease in the UDI-6 score for the surgical groups vs the nonsurgical group: median UDI-6 score = −0.01 (interquartile range [IQR], −7.65-5.55) vs 0 (IQR, 0-11.11) (P = .03). There was no change for the Female Sexual Function Index in the surgical vs nonsurgical groups: median FSFI = 0.20 (IQR, −1.20-1.58) vs 0.95 (IQR, 0.08–2.58) (P = .11). Conclusions Urinary dysfunction improved even at the early time point of three months following abdominal contouring procedures including monsplasty. At the early postoperative period of three months, however, there was no significant change in female sexual function. Monsplasty in conjunction with abdominal contouring is recommended in the MWL female patient. Level of Evidence 2 Therapeutic