Raymond Tse

Suprascapular nerve reconstruction in obstetrical brachial plexus palsy: spinal accessory nerve transfer versus C5 root grafting.

Background: The purpose of this study was to determine whether there is any difference in external rotation following reconstruction of the suprascapular nerve using nerve grafts from the proximal C5 root or nerve transfer using the spinal accessory nerve. Methods: External rotation was assessed using the Active Movement Scale immediately before surgery and 3 years postoperatively. Patients with less than 3 years of follow-up were excluded. For patients who underwent secondary shoulder surgery before the 3-year follow-up, the Active Movement Scale score before shoulder surgery was used as the outcome. Results: One-hundred-six patients underwent nerve grafting, while 71 patients underwent spinal accessory nerve transfer. The spinal accessory nerve transfer group had a greater proportion of patients with total plexus palsies, more avulsions, and an earlier age at surgery (p < 0.001). In the C5 nerve graft group, the mean Active Movement Scale score increased from 0.4 to 2.2 (p < 0.001). In the nerve transfer group, the mean score increased from 0.2 to 3.0 (p < 0.001). Preoperatively, the C5 nerve graft group had significantly better scores than the nerve transfer group (p = 0.03). Postoperatively, there was no significant difference between treatments (p = 0.1). Further statistical analysis failed to demonstrate a significant advantage of one surgical treatment over the other. Conclusions: There was no difference in external rotation after suprascapular nerve reconstruction with either nerve grafting from the proximal C5 root or spinal accessory nerve transfer. The choice of suprascapular nerve reconstruction can be selected depending on specific requirements of the individual lesion.

Objective Measurements for Grading the Primary Unilateral Cleft Lip Nasal Deformity

Background: The purpose of this prospective study was to develop and validate an objective means of grading the presurgical unilateral cleft lip nasal deformity. Our hypotheses are that expert cleft surgeons can reliably rank patients according to their subjective assessment of the degree of unilateral cleft lip nasal deformity and that objective anthropometric measurements correlate consistently with this subjective assessment. Methods: Forty consecutive infants with unilateral cleft lip nasal deformity were subjectively ranked according to the degree of deformity on standardized presurgical photographs by four senior cleft surgeons. Internal agreement was assessed. Correlations between presurgical anthropometric parameters and the subjective panel rankings were determined. To test the reproducibility of subjective ranking, a random subset of images (n = 15) was also ranked by four external expert cleft surgeons of international reputation. Results: There was extremely high agreement of subjective ranking by the expert panels (interclass correlation coefficient, 0.95 for the internal panel and 0.94 for the external panel) and between the two panels (interclass correlation coefficient, 0.97). The nostril width ratio was the most predictive of both internal and external rank scores (r = 0.76, p < 0.0001; and r = 0.81, p = 0.0003, respectively). The columellar angle was also highly predictive of both internal and external expert rank scores (r = 0.73, p < 0.0001; and r = 0.79, p = 0.0005, respectively). Conclusions: Experts are reliably able to subjectively rank patients according to the degree of nasal deformity. Measures of the columellar angle and the nostril width ratio vary in a linear fashion with the perceived deformity and may serve as independent and objective indicators of presurgical severity of unilateral cleft lip nasal deformity.

The white-eyed medial blowout fracture.

Background: The pediatric white-eyed blowout fracture with entrapment of the inferior rectus muscle is well recognized as an easily missed injury with significant morbidity if left untreated. A series of five isolated medial orbital blowout fractures with medial rectus muscle entrapment is described. The purpose of this study was to define this injury pattern and its clinical outcome. Methods: A retrospective review of the presentation, management, and clinical outcomes of identified cases was conducted. Results: Early exploration and release of the entrapped muscle combined with implant reconstruction of the medial orbital wall within 2 weeks resulted in complete resolution of diplopia and full recovery of extraocular movements. Delayed treatment and release of the soft tissues without orbital wall reconstruction were associated with restricted gaze and diplopia. Similar outcomes were confirmed on analysis of other reported cases. Conclusions: Orbital floor blowout fractures in the pediatric population have a high incidence of muscle entrapment that must be recognized and treated early to avoid muscle necrosis and permanent ocular restriction from fibrosis. Medial orbital wall fractures with entrapment are rare, but early recognition and operative release of the entrapped muscles result in better outcomes.

Sensibility following innervated free TRAM flap for breast reconstruction.

Background: The free transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be a reliable means of recreating the aesthetic breast form after mastectomy. The purpose of this study was to determine whether neurotization of the free TRAM flap improved sensation of the reconstructed breast. Methods: Twenty-seven patients undergoing 37 free TRAM flap reconstructions were randomized to receive either an innervated (12 patients, 18 breasts) or a noninnervated flap (15 patients, 19 breasts). A nerve repair between the T10 intercostal of the TRAM flap and the anterior sensory branch of the fourth intercostal nerve was performed for innervation. Sensory testing (Semmes-Weinstein monofilaments, hot-cold discrimination, two-point discrimination) was performed by one blinded examiner in a standardized pattern. Results: Mean follow-up was 16 months. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola reconstruction between patient groups (p > 0.3). Patients in the noninnervated group, however, were heavier (p = 0.03). Preoperative sensation was not significantly different in the noninnervated and innervated groups. Postoperative pressure threshold and temperature discrimination were significantly improved in the innervated flaps (p < 0.05). Noninnervated flaps displayed a pattern of increasing sensibility from the center toward the periphery while innervated flaps regained sensation throughout. Conclusions: Innervation of the free TRAM flap provides improved sensation to the reconstructed breast and is a simple adjunct to breast reconstruction.

Enhanced Dupuytren's disease fibroblast populated collagen lattice contraction is independent of endogenous active TGF-β2

BackgroundDupuytrens disease (DD) is a debilitating fibro-proliferative disorder of the hand characterized by the appearance of fibrotic lesions (nodules and cords) leading to flexion contractures of the fingers and loss of hand function. Although the molecular mechanism of DD is unknown, it has been suggested that transforming growth factor-β2 (TGF-β2) may play an important role in the underlying patho-physiology of the disease. The purpose of this study was to further explore this hypothesis by examining the effects of TGF-β2 on primary cell cultures derived from patient-matched disease and normal palmar fascia tissue using a three-dimensional collagen contraction assay.MethodsFibroblast-populated collagen lattice (FPCL) contraction assays using primary cell cultures derived from diseased and control fascia of the same DD patients were studied in response to exogenous TGF-β2 and neutralizing anti-TGF-β2 antibodies.ResultsContraction of the FPCLs occurred significantly faster and to a greater extent in disease cells compared to control cells. The addition of TGF-β2 enhanced the rate and degree of collagen contraction in a dose-dependent fashion for both control and diseased cells. Neutralizing anti-TGF-β2 antibodies abolished exogenous TGF-β2 stimulated collagen contraction, but did not inhibit the enhanced basal collagen contraction activity of disease FPCL cultures.ConclusionsAlthough exogenous TGF-β2 stimulated both disease and control FPCL contraction, neutralizing anti-TGF-β2 antibodies did not affect the elevated basal collagen contraction activity of disease FPCLs, suggesting that the differences in the collagen contraction activity of control and disease FPCL cultures are not due to differences in the levels of endogenous TGF-β2 activity.

Rounding of the inferior rectus muscle as a predictor of enophthalmos in orbital floor fractures

In spite of established indications for early operative repair of orbital floor fractures 7-10% of patients treated nonoperatively develop enophthalmos. Clearly further indications for repair are required to prevent these post-injury complications. Rounding of the inferior rectus muscle on coronal computerized tomography (CT) scan results from a loss of soft tissue and bony support and may therefore be predictive of late enophthalmos. A four-year institutional review was conducted to identify patients with orbital floor fractures that had been treated nonoperatively. Patients were recruited for late clinical follow-up (mean 30 months) where clinically significant enophthalmos and diplopia were measured. Clinical results were correlated with measurements of the height-to-width ratio of the inferior rectus muscle on CT scans by a blinded examiner. Eighteen of 78 patients were available for late follow-up. Sixteen patients had no enophthalmos whereas 2 patients had enophthalmos. The inferior rectus height-to-width ratios measured in the unaffected orbits were statistically similar between the two groups. There was a significantly increased height-to-width ratio exceeding 1.00 in the affected orbit when the enophthalmos group was compared to the no enophthalmos group. A height-to-width ratio of the inferior rectus muscle on coronal CT scan of greater than or equal to 1.00 is predictive of late enophthalmos.

Sensibility following Innervated Free TRAM Flap for Breast Reconstruction: Part II. Innervation Improves Patient-Rated Quality of Life

Background: Restoring sensory innervation may be a useful adjunct in free flap head and neck reconstruction but, as yet, has not been shown to improve outcomes of breast reconstruction. The authors’ previous study demonstrated objectively improved sensation in a group of innervated transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction patients relative to noninnervated flaps. This study compared patient-rated outcomes of free TRAM breast reconstruction in innervated versus noninnervated flaps. Methods: Twenty-seven women were randomized prospectively to undergo either innervated or noninnervated free TRAM flap breast reconstruction. For innervated flaps, the T10 intercostal nerve was harvested with the TRAM flap and neurotized to the T4 sensory nerve at the recipient site. Three validated outcome tools were administered after surgery: the Medical Outcomes Study 36-Item Short Form Health Survey, the Body Image after Breast Cancer Questionnaire, and the Functional Assessment of Cancer Therapy–Breast. Results were correlated with previously reported objective sensibility outcomes. Results: Eighteen of 27 women returned their questionnaires a mean 48 months after free TRAM flap reconstruction. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola complex reconstruction between randomized patient groups. There was a statistically significant improvement in all three measures in patients who were randomized to receive innervated free TRAM flaps compared with those receiving noninnervated flaps. Conclusion: This study demonstrates that innervation of free TRAM flaps used for breast reconstruction not only improves sensibility but also has a positive effect on patient-rated quality of life.

Late salvage of a free TRAM flap

We present the case of a patient with arterial thrombosis of a free TRAM flap 11 days after surgery. Initial salvage involved thrombectomy through an arteriotomy using a Fogarty catheter. Subsequent return to the operating theatre was necessary because of further vascular compromise. Thrombectomy was combined with flap thrombolysis and anticoagulation, and the flap remained viable at 6 months. Although rates of successful salvage vary, the literature indicates that flaps are rarely saved if signs of compromise present later than 2 days postoperatively. This case demonstrates that aggressive salvage may be successful even in cases of late vascular compromise.

Crowdsourcing as a Novel Method to Evaluate Aesthetic Outcomes of Treatment for Unilateral Cleft Lip

Background: Lack of convenient and reliable methods to grade aesthetic outcomes limits the ability to study results and optimize treatment of unilateral cleft lip. Crowdsourcing methods solicit contributions from a large group to achieve a greater task. The authors hypothesized that crowdsourcing could be used to reliably grade aesthetic outcomes of unilateral cleft lip. Methods: Fifty deidentified photographs of 8- to 10-year-old subjects (46 with unilateral cleft lip and four controls) were assembled. Outcomes were assessed using multiple pairwise comparisons that produced a rank order (Elo rank) of nasal appearance and, on a separate survey, by Asher-McDade ratings. Both surveys were repeated to assess reliability. A group of expert surgeons repeated the same tasks on a smaller subset of photographs. Results: The authors obtained 2500 and 1900 anonymous, layperson evaluations by means of crowdsourcing on each Elo rank and Asher-McDade survey, respectively. Elo rank and Asher-McDade scores were highly reproducible (correlation coefficients, 0.87 and 0.98), and crowd evaluations agreed with those by expert surgeons (0.980 and 0.96 for Elo rank and Asher-McDade score, respectively). Crowdsourcing surveys were completed within 9 hours, whereas the expert surgeons required 3 months. On further analysis of their cleft subject sample set, the authors found that greater initial cleft severity was associated with worse aesthetic outcome. Conclusions: Outcomes assessed by crowds were reliable and correlated well with expert assessments. Crowdsourcing allows acquisition of massive numbers of layperson assessments on an unprecedented scale, and is a convenient, rapid, and reliable means of assessing aesthetic outcome of treatment for unilateral cleft lip. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Rounding of the inferior rectus muscle as an indication of orbital floor fracture with periorbital disruption

OBJECTIVEnTo determine if rounding of the inferior rectus muscle on coronal computed tomographic (CT) scans predicts disruption of the periorbita in orbital floor fractures and therefore predicts delayed enophthalmos.nnnDESIGNnCadaveric study with CT scan analysis.nnnSETTINGnCadaveric laboratory and CT scanner at a tertiary care hospital in London, Ontario.nnnMETHODSnEach orbit of each cadaveric head was randomly assigned to have either intact or disrupted periorbita. Progressively larger orbital floor fractures were made and CT scans were taken before fractures and after each fracture to assess the shape of the inferior rectus muscle. Measurements were made of the length of the long and short axis of the inferior rectus muscle using CT analysis software. The short to long axis ratio was then compared.nnnMAIN OUTCOME MEASURESnChange in the short to long axis ratio of the inferior rectus muscle and correlation of the ratio with intact and disrupted periorbita.nnnRESULTSnOrbital floor fractures measuring 1 x 1 cm show an increase in the short to long axis ratio (rounding) of the inferior rectus muscle only if the periorbita is disrupted. Orbital floor fractures measuring 2 x 2 cm show rounding of the inferior rectus muscle regardless of whether the periorbita is intact or disrupted; however, the degree of rounding is greater if the periorbita is disrupted.nnnCONCLUSIONSnFor small orbital floor fractures, rounding of the inferior rectus muscle predicts periorbital disruption. This may therefore represent an indication for early surgical repair to prevent delayed enophthalmos.