Salah Aldekhayel

The Effectiveness of Mandibular Distraction in Improving Airway Obstruction in the Pediatric Population

Background: Distraction osteogenesis is an effective technique for elongating the deficient mandible. The authors specifically evaluated its effectiveness in the treatment of airway obstruction in pediatric patients with mandibular hypoplasia. Method: A comprehensive literature review of the National Library of Medicine (PubMed) database was performed. English-language studies involving isolated distraction of the pediatric mandible (younger than 18 years) with descriptive reporting of airway changes were included. Extracted data included demographics, initial diagnosis, distractor type, distraction protocol, predistraction and postdistraction airway status, and complications. Results: Seventy-four articles met the inclusion criteria, resulting in 711 patients with craniofacial abnormalities who underwent mandibular distraction osteogenesis. Mean age at the time of distraction was 18.1 months. The most common diagnoses were isolated Pierre Robin sequence (52.9 percent), syndromic Pierre Robin sequence (7 percent), and Treacher Collins syndrome (6.8 percent). Mandibular distraction osteogenesis successfully treated airway obstruction in 89.3 percent of cases. Success was defined as either decannulation of tracheostomy, avoidance of tracheostomy or continuous positive airway pressure, or alleviation or significant improvement of obstructive sleep apnea symptoms. One hundred seventy-one (84.2 percent) of the 203 tracheostomy-dependent patients were successfully decannulated. Among the 181 patients with obstructive sleep apnea, mandibular distraction osteogenesis successfully allowed for either complete resolution or significant improvement of symptoms in 95.6 percent. A 23.8 percent overall complication rate was noted. The mean follow-up time was 28.7 months. Conclusion: In addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients.

Acellular dermal matrix in cleft palate repair: an evidence-based review.

Background: The repair of wide cleft palates and secondary palatal fistulas remains a challenge for pediatric plastic surgeons. To reduce the incidence of fistulization, use of acellular dermal matrix to facilitate closure has been reported in the literature. A review of the literature was performed to assess whether sufficient evidence exists to recommend the routine use of acellular dermal matrix for either primary palatoplasty or secondary palatal fistula repair. Methods: A literature search for the period between 1970 and 2011 was performed. All articles with clinical application of acellular dermal matrix in primary palatoplasty or palatal fistula repair were included. Data were analyzed using weighted averages to compare fistula rates between repairs performed with and without acellular dermal matrix (historical controls) for each repair type (primary versus secondary fistula repairs). Results: Four studies examined the use of acellular dermal matrix in primary palatoplasty (n = 92) with a mean cleft width of 14.2 mm. The overall fistula rate was 5.4 percent compared with 10.6 percent in the non–acellular dermal matrix historical control group. Five studies used acellular dermal matrix in palatal fistula repair (n = 74). The overall recurrent fistula rate was 8.1 percent compared with 12.9 percent in the historical control group. Conclusions: Based on the available data, the results imply that acellular dermal matrix may have a potential benefit in reducing fistula formation/persistence in palate surgery. However, the authors did not find sufficient prospective randomized (level II or better) evidence to recommend the routine use of acellular dermal matrix for cleft palate repair.

Evolving trends in the management of orbital floor fractures.

BackgroundThe management of orbital floor fractures is diverse and continues to evolve. The purpose of the current study was to provide an updated summary of the literature, with a focus on interspecialty differences, and contrast that with current treatment strategies of actively practicing plastic surgeons. MethodsA survey was conducted of surgeons who currently manage orbital floor fractures. The results are summarized and compared with a 10-year literature review (2002–2012) of surgical approaches, indications and timing of surgery, and implant selection in various surgical disciplines. Inclusion criteria included studies in English language with 10 or more patients. ResultsThe survey response rate was 56%, of which 86 surgeons were identified to currently manage orbit fractures. A third of participants reported they are less likely to operate on these fractures relative to earlier in their career. Six factors were found to have the greatest influence on surgeon’s operative decision: enophthalmos, hypophthalmos, positive forced duction, defect size, motility restriction, and persistent diplopia. The most common preferred approach to the orbit is midlid/infraorbital (45%) followed by transconjunctival (31%) and subciliary (24%). Medpor and titanium are the most preferred implants (83%) compared with autologous bone (5%). ConclusionsSignificant interdisciplinary and intradisciplinary differences in the management of orbital fractures exist. The most significant trends are the growing popularity of alloplastic versus autogenous materials for orbital floor reconstruction and the fact that one-third of surgeons are more likely to opt for a nonoperative (conservative) approach compared with earlier in their careers.

Tendon Rupture and Tenosynovitis following Internal Fixation of Distal Radius Fractures: A Systematic Review

Background: Tendon-related complications after plate fixation of distal radius fractures can cause significant morbidity in the patient. This retrospective systematic review aims to report and compare the current rate of tendon rupture and tenosynovitis complicating the operative management of distal radius fractures. Methods: A systematic literature search was performed to identify relevant articles reporting tendon complications after operative management of distal radius fractures. The search included published articles in three electronic databases—Ovid MEDLINE, EMBASE, and the Cochrane Library—starting from the establishment of each database to February of 2016. Results: A total of 56 studies met the inclusion criteria, including 6278 patients. Overall tendon-related adverse events were reported in 420 patients (6.8 percent). The incidence of tendon rupture was 1.5 percent with volar plates and 1.7 percent with dorsal plates. The incidence of tenosynovitis was 4.5 percent with volar plates and 7.5 percent with dorsal plates. Individual tendon complications were reported with volar and dorsal fixation, respectively: extensor pollicis longus tenosynovitis (0.3 percent and 1.1 percent), extensor pollicis longus rupture (0.8 percent and 0.3 percent), flexor pollicis longus tenosynovitis (1.3 percent and 0 percent), flexor pollicis longus rupture (0.6 percent and 0.2 percent), flexor digitorum profundus/flexor digitorum superficialis tenosynovitis (1.2 percent and 1.3 percent), flexor digitorum profundus/flexor digitorum superficialis rupture (0.1 percent and 0 percent), extensor digitorum communis tenosynovitis (1.7 percent and 5.9 percent), and extensor digitorum communis rupture (0.05 percent and 1.3 percent). Conclusion: This systematic review provides an update on the literature regarding tendon-related complications in the management of distal radius fractures.

Iatrogenic arteriovenous fistula in the hand: A case report

Peripheral intravenous cannulation is widely used in medicine. Arteriovenous fistulas are rare complications but their occurrence has never been reported in the hands. We report on a young patient who developed a high flow arteriovenous fistula on the dorsum of her hand two weeks after a failed peripheral intravenous cannulation attempt.

Restoration of shoulder motion using single- versus dual-nerve repair in obstetrical brachial plexus injury

OBJECTIVE The purpose of this study was to compare shoulder abduction and external rotation (ER) after single-nerve repair of the upper trunk alone versus dual-nerve repair of both the upper trunk and the suprascapular nerve. METHODS A retrospective chart review of a single surgeons experience repairing obstetrical brachial plexus injuries between June 1995 and June 2015 was performed. Eight patients underwent repair of the upper trunk alone, and 10 patients underwent repair of the upper trunk and the suprascapular nerve. Shoulder abduction and ER ranges of motion (ROMs) (in degrees) were recorded preoperatively and postoperatively. Postoperative ROM and the difference in ROM gained after surgery were compared by independent t-test analysis. RESULTS The mean follow-up time was 161.4 weeks (range 62-514 weeks, SD 124.0 weeks). The mean patient age at the time of surgery was 31.3 weeks (range 19.9-47.0 weeks, SD 6.9 weeks). The mean postoperative shoulder abduction ROMs were 145.0° (range 85°-180°, SD 39.4°) after single-nerve repair and 134.0° (range 90°-180°, SD 30.3°) after dual-nerve repair (p = 0.51). The mean postoperative shoulder ER ROMs were 67.5° (range 10°-95°, SD 28.8°) after single-nerve repair and 72.0° (range 10°-95°, SD 31.3°) after dual-nerve repair (p = 0.76). CONCLUSIONS The authors found no difference in shoulder abduction and ER between patients who underwent single-nerve repair of the upper trunk alone and those who underwent dual-nerve repair of both the upper trunk and the suprascapular nerve.

Effect of Erythropoietin on Transfusion Requirements for Craniosynostosis Surgery in Children

Background: Pediatric craniosynostosis surgery is associated with significant blood loss often requiring allogenic blood transfusion (ABT). This study explores the clinical effectiveness of preoperative erythropoietin (EPO) administration in pediatric craniosynostosis surgery in reducing transfusion requirements. Methods: A systematic review and meta-analysis of the literature was performed for studies published in English language between 1946 and 2015. Inclusion criteria included original studies in the pediatric population (0–8 years of age) involving preoperative use of EPO in craniofacial procedures with quantitative reporting of perioperative blood transfusion. Extracted data included demographics, hematocrit, hemoglobin, estimated blood loss, number of patients transfused, and amount of ABT. Results: Four studies met the inclusion criteria with a total of 117 patients. Patients were divided into 2 groups: EPO versus control. No statistical differences were found in the demographics between the 2 groups. Mean preoperative hematocrit level was higher in the EPO group compared with control (43% vs 35%). The percentage of patients who required ABT and the volume of transfused blood were less in the EPO group (54% vs 98% and 84 vs 283 mL, respectively). Meta-analysis of 3 comparable studies showed a lower proportion of patients who needed blood transfusion in the EPO group. Conclusions: The present meta-analysis demonstrated that preoperative administration of EPO in pediatric craniosynostosis surgery decreased the proportion of patients requiring ABT. In addition, the volume of transfusion was reduced in patients who received EPO. Future randomized studies are needed to establish the cost-effectiveness of routine preoperative EPO administration in craniosynostosis surgery.

A Review of Tissue Expansion-Assisted Techniques of Cleft Palate Repair.

Background: The purpose of this report was to examine current knowledge of use of tissue expansion techniques to assist cleft palate repair and to review and contrast various techniques reported. Methods: Two separate literature searches were conducted in the Cochrane Library, CINAHL, Medline and Embase databases, from database inception until December 2014 for use of mucoperiosteal expansion (MPE) and distraction osteogenesis (DO) in cleft palate repair. Results: Six articles, reporting a total of 51 patients of palatal MPE, were identified for discussion and analysis. Three different MPE techniques in primary cleft palate repair were described: intraoperative rapid expansion, tumescent injections, and a 2-stage repair with an osmotic expander. Average fistula rate was 26.19%. The search for use of DO on palatal clefts revealed 6 animal models, a finite element analysis study, and 1 case report. Moreover, 2 patients were reported of the use of DO to assist in secondary palatal fistula closure. No fistula rate could be calculated due to the heterogeneity of the data. Conclusions: The experience with MPE in assisting cleft palate repair remains limited. Among expansion techniques, the use of osmotic expanders was associated with the highest rates of postoperative fistulae. The literature provides little evidence supporting the efficacy of MPE expansion in cleft palate repair. The majority of studies utilizing DO to assist primary cleft palate repair are in animal models with the exception of isolated case reports in human subjects. Although limited, the results demonstrate promise and the need for further research in this domain.

Pseudoangiomatous Stromal Hyperplasia: A Rare Cause of Idiopathic Gigantomastia.

Summary: Gigantomastia remains a rare clinical diagnosis with significant physical and psychological impacts on patients. We present the case of a 40-year-old woman with idiopathic breast enlargement. Further histological analysis of the breast tissue revealed pseudoangiomatous stromal hyperplasia. This is the first reported case of diffuse breast enlargement resulting from pseudoangiomatous stromal hyperplasia.

Supernumerary Carpal Bones in Larsen Syndrome: A Review of the Literature and Case Study

Larsen syndrome is a rare congenital disorder commonly associated with dysmorphic facies, large joint dislocations, equinovarus or equinovalgus foot deformities, and various hand anomalies, including supernumerary carpal bones. The authors present a case of Larsen syndrome with bilateral supernumerary carpal bones as the sole clinical manifestation. A literature review investigating skeletal anomalies in patients with Larsen syndrome was performed and revealed that the present case represents a unique presentation of this disorder, lacking all of the major clinical features previously described in the literature. An approach to patients with supernumerary carpal bones is discussed.