Search

Femoroacetabular impingement syndrome (FAIS) is commonly associated with acetabular labral tears. Correction of impingement morphology and suture anchor repair of labral tears have demonstrated successful early and midterm patient-reported outcomes. The purpose of this study was to evaluate the posterior and anterior extent and size of labral tears in patients with FAIS undergoing arthroscopic labral repair, and to evaluate the number of suture anchors required to repair these tears. The design of this study was retrospective case series (Level 4). A single surgeon's operative database was retrospectively reviewed to identify patients undergoing primary arthroscopic hip labral repair between November 2014 and September 2019. Patient-specific factors and radiographic measurements were recorded. Arthroscopic findings including labral tear posterior and anterior extents, and the number of suture anchors utilized for the repair were recorded. Linear regression was performed to identify factors associated with labral tear size. The number of suture anchors used relative to labral tear size was calculated. Three-hundred and thirteen patients were included in the study. The mean posterior and anterior extent for labral tears were 11:22 ± 52 and 2:20 ± 34 minutes, respectively. Mean tear size was 2 hours, 58 minutes ± 45 minutes. The mean number of suture anchors utilized for labral repair was 3.1 ± 0.7. The mean number of anchors per hour of labral tear was 1.1 ± 0.3. Increased age, lateral center edge angle, and α angle were associated with larger labral tears. Our study found that acetabular labral tears associated with FAIS are, on average, 3 hours in size and centered in the anterosuperior quadrant of the acetabulum. Arthroscopic labral repair required 1.1 anchors per hour of tear size, resulting in a mean of 3.1 anchors per repair.

One of the primary aim of total knee arthroplasty (TKA) is restoration of the mechanical axis of the lower limb. Maintenance of the mechanical axis within 3 degrees of neutral has been shown to result in improved clinical results and implant longevity. The aim of this study was to investigate the efficacy of this robotic-assisted system in coronal plane component positioning in TKA. We also describe the learning curve associated with adoption of this technology. A total of 72 total knee replacements were completed between November 2017 and September 2018 by a single surgeon using the robotic-assisted surgery (RAS) system. Cases were recorded from the time the study surgeon first adopted this technology and represent the “learning curve.” Pre- and postoperative coronal weight-bearing alignments were measured and intraoperative robotic-assisted registration data and duration of use were collected. Of the 72 TKAs in this series, 93.3% were corrected to the desired alignment of within 3 degrees of neutral. The knees that were not corrected to neutral had a mean preoperative alignment of 11.57 degrees of deformity as compared with 4.29 degrees for those that were corrected to neutral. A learning curve effect during adoption of this new technology was not found when analyzing RAS usage time. The RAS system produced accurate coronal alignment in TKA in more than 93% of cases with no learning curve effect. Our study suggests that this system is easily adopted, safe, and accurate.

Dislocation rates after total hip arthroplasty (THA) in patients with fixed spinopelvic motion have been reported as high as 20%. Few studies exist specifically for lumbar spine degenerative joint disease (DJD) and its relationship to THA instability. There were two study objectives: (1) report the incidence of lumbar spine DJD and previous lumbar spine fusion and (2) evaluate the relationship of these two conditions and other potential risk factors to postoperative dislocation after THA. We retrospectively reviewed 818 consecutive THAs performed by a single surgeon utilizing a posterior approach. Comprehensive medical chart and radiographic review was performed to identify patients with lumbar spine DJD and lumbar spine fusion. Radiographic measurements, patient factors, surgical factors, and incidences of dislocation also were recorded. Eight hundred and twelve THAs were analyzed. There were 10 dislocations (1.2%, 10/812). Lumbar spine DJD and previous lumbar spine fusion occurred in 33.4% (271/812) and 5.9% (48/812) of patients, respectively. Lumbar spine DJD, acetabular protrusio, and female sex were significant predictors of dislocation using a Firth penalized maximum likelihood estimation specifically for rare events (area under receiver-operator characteristic curve = 0.91, 95% confidence interval 0.86, 0.96). Interestingly, only 2 of 10 dislocations had a previous lumbar spine fusion. Lumbar spine DJD, acetabular protrusio, and female sex were significant predictors of dislocation, while lumbar spine fusion was largely unrelated. This study used data available to most practicing surgeons and provides useful information for counseling patients preoperatively.

Posttraumatic arthrofibrosis is a common problem encountered in the orthopaedic setting for which there is no agreement on the optimal management strategy. The literature does not optimally describe the efficacy of arthroscopic lysis of adhesions for arthrofibrosis following tibial plateau fracture. The purpose of this study is to quantify the efficacy of arthroscopic lysis of adhesions with manipulation for the treatment of arthrofibrosis of the knee in patients who previously underwent surgical management of tibial plateau fracture. All patients who underwent arthroscopic lysis of adhesions from a single surgeon since 1999 were retrospectively reviewed. Clinical outcomes were evaluated by flexion, extension, and range of motion (ROM) preoperatively, intraoperatively, and postoperatively at intervals of 1, 4, 8, and 12 weeks, and any additional long-term follow-up. A total of 28 patients who had developed arthrofibrosis following surgical management of a tibial plateau fracture and failed nonsurgical management of knee stiffness were included in this study. There were significant improvements in total ROM following intervention at all time points compared with preoperative values (p

Background This study aimed at risk-stratifying aortic dilatation using aortic wall thickness (AWT) and comparing methods of AWT assessment. Methods Demographic, epidemiological, and perioperative data on 72 consecutive aortic surgeries (age = 62 years[standard deviation (SD) = 12] years) performed by a single surgeon were collected from hospital database. Aortic thickness was measured on computed tomography scans, as well as intraoperatively in four quadrants, at the level of aortic sinuses, as well as midascending aorta, using calipers. Aortic wall stress was calculated using standard mathematical formulae. Results The ascending aorta was 48.2 (SD = 8) mm and the mean thickness at ascending aorta level was 1.9 (SD = 0.3) mm. There was congruence between imaging and intraoperative measurements of thickness, as well as between the radiologist and surgeon. Preoperatively, 16 patients had multiple imaging studies showing an average rate of growth of 1.2 mm per year without significant difference in thickness. The wider the aorta, the thinner was the lateral or convex wall. Aortic stenosis (p = 0.01), lateral to medial wall thickness ratio (p = 0.04), and history of hypertension (p = 0.00), all had protective effect on aortic root stress. The ascending aortic stress was directly affected by age (p = 0.03) and inversely related to lateral to medial wall thickness ratio (p = 0.03). Conclusion Aortic thickness can be measured preoperatively and easily confirmed intraoperatively. Risk stratification based on both aortic thickness and diameter (stress calculations) would better predict acute aortic events in dilated aortas and define aortic resection criteria more objectively.

The use of minimally invasive transpsoas lateral lumbar interbody fusion (LLIF) surgery for treatment of adult degenerative scoliosis is rapidly increasing in popularity. However, limited data is available regarding its use in adult degenerative lumbar scoliosis surgery. The objective of this study was to evaluate the clinical outcomes of adults with degenerative lumbar scoliosis who were treated with minimally invasive LLIF. Thirty-two consecutive patients with adult degenerative scoliosis treated by a single surgeon at two spine centers were followed up for an average of 13.2 months. Interbody fusion was completed using the minimally invasive LLIF technique with supplemental 360 degrees’ posterior instrumentation. Oswestry disability index (ODI) scores were obtained preoperatively and at most recent follow-up. Complications were recorded. The study group demonstrated improvement in clinical outcome scores. ODI scores improved from 36.8 to 23.4 (p

The learning curve has been established for robotic-assisted total knee arthroplasty (RATKA) during the first month of use; however, there have been no studies evaluating this on a longer term. Therefore, the purpose of this study was to compare operative times for three cohorts during the first year following adoption of RATKA (initial, 6 months, and 1 year) and a prior cohort of manual TKA. We investigated both mean operative times and the variability of operative time in each cohort. This is a learning curve study comparing a single surgeon's experience using RAKTA. The study groups were made up of two cohorts of 60 cementless RATKAs performed at ∼6 months and 1 year of use. A learning curve was created based on the mean operative times and individual operative times were stratified into different cohorts for comparison. Study groups were compared with the surgeon's initial group of 20 cemented RATKAs and 60 cementless manual cases. Descriptive numbers were compiled and mean operative times were compared using Student's t-tests for significant differences with a p-value of

Objective Cerebrospinal fluid (CSF) leaks are the most common complication during endonasal endoscopic transsphenoidal approach (EETSA) and prevention of postoperative CSF leaks is critical. In this study, we report a single surgeon's experience of sellar floor reconstruction using abdominal fat grafts for prevention of postoperative CSF leaks in EETSA for pituitary adenomas. Study Design This study is presented as case series with retrospective chart review. Setting Present study was conducted at tertiary referral center. Participants A total of 216 patients who underwent surgery via EETSA for pituitary adenomas between 2008 and 2018 at our institution were evaluated. When an intraoperative CSF leak occurred, sellar floor reconstruction was performed using a fat graft harvested from the abdomen via a 2-cm skin incision. Main Outcome Measures Primary outcome and measures of this study was postoperative CSF leaks. Results A total of 53 patients showed intraoperative CSF leaks (24.5%) and 2 patients showed postoperative CSF leaks (0.93%). There were no postoperative CSF leaks in any patients who showed intraoperative CSF leaks and received sellar floor reconstruction using fat grafts. There were also no postoperative CSF leaks in 12 patients who received preventative sellar floor reconstruction using fat grafts due to extensive arachnoid herniation without intraoperative CSF leaks. However, there were two postoperative CSF leaks in patients who did not show intraoperative CSF leaks and did not receive sellar floor reconstruction. Conclusion The effectiveness of sellar floor reconstruction using abdominal fat grafts in patients receiving EETSA for pituitary adenoma was reported. We suggest that identification of intraoperative CSF leaks is important and preventive sellar floor reconstruction without evidence of intraoperative CSF leaks can also be beneficial.

Repair of nasal defects is technically challenging due to inelastic nasal skin and unforgiving nasal geometry. The bilobe flap is a double transposition flap that can transpose skin from cephalad to caudad to repair defects of the lower third of the nose. However, pincushioning may complicate this flap, yielding untoward aesthetic outcomes. We review our single surgeon series of patients who underwent bilobe flap reconstruction of nasal defects, and describe our surgical technique to minimize pincushioning and poor aesthetic outcomes. This was a retrospective chart review of patients who underwent bilobe flap reconstruction of nasal defects at a tertiary referral facial plastic and reconstructive surgery clinic between January 1, 2010 and February 12, 2019. All postoperative clinic notes were analyzed for complications, reports of unfavorable cosmetic outcome, and rates of revision procedures. Surgical technique is described. In the analysis, 125 patients were included, of whom 84 (67%) patients were women, and the mean (standard deviation) age was 60.7 (12.5) years. Complications were reported in 20 (16%) patients, including scars, pincushioning, and nasal obstruction. Five patients underwent revision surgery (4%), including scar revision and z-plasty. Pincushioning was reported in four patients (3.2%), of whom three underwent scar revision procedures. One patient had alar notching requiring correction. There was no statistically significant association between ear cartilage graft and complications (p = 0.84) or requirement of intervention (p = 1.0). Univariate and multivariate logistic regression did not show statistically significant association between size of the defect and the presence of complications (p > 0.05). The bilobe flap is an excellent transposition flap for the repair of small nasal tip defects. By adequately thinning the transposition flap of excess subcutaneous tissue prior to inset, rates of poor aesthetic outcomes, revision procedures, and pincushioning are minimized.

Background Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of “proximal pole scaphoid fractures” who underwent surgical fixation by a single surgeon over an 11-year period (2006–2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm3 and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm3. Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8–16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence This is a Level IV, case series study.

There is abundant data concerning morphological dimensions of the distal femur, particularly in women, which has led to redesign of the femoral component in total knee arthroplasty (TKA). Clinical experience reveals existing asymmetry of the femoral posterior condyles, yet current implant designs have a symmetrical femoral component. The objectives of this study were to analyze the dimensions of posterior condylar bone resection from a group of patients undergoing TKA and correlate the measurements to one prosthetic system. We retrospectively reviewed single surgeon morphological data from the posterior condyles of 105 knees during TKA. The study included 54 males and 51 females. Measurement of the posterior condylar bones was performed with a standard metric metal ruler by one investigator. Known dimensions of a single type of implant design were compared with the resection data. The average difference of posterior medial and lateral condylar width was 5.7 and 5.3 mm in males and females, respectively. The average host posterolateral condylar bone was 5.4 mm less than the trial implant across five sizes in both males and females. Results suggest that the dimension of the posterior lateral condyle is much smaller than the dimension of the implant in both groups of patients. Dimension of the posterior medial is close to dimension of the implant. Overhang of the component posterolaterally can create soft tissue irritation and result in postoperative pain and decreased range of motion. Our results increase awareness of the dimensions of the native posterolateral condyle and may influence future design of femoral implants used in total knee arthroplasty.

Just as in the craft of carpentry, a stable foundation and framework are absolutely essential to the final function of a building, but no more important than the drywall, trim, and paint that make the building functional, durable, and livable. Reconstruction of the lower extremity is similar; the orthopaedic surgeon must obtain stable fixation of the damaged or diseased bone once a thorough debridement of nonviable bone is performed, while the plastic or orthopaedic soft tissue surgeon must provide vascularized, stable coverage. These two components are complementary and both contribute to the success or failure of functional limb restoration. The stability of bone repair will predict the ultimate functional status, while the vascularized envelope will enhance the biology of bone and soft tissue healing. When both components are properly attended to, the result is often a functional limb with an acceptable appearance. While a single surgeon need not perform both of these tasks (although some may choose to do so), the orthopaedic and plastic surgeon involved in this care must have a clear understanding of each other's role and their importance for a good outcome. This is what we call the orthoplastic approach to reconstructive surgery of the extremities, that is, the application of principles and practice of both specialties applied simultaneously to optimize the outcomes in limb reconstruction. In this review article, we discuss the history of orthoplastic surgery, the key elements of orthoplastic surgery, and thoughts on factors that lead to good outcomes through select cases.

Background No consensus exists regarding the optimal strategy for perioperative thromboprophylaxis in high-risk microsurgical populations. We present our experience with lower extremity free tissue transfer (FTT) in thrombophilic patients and compare outcomes between non-stratified and risk-stratified anticoagulation protocols. Methods Between January 2013 and December 2017, 57 patients with documented thrombophilia underwent FTT for non-traumatic, lower extremity reconstruction by a single surgeon. Patients were divided into two cohorts based on the introduction of a novel, risk-stratified algorithm for perioperative anticoagulation in July 2015. Demographic data, chemoprophylaxis profiles, flap outcomes, and complications were retrospectively compared across time periods. Results Fifty-seven free flaps were performed in hypercoagulable patients treated with non-stratified (n = 27) or risk-stratified (n = 30) thromboprophylaxis. Patients in the risk-stratified cohort received intravenous heparin more often than non-stratified controls (73 vs. 15%, p Conclusion Selective therapeutic anticoagulation may improve microsurgical outcomes in high-risk patients with thrombophilia. Our findings highlight the importance of meticulous technique and recipient-vessel selection as critical determinants of flap success in this population.

Background Open carpal tunnel release (CTR) is one of the most commonly performed operative procedures with operative duration being a primary metric of operating room efficiency. The purpose of this study was to identify factors associated with prolonged operative duration, in performing CTR. Materials and Methods CTR cases performed by a single surgeon from September 2013 to October 2015 were reviewed. Patient age at the time of surgery, sex, location of surgery (specialty orthopaedic hospital versus ambulatory surgery center), body mass index (BMI), American Society of Anesthesiologists classification, total operative duration (TOD), and procedure time (PT) were recorded. Obesity was defined as BMI > 30 and morbid obesity was defined as BMI > 35. Data were analyzed to identify factors associated with prolonged TOD or PT. Results One hundred and nine consecutive patients underwent isolated CTR. Mean age at time of surgery was 62 years (range: 24–92 years). Nonobese patients were found to have significantly shorter TOD than obese patients (22.3 vs. 24.4 minutes). Similarly, patients who were not morbidly obese had significantly shorter TOD than morbidly obese patients (22.6 vs. 26 minutes). No other factors were associated with prolonged TOD. No difference in PT was found between normal weight, obese, and morbidly obese groups. Conclusions TOD, but not procedure time, is significantly affected by obesity. Our findings are relevant when scheduling and preparing obese patients for surgery, which may have a significant impact on health resource utilization. Level of Evidence This is a Level III, economic/decision analysis study.

Generally, reconstruction of knee defects with exposed bone, joint, tendon, and/or hardware requires a vascularized muscle flap for coverage. Although there are several surgical options for a knee defect reconstruction, the pedicled gastrocnemius muscle still remains the workhorse flap. Although this flap is commonly used for knee defect reconstruction and the technique is described very well, there is an absence of information in the literature detailing the technique of harvesting and insetting of the gastrocnemius flap step by step with illustrations. The purpose of this article is to describe in detail the technique to reconstruct defects of the knee with pedicled gastrocnemius muscle flap as well as to present demographics and surgical results of 21 patients who had knee reconstruction with a pedicled gastrocnemius muscle flap and split-thickness skin grafting.

Accurate and precise acetabular component position in total hip arthroplasty remains challenging even for experienced, high-volume surgeons. Some variability may result from the press-fit technique of cementless components and maybe magnified by the use of highly porous cups with high-friction surfaces. The purpose of this study is to investigate the acetabular component positioning of a hemispherical, highly porous cup with line-to-line reaming compared with press-fit techniques. A retrospective cohort study was performed of 110 consecutive primary total hip arthroplasties performed by a single surgeon using a highly porous acetabular component. Half of the patients had the component implanted with a line-to-line reaming technique and the other half were implanted using a 1 mm press-fit technique. Postoperative radiographs were evaluated for component positioning and loosening at a minimum of 1 year postoperatively by two independent surgeons. Records were reviewed for subsequent surgery. There were no differences between the groups with respect to age, sex, body mass index, operative side, or acetabular component size. The press-fit group had an average abduction angle of 49.4 ± 5° and anteversion of 20.6 ± 7°. The line-to-line group had an average abduction angle of 45.02° [standard deviation (SD) 4.58] and anteversion of 25.42° (SD 4.44) and were statistically different from the press-fit group (p

The double-half bilobe flap was initially described by the senior author (S.P.M.) in 2012 to address defects of the midline nasal tip typically after ablative carcinoma resection. It is a unique reconstructive option for the nasal tip, as it does not depend on a unilateral tissue advancement vector, instead using bilateral and opposing vectors to maintain symmetry. In this retrospective cohort series, we evaluated patient- and physician-derived outcomes and baseline characteristics from a group of 17 patients that underwent reconstruction with the double-half bilobe flap. A control group of 65 patients that underwent traditional bilobe reconstruction for defects of one nasal subunit (tip, side wall, or dorsum) was used for comparison. Outcome measures included infection, symmetry, pin-cushioning, scarring, reoperation, and adjunct procedures. Also, patient satisfaction was evaluated by using frequency of follow-up as a surrogate for patient discontentment with aesthetic outcome. The double-half bilobe flap provides improved symmetry and otherwise similar overall outcomes compared with the traditional bilobe flap, and should be considered as a primary option for the reconstruction of midline nasal tip defects less than 15 mm in diameter.

Background Microsurgical breast reconstructions (MBRs) are time and labor intensive procedures. To circumvent these barriers, plastic surgeons have started working together as cosurgeons (CSs). This study aims to evaluate the impact of the CS model (CSM) specifically on bilateral MBR. The hypothesis is that CS procedures reduce operative time and surgical complications. Study Design This was a single institutional retrospective cohort study, which included all consecutive patients who underwent bilateral MBR from 2014 to 2016. Patients were grouped into single surgeon (SS) or CSs based on the number of the attending plastic surgeons present. Demographic and clinical characteristics including age, body mass index, smoking, American Society of Anesthesiologist class, radiation, and the timing of the reconstruction were assessed. Univariate and multivariate analyses were performed for outcomes including operative time and postoperative complications. Results Of the 136 patients included in the study, 41% had breast reconstruction performed by CSs, whereas 59% had a SS. Sociodemographic features were evenly distributed with the exception of a greater number of delayed reconstructions in the SS group (33 vs. 13%; p Conclusion The CSM is associated with improved operative efficiency for bilateral MBR. Further evaluation of the CSM may prove useful in other surgical disciplines with time and labor intense procedures.

The purpose of this study is to compare failure rate and functional outcome in young, active patients (< 25 years) with two-incision (rear-entry) versus transtibial (all-endoscopic) anterior cruciate ligament (ACL) reconstructions.Utilizing a computerized relational database (Access 2007, Microsoft Inc., Redmond, WA), 480 patients were identified that underwent ACL reconstruction, using a bone-patellar-tendon-bone autograft, by a single surgeon between January 2000 and December 2010 via a transtibial or two-incision technique. Totally, 377 (78.6%) of these patients were less than 25 years of age. Data for each patient were collected at their initial clinic visit, at the time of surgery, and at each follow-up clinic visit and entered into the computerized relational database. Overall, 274 patients (72.7%) underwent ACL reconstruction with a transtibial technique, and 103 patients (27.3%) underwent reconstruction with a two-incision technique. Failures were identified as a 2+ Lachman, 1+ or greater pivot shift, or a KT-1000 arthrometer difference of five or more.In patients Our study showed no statistical difference between the two-incision technique and the transtibial technique for ACL reconstruction using bone-patellar-tendon-bone autograft with an overall 10.1% failure rate in young, active patients (< 25 years of age). The level of evidence is level IV.

Accurate placement of the femoral tunnel is critical for long-term clinical success following anterior cruciate ligament (ACL) reconstruction. The purpose of the present study is to evaluate the accuracy of femoral tunnel placement when referencing osseous landmarks during ACL reconstruction. We hypothesize that referencing osseous landmarks during ACL reconstruction consistently results in anatomic placement of the ACL femoral tunnel. This study was a retrospective case series. We reviewed 83 consecutive ACL reconstructions performed by a single surgeon. The lateral intercondylar ridge and lateral bifurcate ridge were referenced intraoperatively for anatomic placement of the ACL femoral tunnel during single-bundle reconstruction. Using these landmarks, the femoral tunnel was placed in the center of the anteromedial bundle footprint on the lateral wall of the intercondylar notch. We reviewed all operative notes and intraoperative arthroscopic images to assess tunnel placement. Postoperative anteroposterior and lateral radiographs were obtained in all patients. Anatomic placement was confirmed by review of lateral radiographs utilizing both the quadrant method (QM) and Blumensaat-ridge ratio (BRR). We used a total of 80 patients for our study. Review of arthroscopic images confirmed anatomic placement of the ACL femoral tunnel in all patients. All patients demonstrated that the femoral tunnel was placed anatomically according to the BRR method. Using the QM, all femoral tunnels were placed anatomically except for one tunnel that was placed slightly anteriorly. There was excellent agreement between the two radiographic measurement techniques. The principal finding of this study indicates that the lateral intercondylar ridge and the lateral bifurcate ridge are reliable landmarks for anatomic placement of the ACL femoral tunnel. Referencing osseous landmarks during surgery can help surgeons avoid nonanatomic placement of the ACL femoral tunnel, especially in cases where the soft-tissue footprint is no longer present. Furthermore, both the radiographic QM and the BRR are valid techniques to assess for anatomic ACL femoral tunnel placement both intraoperatively and postoperatively.

Refining the nasal dorsum has become a major challenge in modern rhinoplasty as irregularities of the nasal dorsum account for a significant number of revision surgeries. In our department, free diced cartilage is now routinely applied for smoothening of the nasal dorsum. In this retrospective study, the outcomes with regard to irregularities or contour deficits of the nasal dorsum of 431 rhinoplasty cases operated by a single surgeon between July 2013 and June 2015, using free diced cartilage, are compared with 327 cases operated by the same surgeon between January 2007 and December 2008, before the introduction of the free diced cartilage technique. A decrease in early revision surgeries (i.e., revision within the 2-year period evaluated) due to dorsal irregularities or contour deficits is seen. Being a quick, easy, and highly cost-effective procedure, we feel that free diced cartilage is currently the ideal technique for refinements of the nasal dorsum.

The forehead is a unique facial region with distinct boundaries and variability in shape from patient to patient. When reconstructing the forehead, it is critical to take into account the regional boundaries as their distortion may result in noticeable facial asymmetry. We propose subdividing the forehead into newly defined zones and put forth a rational algorithm for forehead repair based on these divisions. We retrospectively reviewed a single surgeon's (F. H. S.) experience with Mohs excision and immediate reconstruction of the forehead over a 3-year period. A total of 227 consecutive post-Mohs forehead reconstructions were identified, and the reconstructive technique for a given defect size and location and postoperative complications were recorded. The average patient age was 69 years and 114 (50%) patients were female. Reconstructive techniques varied based on defect size and location within the five distinct forehead zones. Primary closure was the favored technique when appropriate, with variation in orientation based on forehead zone. Modified Burow's advancement flap was the most commonly utilized reconstruction for defects of midlateral forehead and suprabrow area, accounting for 51.7 and 62.5% of repairs, respectively. Other techniques included A-to-T flaps, rotation flaps, and full-thickness skin grafting. Using our defined zones, most common repair techniques, and final outcomes, a reconstructive algorithm for post-Mohs excisions on the forehead was derived. Consideration of the five distinct forehead zones and application of an algorithm to guide technique selection for post-Mohs forehead defect repair can lead to consistent results.

Cleft rhinoplasty has spurred much interest in literature because of the difficult task in obtaining a normal nasal form, function, and development. The pursuit of perfection has resulted in myriad techniques, modifications, and innovations to optimize results, but no one protocol or algorithm was proved to be completely satisfactory. Controversies still exist in timing, surgical approach, nonsurgical techniques, and outcome assessment. This article submits a humble contribution that might hopefully help in reaching consensus. Throughout a period of 18 years, 800 patients with different ages and types of clefts were managed by single surgeon using various procedures to correct their nasal deformities. These procedures included preoperative naso-alveolar molding, gingivoperiosteoplasty, primary closed or open rhinoplasty, postoperative nasal stents and nasal molding, and secondary open septorhinoplasty. The outcome was judged by panel assessment and computer-assisted anthropometry. Clinical results were satisfactory for most patients, parents, and surgeon panel. Computer-assisted anthropometry proved helpful in outcome assessment and analysis. Cleft rhinoplasty is neither optional nor separable from cleft lip repair. It requires clear perception of the complex pathogenesis and the governing dynamics of the cleft deformity. A perfect nose with no deformity is unusual, but a reasonably good result is attainable when the principles of nasal repair are fully grasped and faithfully applied.

Background and Study Aims The learning curve associated with the adoption of minimally invasive surgery techniques has limited its adoption by many traditionally open surgeons. The use of dynamic electromyography (EMG) to guide the placement of percutaneous pedicle screws (PS) can lessen the learning curve by providing real-time feedback on neural proximity relative to the screw. This study aimed to investigate the safety and accuracy of a single surgeon's experience transitioning from open pedicle screws (OS) to PS using intraoperative fluoroscopy and dynamic EMG. Materials and Methods Forty consecutive patients were treated with EMG and fluoroscopy-guided PS placement by a single surgeon and followed through a prospective registry. This was cross-referenced with a cohort of 53 consecutive patients treated with OS in 2011. Computed tomography was used to check the screw position 1 day after surgery. A misplaced pedicle screw was defined as a breach of the pedicle wall. The accuracy of PS placement in association with dynamic EMG was compared with that of OS. Results A total of 204 PS were inserted in the study cohort with 97.5% accuracy. Five (2.5%) were misplaced (three medial and two lateral). All three medial screws displayed a caution message (yellow: 8mA) on insertion. No screw caused visceral or neurologic complications postoperatively, and none required revision. In the OS cohort, 254 screws were placed with 94.9% accuracy, 13 (5.1%) were misplaced (8 medial, 3 lateral, and 2 superior), and 3 (1.2%) required revision. Conclusions Dynamic EMG combined with intraoperative fluoroscopy and advanced instrumentation provides a safe, real-time, and accurate method for PS placement.

Objectives In microvascular decompression (MVD) for hemifacial spasm (HFS), the patient is placed in the lateral or park-bench position that is complicated and uncomfortable for anesthesiologists, nurses, and even the patient. Careless retraction of the cerebellum by a spatula could be the major cause of surgical complications. In our method, a patient is laid supine avoiding the complicated positioning. The subfloccular approach from a small cranial window sited on the more lateral and basal side of the occipital cranium enables the surgeon to reach all the segments of the facial nerve root without a spatula. We introduce our surgical procedures in detail along with our excellent results. Methods A total of 100 consecutive patients experiencing primary HFS were operated on with MVD by a single surgeon in our institution from August 2012 to April 2014. Results Overall, 94 patients showed the complete disappearance or a satisfactory alleviation of HFS. De novo neurologic deficits were not encountered after surgery including hearing impairment. In 47 cases, multiple offending vessels were observed in multiple possible affected sites in addition to the root entry/exit zone. Conclusions We believe this approach is superior for the safe and precise decompression of any part of the facial nerve root.

Objectives During microvascular decompression (MVD) of the facial nerve for hemifacial spasm (HFS), an abnormal muscle response can be recorded upon stimulation of the facial nerve, also known as the lateral spread response. This response may vanish after MVD and has been associated with a successful outcome. The purpose of this study was to determine if resolution of lateral spread correlated with the elimination of HFS in a single surgeon's experience. Design and Setting (1) Retrospective analysis of 38 patients undergoing MVD with intraoperative electromyography for HFS. (2) Meta-analysis of studies from the literature. Main Outcome Measure Presence or absence of HFS and any complications. Results Lateral spread response was seen in 36 patients; 20 patients had full resolution. Of these, 15 patients became HFS free, and 5 five patients still had some degree of HFS. Sixteen patients had a persistent lateral spread response despite a technically successful MVD; 11 of these became spasm free, and 5 still suffered from some degree of facial twitching. Analyzing 16 studies reporting a total of 1301 patients, a significant correlation (p

Objectives To analyze surgical outcomes and predictive factors of disease remission in acromegaly patients who underwent microscopic transsphenoidal surgery (TSS) for a growth hormone (GH)-secreting adenoma. Design A 6-year retrospective review of 86 consecutive acromegaly surgeries. Setting Procedures performed at a single institution by a single surgeon. Participants Seventy acromegaly patients. Main Outcome Measures Demographic information, preoperative laboratory values, tumor imaging data, and morphological and immunohistochemical data were collected. Predictive values using the latest and most stringent biochemical remission criteria were determined using univariate and multivariate statistical analyses. Results Remission rate for 59 (18 males) acromegaly patients meeting the study inclusion criteria was 52.5%. Remission rates for micro- and macroadenomas were 81.8% and 45.8%, respectively. Patients of older age, with a smaller tumor, lower Knosp grade, lower preoperative GH, and insulinlike growth factor 1 levels were more likely to achieve remission. Remission rate decreased significantly with repeat surgeries. Those patients with adenomas that stained positive for somatostatin receptor subtype 2A were less likely to experience tumor recurrence and more likely to respond to medical treatment with persistent or elevated GH hypersecretion. Conclusions Microscopic TSS continues to be a viable means for treating acromegaly patients. Patients should be followed long term.

Study Design This is a retrospective review of a prospectively maintained database of anterior cervical discectomy and fusion with plating (ACDFP) cases. Objective The aim of this study is to evaluate within a clinical practice evidence-based results of short-term morbidity with multilevel ACDFP. Methods Clinical morbidity, length of hospital stay, visual analog scale (VAS) and Odom scores, Neck Disability Index (NDI), hardware failure, and return-to-work (RTW) status were prospectively collected in an electronic database for 678 patients who underwent 1-, 2-, 3-, or 4-level ACDFP during an 8-year period. A total of 519 patients met the study criteria and were retrospectively analyzed. Results The majority of all patients noted “Excellent” or “Good” status for 1 month (91%), 2 months (92%), and 3 months (96%). Patients with 1-, 2-, and 3-level ACDFP returned to work sooner, 60% at 1 month, 70% at 2 months, and 68% at 3 months. For 4-level patients, the majority did not RTW until 3 months (71%). The only significant increase in morbidity with increasing levels was hospital stay for 3- and 4-level ACDFP and RTW for 4-level ACDFP. Conclusion Multilevel ACDFP can be performed with low initial morbidity. An individual practice can review results to allow for ongoing evidence-based care. Final class of evidence - treatment Yes Study design RCT Cohort • Case control Case series Methods Concealed allocation (RCT) Intention to treat (RCT) Blinded/independent evaluation of primary outcome • F/U ≥ 85% Adequate sample size • Control for confounding Overall class of evidence III

Objectives This study aims to compare the surgical and functional outcomes of superolateral orbitotomy (group A) and conventional superior orbitotomy (group B) for benign orbital tumors. Design A retrospective review of 31 consecutive orbital tumor surgeries with the fronto-orbital approach was conducted. Setting Procedures were performed at two institutions by a single surgeon. Participants A total of 31 orbital tumor patients participated in this study. Overall, 11 intraconal and 2 extraconal tumors in group A and 11 intraconal and 7 extraconal tumors in group B were resected by superolateral orbitotomy, respectively. Main Outcome Measures Demographic information, pre- and postoperative neurological findings and neuroimaging data, and pathological data were collected. Surgical and functional outcomes were compared and statistically analyzed between the two different surgical procedures. Results The surgical outcomes were not significantly different between the two groups. In patients with intraconal tumors, the functional outcome was significantly better in group A than in group B. Conclusion Superolateral orbitotomy provides better functional outcomes.

Objective We aimed to compare the rates of wound separation (WS) and surgical site infection (SSI) after cesarean delivery (CD) by a single surgeon. Pfannenstiel skin incision (PSI) was closed with Dermabond, staples, or suture. Study Design Retrospectively all women having CD via PSI were identified. WS and SSI rates with Dermabond were compared with other two techniques. Results Of 239 CDs performed, 88% ( n = 211) were available for postpartum evaluation. The PSI was closed with Dermabond in 85 (40%), staples in 76 (36%), and suture in 50 (24%). Overall WS rate was 7%; with Dermabond, it was 5% versus 13% with staple ( p = 0.090) and 2% with suture ( p = 0.651). Post hoc calculation suggests a randomization of 4325 women is needed to determine if Dermabond has one-third less wound complication than suture. Conclusion For the PSI closure, Dermabond may be a useful alternative skin closure device, though a randomized trial is warranted.

The first 103 consecutive minimally invasive total knee arthroplasties performed by a single surgeon were assessed to determine the clinical and radiographic outcomes at a mean of 9-year follow-up (range, 8 to 10 years). Patients who died before final follow-up were 10 (13 knees), leaving 90 knees in 69 patients for final review. Outcome was evaluated using Knee Society pain and functional scores. Survival with revision as an end point was 97.1%. Knee Society scores and range of motion improved significantly to a mean of 96 and 92 points and a mean of 115 degrees, respectively. There were five patients who required surgical intervention for unexplained pain with findings of retained cement and adhesions. Radiographic analysis did not reveal any progressive radiolucencies. These results suggest that excellent long-term outcomes can be achieved with minimally invasive total knee arthroplasty.

Newer technologies have seen a gradual decline in mechanical causes for total knee arthroplasty (TKA) failures. As these mechanical mechanisms of failure have slowly diminished, infections have come to comprise an even larger proportion of complications in knee replacement surgery. This article presents a retrospective review of a single surgeon's incidence of late hematogenous infections after 3013 consecutive primary TKAs using a standard surgical technique. Fifteen late hematogenous infections were found in 14 (0.5%) patients at an average of 10 years postoperatively. The surgical protocol is reported and the late infections are analyzed for their etiologies and outcomes.

Fixed-bearing, medial unicondylar knee arthroplasties were performed in 33 knees (32 patients). We report a minimum 2-year follow-up, with a mean follow-up of 3 years. Kaplan-Meier survivorship analysis reported 97% survivorship at a mean follow-up of 38 months. Average preoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores improved significantly from 40+/-22 to 92+/-15 (P

The management of hemangiomas has always been a matter of controversy. Traditionally, observation has been the mainstay of therapy, with the expectation that most of the lesions will disappear spontaneously. This treatment plan was based on the premise that surgical excision or other treatments might produce a worse result than simply waiting for the lesion to resolve with an acceptable cosmetic result. This plan has been challenged because of a growing number of specialty teams that address these lesions. This article examines various cases of pediatric hemangioma and evaluates the possibility of surgical excision as a first-choice treatment in these cases. One hundred fifteen cases of surgical excision of pediatric hemangiomas performed by a single surgeon over a period of 7 years were examined. Pre- and postoperative photographs were examined. Hemangioma location, size, and type; patient's age; and surgical technique are described. Acceptable cosmetic and functional results were achieved in all surgical cases. Early excision of hemangioma should be the procedure of choice in selected cases of hemangioma. Hemangiomas in areas where a significant cosmetic defect or functional defect might ensue should have surgical excision considered as first-line treatment.

From 1994 to1999, 24 patients were subjected to tenoarthrolysis of the PIP joint by a single surgeon for various reasons. All cases were documented by the surgeon in photographs and the achieved extent of mobility was followed up to at least one year postoperatively. All results were documented in photographs or on video films. The patients did not have conventional arthrolysis following injury of the capsular ligaments of the PIP joint (with the exception of one case), but complex injuries of bone, flexor tendons, diseases, and conditions after infections, some of which had occurred up to seven years previously. Four patients had been subjected to tenoarthrolysis twice, one had undergone tenoarthrolysis even three times. Five joints were fully ankylotic before surgery and had 0 degrees of mobility. All cases were referred from external surgeons. It was not possible to find common denominators for these cases and to include them in a regular study. The sole criterion used for assessment, which has also been used in comparable studies, was preoperative mobility and the postoperative mobility achieved after one year. Preoperative mobility in the PIP joint was on average 27.5 degrees (range, 0 - 60) and could be increased to a mean of 70 degrees (range, 0 to 120) after one year. Thus, an improvement of 42.5 degrees was achieved. As the cases were very different, this study will probably be no more than a case presentation. Nevertheless, based on a careful assessment of video films and photographs and the results achieved in individual cases, conclusions may be drawn regarding technique, surgical planning and prognosis. The author believes that although the data does not suffice to make up a valid study, they still are worthy of presentation.