No abstract

Background: There is debate on the utility of a preoperative Allen test or ultrasound before radial forearm free flap (RFFF) harvest. This study sought to evaluate correlations between preoperative testing and donor-site morbidity. Methods: A survey of plastic surgery and otolaryngology RFFF patients was conducted at a Midwestern academic center. The modified Cold Intolerance Symptom Severity (modCISS) and Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) instruments were administered. A retrospective chart review was performed to assess perioperative factors. Results: Of 212 RFFFs completed over 7 years, 144 patients were contacted, and 71 patients completed the survey (33% response rate). Preoperative Allen test was negative in 92% of patients (65 of 71). There was no statistical association between Allen test and duplex ultrasound findings (P = 0.19). Cold intolerance screening was positive on 20% of donor arms (14 of 71), with an average positive modCISS score of 39.0 ± 14.7. Disability was reported on the QDASH by 76% of patients (54 of 71), with an average score of 21.0 ± 22.3. There was no statistical correlation between preoperative Allen test or ultrasound classification and modCISS or QDASH score. There was a borderline positive correlation between modCISS and QDASH scores that did not reach statistical significance (r = 0.22, P = 0.067). Operative characteristics also did not predict modCISS or QDASH scores. Conclusions: Following RFFF harvest, donor extremity cold intolerance is reported in 20% of patients, and extremity-related disability is reported in the majority of patients. Preoperative ultrasound and physical examination findings are not predictive of morbidity.

Summary: Genioglossus advancement plays an important role in the armamentarium of the obstructive sleep apnea surgeon and has gone through many iterations over several decades. A recently described technique involves creating a box osteotomy, which is carried through the inferior border of the mandible in order to increase recruitment of the suprahyoid musculature. Here we introduce a further modification of the technique that uses virtual planning to improve the safety and accuracy of genial tubercle capture. In addition, angulation of the lateral osteotomies enhances bone to bone contact. Before the osteotomy, the surgeon has the opportunity to drill the buccal plate to reduce the chin profile. This approach is particularly valuable in the patient who is prognathic at baseline or who becomes prognathic after simultaneous maxillomandibular advancement. Here we discuss this unique approach, demonstrating how the patient profile may be balanced even as the genial tubercle is advanced.

The American Academy of Orthopedic Surgeons (AAOS) published Appropriate Use Criteria (AUC) in 2014 to aid physicians in the management of pediatric supracondylar humerus fractures. AUC should be evaluated in real practice, and if necessary modified based on identified problems. This study compares AAOS AUC recommendations with actual treatment performed in a cohort of patients treated for type III supracondylar humerus fractures. Medical record review of patients treated for type III supracondylar humerus fractures at our hospital from 2009 to 2016. Criteria required by the AAOS AUC were collected and entered into the AAOS AUC web-based application to determine the ‘appropriateness’ and score of each treatment. These were compared with the actual treatment the patient received. Over the study period, 585 patients (mean age: 6.5 years, 51% male, 49% female) were treated for type III supracondylar humerus fractures. Of the 585 cases, 561 (95.9%) were classified as ‘appropriate’, 24 (4.1%) as ‘maybe appropriate’, and 0 (0%) as ‘rarely appropriate’. Of the ‘maybe appropriate’ cases there was a significant decrease in the proportion that deviated from the AUC over time (P = 0.0076). The main reasons for deviation were that an open reduction was performed due to difficulty with closed reduction (75% of deviations) or the surgery was not performed emergently (25% of deviations). The vague definition of ‘emergent’ and not allowing for open reduction if needed are limitations of the AUC that should be clarified or improved by the AAOS.

Summary: An 11-year-old male patient presented with a large, highly vascular, destructive mandibular mass. An intraoral biopsy showed pleomorphic spindle cells arranged in intersecting fascicles, with scattered atypia. A diagnosis of low-grade myofibroblastic sarcoma was made. The lesion was treated with preoperative arterial embolization followed by surgical resection and reconstruction with a fibular osteomyocutaneous free flap. To our knowledge, no reports of highly vascular mandibular low-grade myofibroblastic sarcoma are available in the literature.