Objective The purpose of this study was to evaluate if narrowing and approximation of the alveolar cleft through presurgical alveolar molding followed by gingivoperiosteoplasty (GPP) at the time of lip repair reduces the need for a bone-grafting procedure. Design This was a retrospective blind study of patients with unilateral or bilateral alveolar clefts who underwent presurgical infant alveolar molding and GPP by a single surgeon. Alveolar bone formation was assessed prior to the eruption of the maxillary lateral incisor or canine by clinical examination, panoramic and periapical radiographs, and/or a dental CT scan. The criterion for bone grafting was inadequate bone stock to permit the eruption and maintenance of the permanent dentition. Setting This study was performed at the Institute of Reconstructive Plastic Surgery by the members of the Cleft Palate Team. Patients All patients with unilateral (n = 16) or bilateral (n = 2) alveolar clefts who underwent presurgical infant alveolar molding and GPP by a single surgeon from 1985 to 1988 were studied. The control population consisted of all alveolar cleft patients (n = 14) who did not undergo alveolar modeling or GPP during the same time period. Interventions Presurgical alveolar modeling was performed with an intraoral acrylic molding plate. This plate was modified on a weekly basis to align the alveolar segments and close the alveolar gap. The surgical intervention consisted of a modified Millard GPP. Main outcome Measures The primary study outcome measure was the elimination of the need for a secondary bone graft in patients who underwent presurgical alveolar molding and GPP. Results Of the 20 sites in the 18 patients who underwent GPP, 12 sites did not require an alveolar bone graft. Of the 8 sites requiring a bone graft, 4 presented minimal bony defects. All 14 patients in the control group required bone grafts. Conclusions In this series of 20 alveolar cleft sites treated with presurgical orthopedics and GPP, 60% did not need a secondary alveolar bone graft in the mixed dentition.

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A high prevalence of visual impairment in patients with craniosynostotic syndromes was found, almost half of them due to potentially correctable causes, including amblyopia and ametropia. Optic atrophy remains an important cause of visual impairment. Further studies are needed to assess the timing and efficacy of intervention for modifiable causes of visual loss in craniosynostotic syndromes.

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Distraction osteogenesis has become a widely used clinical approach in the treatment of craniofacial and orthopedic disorders. The exact biological mechanism of bone formation remains illusive, however. The aim of this study was to evaluate the role of bone morphogenetic protein-2, bone morphogenetic protein-4, and transforming growth factor-beta superfamily-related postreceptor signaling glycoproteins Smads 1 through 5 in distraction osteogenesis. Twelve sheep randomly divided into two groups were distracted to 24 mm at 1 or 4 mm/d using a submandibular osteotomy and an external distractor. After a 5-week fixation period, the mandibles were harvested. Employing immunohistochemical techniques, the sections were investigated for the previous antigens. Osteoblasts and periosteal lining cells were strongly positive. The matrix did not stain for the antigens investigated. Osteocytes demonstrated weak staining for the antigens. No significant difference between the groups was noted. In fracture healing, bone morphogenetic proteins 2 and 4 have been localized to the cambial layer of the periosteum, where healing occurs by intramembranous ossification. Their diffuse staining of the osteoblasts in the distracted region supports a similar role in distraction osteogenesis, where bone formation is predominantly through intramembranous ossification. Furthermore, bone morphogenetic proteins 2 and 4 have been demonstrated to promote mesenchymal cell conversion to osteoblasts. This is similar to the process observed in distraction osteogenesis. The presence of related Smads confirms postreceptor activity of these bone morphogenetic proteins in the process of distraction osteogenesis. This study supports induction of bone morphogenetic proteins 2 and 4, their related postreceptor signaling system (Smads), and intramembranous bone formation associated with mechanical strain in distraction osteogenesis.

In patients with advanced or recurrent melanoma confined to a limb, hyperthermic isolated limb perfusion (ILP) with melphalan produces complete remission in 35-40% of cases and partial remission in a further 35-40%. Mild or moderate limb toxicity is usual, but severe toxic reactions in the limb sometimes occur. After preliminary reports suggested that cisplatin administered by ILP was even more effective than melphalan yet less toxic, a study was undertaken to further assess the value of hyperthermic ILP with cisplatin in the management of limb melanoma. Ten patients were treated. The procedure failed to eliminate melanoma in the limb in 5 of the 6 who received therapeutic ILPs for recurrent disease, and recurrence developed in 2 of the 4 patients who received prophylactic ILPs. Toxicity in the perfused limbs was unacceptably high, with 2 of the 10 patients having severe reactions, one necessitating amputation. We conclude from the results of this study and from a review of literature that neither cisplatin nor any other drug or drug combination so far used for ILP in melanoma patients achieves results which are clearly superior to those achieved with melphalan. Studies are currently in progress investigating double perfusion protocols, new strategies with regional hyperthermia, and the administration by ILP of biological response modifiers such as tumor necrosis factor and interferon. However, for the present, hyperthermic ILP with melphalan remains the treatment most likely to be successful in eliminating or controlling advanced or recurrent melanoma in a limb.

With increased numbers of reports using barbed sutures for tendon repairs we felt the need to design a specific tendon repair method to draw the best utility from these materials. We split 30 sheep deep flexor tendons in two groups of 15 tendons. One group was repaired with a new four-strand barbed suture repair method without knot. The other group was repaired with a conventional four-strand cross-locked cruciate repair method (Adelaide repair) with knot. Dynamic testing (3–30 N for 250 cycles) and additional static pull to failure was performed to investigate gap formation and final failure forces. The barbed suture repair group showed higher resistance to gap formation throughout the test. Additionally final failure force was higher for the barbed suture group compared with the conventional repair group. When used appropriately, barbed suture materials could be beneficial to use in tendon surgery, especially with regard to early loading of the repair site and gap formation.