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Introduction Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC. Methods A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 – July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections. Results Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P Conclusion Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.

Stasis from obstruction at the level of the internal anal sphincter (IAS) can lead to Hirschsprung-associated enterocolitis (HAEC) and may be improved by botulinum toxin (BT) injections. Our aim was to determine if BT injection during HAEC episodes decreased the number of recurrent HAEC episodes and/or increased the interval between readmissions. A retrospective review was performed of patients admitted for HAEC from January 2010 to December 2019. Demographics and outcomes of patients who received BT were compared to patients who did not receive BT during their hospital stay. A total of 120 episodes of HAEC occurred in 40 patients; 30 patients (75%) were male, 7 (18%) had Trisomy 21 and 10 (25%) had long-segment disease. On multivariate analysis, patients who received BT during their inpatient HAEC episode had a longer median time between readmissions (p = 0.04) and trending toward an association with fewer readmissions prior to a follow-up clinic visit (p = 0.08). The use of BT in HD patients hospitalized for HAEC is associated with an increased time between recurrent HAEC episodes and trended toward fewer recurrent episodes. The use of BT should be considered in the management of patients admitted with HAEC.

PURPOSE To critically examine reported data to compare patient outcomes between load-sharing and load-bearing plate fixation for edentulous mandibular fractures. MATERIALS AND METHODS A systematic review and meta-analysis were designed to test the null hypothesis of no difference in postoperative outcomes between load-sharing and load-bearing plate fixation in atrophic, edentulous mandibular fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried up until July 2016. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS A total of 1212 studies were screened for inclusion of which we included 1 high-quality Cochrane review, 6 narrative reviews, and 21 publications of case reports and case series. Overall, the quality of evidence was low. No difference was found between load-bearing and load-sharing fixation in functional recovery, nonunion, or infection. An uncontrolled case series portrayed complete functional and morphological restoration in 96.9% of patients (83.2-99.5; 95% confidence interval) in load-bearing osteosynthesis while another demonstrated the same outcome in only 40.0% of patients (17.5-65.0; 95% confidence interval). CONCLUSIONS The authors did not find a statistically significant difference between load-bearing and load-sharing plate fixation in edentulous atrophic mandibular fracture patients; although this finding may be influenced by type 2 statistical error. Surgeons should continue to use their best clinical judgment in deciding on treatment approach for these challenging fractures. Future studies with higher level evidence are necessary to guide optimal fracture management.

Background Encephaloceles are herniations of intracranial neural tissue and meninges through defects in the skull. Basal encephaloceles are rare anterior skull base defects incident in 1 in 35,000 live births. Sphenoethmoidal encephaloceles are even more uncommon, with an incidence of 1 in 700,000 live births. Anterior skull base encephaloceles may be life-threatening in infants, presenting as airway obstruction and respiratory compromise. They can also present with cerebrospinal fluid (CSF) rhinorrhea, purulent nasal drainage, or meningitis. Objective To report a novel technique for repairing a giant sphenoethmoidal encephalocele containing eloquent neural tissue. Methods A 16-mo-old girl presented with progressive airway obstruction from a giant sphenoethmoidal encephalocele that filled her oral cavity. She had multiple congenital anomalies including agenesis of the corpus callosum and cleft lip and palate. Computed tomography showed complete absence of the bony anterior cranial base, and magnetic resonance imaging demonstrated the presence of the pituitary gland and hypothalamus in the hernia sac. Results We repaired the encephalocele using a combined microsurgical and endoscopic multidisciplinary approach working through transcranial, transnasal, and transpalatal corridors. The procedure was completed in a single stage, during which the midline cleft lip was also repaired. The child made an excellent neurological and aesthetic recovery with preservation of pituitary and hypothalamic function, without evidence of CSF fistula. Conclusion The authors describe a novel multidisciplinary technique for treating a giant sphenoethmoidal encephalocele containing eloquent brain. The cleft lip was also repaired at the same time. The ability to work through multiple corridors can enhance the safety and efficacy of an often-treacherous operative endeavor.

Background The purpose of this study was to examine injury patterns in pediatric mandibular condylar fractures and to propose and evaluate the validity of an institutional treatment algorithm for such fractures. Methods A retrospective chart review was conducted on pediatric patients who presented to the authors' institution with isolated mandibular condylar fractures between 1990 and 2016. Patients were categorized by dentition, and information regarding demographics, injury characteristics, management, and complications was compiled. Results Forty-three patients with 50 mandibular condylar fractures were identified. Twelve patients (27.9 percent) had deciduous dentition, 15 (34.9 percent) had mixed dentition, and 16 (37.2 percent) had permanent dentition. The most common fracture pattern in all groups was diacapitular [n = 30 (60 percent)]; however, older groups showed higher rates of condylar base fractures and bilateral fractures (p = 0.029 and p = 0.011, respectively). Thirty-one patients (72.1 percent) were treated with nonoperative management, 10 (23.2 percent) with closed treatment and mandibulomaxillary fixation, and two (4.7 percent) with open treatment and mandibulomaxillary fixation; nonoperative treatment was more common in younger patients (p = 0.008). Management for 10 patients (23.2 percent) was nonadherent to the treatment algorithm. Eight patients had complications (18.6 percent). Common complications included temporomandibular joint ankylosis (n = 2) and malocclusion (n = 2). Although complications were seen in all groups, adherence to the algorithm was associated with an 81.8 percent reduction in odds of complications (p = 0.032). Conclusions Nonoperative management has a low complication rate in deciduous children. Children with permanent/mixed dentition may undergo closed treatment and mandibulomaxillary fixation if they have malocclusion/contralateral open bite, significant condylar dislocation, and ramus height loss greater than 2 mm. Clinical question/level of evidence Therapeutic, III.

Study Design: Retrospective, quasi-experimental difference-in-differences investigation. Objective: Pediatric craniofacial fractures are often associated with substantial morbidity and consumption of healthcare resources. Maryland’s All Payer Model (APM) represents a unique case study of the health economics surrounding pediatric craniofacial fractures. The APM implemented global hospital budgets to disincentivize low-value care and encourage preventive, community-based efforts. The objective of this study was to investigate how this reform has impacted pediatric craniofacial fracture care in Maryland. Methods: Children (≤18 years) receiving inpatient craniofacial fracture-related care in Maryland between January, 2009 through December, 2016 were investigated. New Jersey was used for comparison. Data were abstracted from the Kid’s Inpatient Database (Healthcare Cost and Utilization Project). Results: Between 2009–2016, 3,655 pediatric patients received inpatient care for craniofacial fractures in Maryland and New Jersey. Prior to APM implementation, around 20% of Maryland patients received care outside of urban teaching hospitals. After APM implementation, less than 6% of patients received care outside of urban teaching hospitals ( p = 0.003). Implementation of the APM in Maryland also resulted in fewer pediatric craniofacial fracture admissions than New Jersey, though this only reached borderline significance (adjusted difference-in-differences estimate: −1.1 fewer admissions, 95% confidence interval: −2.1 to 0.0, p = 0.05). Inpatient costs for pediatric craniofacial care and mean did not change post-APM. Conclusions: Maryland’s APM consolidated pediatric craniofacial fracture inpatient care at urban, teaching hospitals. Inpatient costs and lengths of stay did not change after policy implementation, but overall admission rates decreased. Such considerations are important when considering national expansion of global hospital budgeting.

Introduction The U.S. Navy Medicine has a long history of conducting global health missions that foster international diplomacy through medical knowledge exchange with a goal of increasing partner nation’s health care capacity. Pacific Partnership is an annual U.S. Navy-sponsored joint operation that enhances medical collaboration with participating nations throughout the Indo-Asia-Pacific region. Since 2015, a U.S. Navy Cardiology team has conducted a structural heart disease interventional workshop focused on congenital heart disease with the cardiologists at the Da Nang General Hospital, Da Nang, Vietnam. Herein, we describe the multinational collaborative project including the patient registry we developed to monitor the short- and long-term outcomes of structural heart disease interventions preformed during Pacific Partnership 2015 and 2016. Materials and Methods Our team developed a sustainable procedural registry with the goal of following the long-term outcomes of cardiac interventions for congenital heart disease in Vietnamese patients. Specifically, the registry was designed to record the changes in symptoms referable to the cardiovascular system and for device placement–associated complications for devices placed in 2015 and 2016 and has been updated annually thereafter. Results Twelve patients (age range, 7 months to 31 years) underwent successful atrial septal defect closure in 2015 without procedural complications. The follow-up rate was 75% at 1 year and 67% at 2 years, and all devices were in appropriate position with no complications identified. Fifteen patients (age range, 20-66 years) underwent successful atrial septal defect closure in 2016. The follow-up rate was 62.5% at 1 year, and all devices were in appropriate position with no complications identified. Three patients (age range, 5-25 months) underwent successful device closure of the patent ductus arteriosus in 2015 without complications. The follow-up rate was 67% in 2016 and again in 2017. Six patients (age range, 9-74 years) underwent successful patent ductus arteriosus closure in 2016 without complications. The follow-up rate was 67% in 2017, and all devices were in appropriate position with no device-related complications identified. Conclusions The development of a patient registry during these missions allowed for the longitudinal monitoring of outcomes for cardiac interventions. Notably, treated patients experienced symptomatic improvement without significant long-term procedural complications. Following patients longitudinally across medical missions is of recognized importance but remains a difficult objective to achieve for a multitude of factors including administrative and financial burdens on both the medical systems and the patients of host nations. Despite these limitations, longitudinal follow-up of patient care facilitated by a patient registry has a vital role in monitoring the quality of care provided and should be an integral part of all future global medical missions.

Introduction A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden," "buried," and "trapped" penis are used interchangeably. To date, there is no classification system that adequately characterizes the spectrum of this condition. In this study, we propose a simplified nomenclature and classification system for adult-acquired hidden penis. Methods We performed a retrospective review of all adult patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A "buried" penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a "trapped" penis presented with scarred or fibrous tissue, which required surgical lysis, phalloplasty, and penile skin resurfacing. Results Thirteen patients met the inclusion criteria. The cohort was aged 53 ± 15.7 years with a mean body mass index of 37.4 ± 4.3 kg/m2. Two patients required repeat operations, yielding a total of 15 operative encounters. Six were defined as buried, and 9 as trapped. Inability to achieve erection was the most common preoperative complaint in those with buried penis (67%), whereas difficulties in voiding were most common with trapped penis (78%). Patients with trapped penises had a significantly larger body habitus than those with a buried penis (39.8 vs 34.2 kg/m2, P = 0.0088). Operative duration and length of hospital stay were comparable between the trapped and buried penis groups (206 vs 161 minutes, P = 0.3664) (5 vs 1 day, P = 0.0836). One third experienced wound complications, but this was not significantly different between buried and trapped penises (17% vs 44%, P = 0.5804). Postoperatively, 5 patients experienced spontaneous erections, and 7 were able to void while standing. Conclusions Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our nomenclature and classification system offer a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.

BACKGROUND Currently, the pathogenesis of leptomeningeal cysts, also known as growing skull fractures, is still debated. The purpose of this study was to examine the specific skull fracture characteristics that are associated with the development of growing skull fractures and describe the authors' institutional experience managing this rare entity. METHODS A retrospective cohort study was performed that included all patients younger than 5 years presenting to a single institution with skull fractures from 2003 to 2017. Patient demographics, cause of injury, skull fracture characteristics (e.g., amount of diastasis, linear versus comminuted fracture), concomitant neurologic injuries, and management outcomes were recorded. Potential factors contributing to the development of a growing skull fracture and neurologic injuries associated with growing skull fractures were evaluated using univariate logistic regression. RESULTS A total of 905 patients met the authors' inclusion criteria. Of these, six (0.66 percent) were diagnosed with a growing skull fracture. Growing skull fractures were more likely to be comminuted (83.3 percent versus 40.7 percent; p = 0.082) and to present with diastasis on imaging (100 percent versus 26.1 percent; p < 0.001; mean amount of diastasis, 7.1 mm versus 3.1 mm; p < 0.001). Univariate logistic regression analysis confirmed the role of a comminuted fracture pattern (OR, 7.572) and the degree of diastasis (OR, 2.081 per mm diastasis) as significant risk factors for the development of growing skull fractures. CONCLUSIONS The authors' analysis revealed that fracture comminution and diastasis width are associated with the development of growing skull fractures. The authors recommend dural integrity assessment, close follow-up, and early management in young children who present with these skull fracture characteristics. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

BACKGROUND Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic. METHODS The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols. RESULTS Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P

Social determinants of health (SDOH) are integral to consider when delivering craniomaxillofacial and facial reconstructive care for patients. The American Cleft Palate-Craniofacial Association (ACPA) has instituted a formalized multidisciplinary care team model that recognizes such determinants and has aggregated patient-led organizations to strengthen patients’ education and support system. This review discusses the need for all surgeons engaged in facial and craniomaxillofacial reconstruction to consider SDOH in their practice. Additionally, we explore how factors such as race, insurance status, education level, cost, and access to follow-up care, impact surgical care for craniosynostosis, facial trauma, orthognathic surgery, head and neck cancer, and facial paralysis. We propose that the ACPA team model be applied to other societies that care for the broader scope of patients in need of facial and craniomaxillofacial reconstruction to strengthen the communication, collaboration, and standardization of care delivery that is personalized to the needs of each patient.

PURPOSE Within the academic surgical setting resident involvement may confer longer operative times. The increasing pressures to maximize clinical productivity and decreasing reimbursement rates, however, may conflict with these principles. This study calculates the opportunity cost of resident involvement in craniofacial surgery. METHODS Retrospective analysis was conducted with patients who underwent craniofacial procedures from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Patients were selected based on relevant Current Procedural Terminology codes for craniofacial pathologies (ie, trauma, head and neck reconstruction, orthognathic surgery, and facial reanimation). Variables included patient demographics, operative time, and presence or absence of resident trainee. Average relative value units were calculated to determine the opportunity cost of resident involvement for each craniofacial procedure. RESULTS In total, 2096 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Resident involvement was associated with a statistically significant higher operative time (P

Complex gastroschisis and other etiologies of intestinal compromise present a difficult medical and surgical challenge in the neonatal and pediatric population. Aggressive resection of intestinal length in these cases can lead to significant short bowel syndrome and prolonged or lifelong dependence on parenteral nutrition. This method of bowel preservation previously described has led to additional patients achieving enteral autonomy and we present their cases and most recent outcomes.

While many studies have examined potential risk factors for nonsyndromic craniosynostosis, there have been no publications to date investigating the role of ethnicity in the United States. The current study was undertaken as the first multi-center investigation to examine the relationship between ethnicity and nonsyndromic craniosynostosis, looking at both overall prevalence as well as potential correlation between ethnicity and pattern of affected suture site. A chart review of patients diagnosed with nonsyndromic craniosynostosis treated at four major children's hospitals was performed to obtain ethnicity data. Analysis was preformed based on ethnic group as well as suture site affected. To account for potentialOne regional selection bias, the KID database (1997-2012) was utilized to identify all cases of craniosynostosis on a national level. This data was analyzed against birth rates by ethnicity obtained from CDC WONDER natality database.Amongst the 2112 cases of nonsyndromic craniosynostosis at all institutions, Caucasians and African Americans were consistently the predominant ethnic groups. There was a statistically significant difference in the distribution of affected suture type with African Americans more likely to present with unicoronal synostosis and Caucasians more likely to present with metopic synostosis (P = 0.005). The national data revealed that there were more cases of craniosynostosis in Caucasians and fewer in African Americans than expected when compared to population birth rates. Our findings demonstrate that the Caucasian race is associated with increased rates of synostosis.

The purpose of the study was to determine the accuracy of acoustic radiation force impulse (ARFI) ultrasound elastography in assessing the degree of liver disease in children with short bowel syndrome (SBS).A prospective observational cohort study of patients with SBS who underwent a liver biopsy and ARFI elastography was performed. Mean shear wave speed (SWS) and stage of fibrosis was evaluated using t-tests. Receiver operating characteristic curves (ROC) were generated and the area under the curves (AUC) estimated in order to assess the accuracy of SWS measurements to discriminate between stages of fibrosis.Thirty-seven paired elastography and biopsy samples from 31 patients were included. The median age was 0.6 years, and 61% were male. There was a significant positive correlation between stage of fibrosis and mean SWS (β=0.16 m/s increase per stage, p=0.001). ROC analysis revealed that mean SWS had good accuracy for discriminating between mild liver fibrosis (F0-F1) and moderate to severe fibrosis (F2-F4) (AUC=0.80, 95% CI 0.65-0.95). In addition, ROC analysis demonstrated that mean SWS can also accurately discriminate between mild to moderate fibrosis (F0-F2) and more severe fibrosis (F3-F4) (AUC=0.84, 95% CI 0.71-0.96).ARFI elastography is an accurate, non-invasive method to monitor liver disease in children with SBS.Retrospective Cohort Study LEVEL OF EVIDENCE: II.

Combined sagittal and metopic craniosynostosis is an uncommon condition that may result in a wide spectrum of cranial morphologies. This occurs as a result of the compound effects of both prematurely fused sutures. The authors present an incidence of sagittal craniosynostosis with a specific altered head morphology, and delayed diagnosis that the authors believe occurred due to structural changes associated with concurrent metopic suture synostosis This patient underscores the limitations of relying on classic diagnostic patterns and highlights the critical role of noninvasive imaging in the diagnosis of craniosynostosis.

Background Combined symphyseal-condylar mandible fractures are relatively common but difficult to manage in children. This study investigated the cause and management of symphyseal-condylar fractures in pediatric patients. Methods This study presents a retrospective review and expert opinion of pediatric symphyseal-condylar mandibular fracture management at the authors' institution between 1990 and 2019. National data from the Healthcare Cost and Utilization Project Kids' Inpatient Database (2000 to 2016) were used to determine whether institutional data had national applicability. Results Twenty-one patients at the authors' institution met inclusion criteria. Of these patients, 26.7 percent of deciduous dentition patients underwent open reduction and internal fixation, 40 percent underwent closed treatment (maxillomandibular fixation), and 33.3 percent received a soft diet. All mixed dentition patients underwent open reduction and internal fixation or closed treatment; all permanent dentition patients underwent open reduction and internal fixation. The national database (n = 1708) demonstrated similar treatment patterns: most permanent dentition patients (88.7 percent) underwent open reduction and internal fixation, most mixed dentition patients (79.2 percent) underwent closed treatment, and among deciduous dentition patients, 53.5 percent patients received a soft diet; 38 percent received closed treatment. In this study, the overall posttreatment complication rate was 62.5 percent among open reduction and internal fixation patients, 14.3 percent among closed treatment patients, and 16.7 percent among patients treated with a soft diet. Conclusions Symphyseal-condylar mandibular fractures were associated with substantial morbidity in children. The authors created a treatment algorithm to maximize outcomes in children who suffer from this challenging fracture pattern. Clinical question/level of evidence Therapeutic, III.

Treacher Collins syndrome (TCS) is a genetic disorder that presents with a variety of craniofacial deformities. One classic feature of TCS is a steep, counterclockwise rotation of the occlusal plane, and microretrognathia with bony deficiencies in both the body and ramus of the mandible. This morphology commonly necessitates reconstruction by the craniofacial surgeon. This article discusses strategies and considerations for surgically correcting the mandibular deformity associated with TCS using mandibular distraction osteogenesis and other related techniques. The proper implementation of these techniques can yield excellent results that greatly improve quality of life in this challenging patient population.

Background/purpose Virtual surgical planning (VSP) in orthognathic surgery has enabled reconstructive surgeons to achieve more predictive results when compared to conventional methods. Still, few studies have evaluated the accuracy of VSP in more complex cases, such as those requiring maxillary segmentation. The aim of this study was to examine the conformity of virtual surgical plans to postoperative results following segmental procedures performed by a single surgeon. Methods This was a retrospective study of patients who had undergone triple jaw (segmental Le Fort I, bilateral sagittal split osteotomy, and genioplasty by the senior author (DMS) between 2016 and 2020. The preoperative virtual surgical plan and postoperative cone beam computed tomographic scan were registered in 3-Matic software (Materialise, Leuven, Belgium) using cranial base landmarks. The conformity of the postoperative skull model to the virtual surgical plan was quantified using linear and angular measurements at various 3D bony landmarks. The average mean difference (AMD) in the x-, y-, and z-axes was calculated. Paired T-tests were used to compare postoperative measurements with those from the pre-operative STL. Multivariate linear regression was performed to analyze and modifying effects of age, gender, number of segments (2 vs. 3), and malocclusion class. Results Twenty-nine patients were included (mean age 24.5 years; 72.4% female). Three-dimensional analysis showed significant AMD between the virtual plan and postop CBCT for the following landmarks: U1 Midpoint (y, AMD: 1.65mm, P = .03), B point (y, AMD: 1.63mm, P = .005), pogonion (y, AMD: 2.38mm, P = .0005), menton (y, AMD: 2.22mm, P = .0003). There were no differences between the virtual plans and postop CBCT at any other points. Transversely, the overall AMD was 1.15mm, with under-expansion occurring in 79.3% (2.18mm) and over-expansion in 20.7% of patients (1.65mm). Angular measurements revealed statistical significance for SNB (AMD: 1.38, P = .02), but not for SNA and ANB values. Multivariate regression showed no association between age, gender, segmentation (2 vs. 3), or class of malocclusion and the extent of conformity for any measurements. Conclusion There is a high degree of conformity between the VSP and postoperative results following triple jaw orthognathic surgery with segmental maxillary osteotomies. The greatest nonconformity was found in the sagittal plane and was mostly limited to the mandible. Segmentation did not affect surgical accuracy of the maxillary movements.

The treatment of asymptomatic non-occult pneumothoraces (ANOPTX) secondary to blunt chest trauma (BCT) has not been well delineated. We sought to analyze our experience with ANOPTX in pediatric trauma patients and determine if a chest tube (CT) is mandatory.A retrospective chart review of patients17 years old with ANOPTX from BCT who presented to a level 1 trauma children's hospital, between January 2000 and June 2015 was performed. Demographics, vitals, trauma scores, imaging, interventions, hospital expenses and outcomes were analyzed.Of the 77 patients who had ANOPTX, 48 (62.3%) were managed with observation only, while 29 (37.7%) underwent CT placement. The median length of stay for patients who had CT placement was 7 days (IQR, 4, 12) and 2 days (IQR, 1, 4) in those observed (p 0.01). All patients who were observed had complete resolution of the pneumothorax without recurrence or the need for CT placement. Patients who had CT placement had more imaging performed and more hospital expenditure compared to those who were observed.CT is not mandatory in all pediatric patients with ANOPTX from BCT and observation has been found to be safe and cost effective.

BACKGROUND Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population. METHODS The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population. RESULTS In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P

BACKGROUND Surgical resection of maxillary tumors can result in defects that can be difficult to reconstruct by conventional means due to the complex functional and anatomic nature of the midface and lack of regional bone flap options in the head and neck. Many reconstructive methods have been used to repair maxillary defects, but the ideal technique for the reconstruction of hemi-maxillectomy defects in growing pediatric patients has yet to be determined. METHODS The authors present a rare pediatric patient with melanotic neuroectodermal tumor of infancy resulting in a hemi-maxillectomy defect after resection that was reconstructed using a pedicled vascularized composite flap consisting of temporalis muscle, pericranium, and parietal bone. RESULTS The patient achieved successful long-term bony reconstruction of his right maxilla with this flap. Stable skeletal fixation with adequate orbital support was maintained over a >3-year follow-up period. CONCLUSION A vascularized composite parietal bone flap is a reliable reconstructive option for reconstruction of large maxillectomy defects providing low donor-site morbidity, adequate globe support, excellent long-term skeletal stability, and malar symmetry in rapidly growing pediatric patients. Successful reconstruction for a rare patient with maxillary melanotic neuroectodermal tumor of infancy requiring hemi-maxillectomy was demonstrated with >3-year follow-up.

Objective: Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO. Design: Retrospective cohort analysis. Setting: Three tertiary care institutions. Patients: Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019. Main Outcome Measures: The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events. Results: Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO ( P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea–hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002). Conclusion: Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

BACKGROUND Mandible angle fractures can result in significant, long-term morbidity in children. However, management of this particular mandibular fracture type is not well-characterized in the pediatric population. This study investigated isolated mandibular angle fractures in the pediatric patients. METHODS This was a 30-year retrospective, longitudinal cohort study of pediatric patients presenting to a single institution with mandibular angle fractures. Patient data were abstracted from electronic medical records. Subgroup analyses were completed by dentition stage. RESULTS Seventeen patients met inclusion criteria, of whom 6 (35.3%) had deciduous, 4 (23.5%) had mixed, and 7 (41.2%) had permanent dentition. Deciduous/mixed dentition patients with mobile, displaced fractures underwent ORIF, whereas those with nondisplaced fractures underwent treatment with soft diet. Among permanent dentition patients, most patients (71.4%) underwent ORIF regardless of fracture severity. The post-ORIF complication rate was 55.6%; no complications were reported after soft diet or closed treatment (Fischer exact: P = 0.05). The most common post-ORIF complication was alveolar nerve paresthesia (17.6%) and post-ORIF complication rates did not vary by age (deciduous: 16.7%, mixed: 25.0%, permanent: 42.9%, Fischer exact: P = 0.80). ORIF patients who received a single upper border miniplate had a lower complication rate (42.9%) than other plating methods (upper and lower miniplates-100%). Fracture severity was predictive of post-ORIF complications (odds ratio: 2.23, 95% confidence interval: 2.22-2.24, P

Background Isolated symphyseal or parasymphyseal mandibular fractures can confer significant morbidity in children. However, this mandibular injury pattern has not been well-characterized in children. This study investigated isolated symphyseal/parasymphyseal mandibular fractures in pediatric patients. Methods This was a 29-year retrospective, longitudinal cohort study of pediatric patients who presented to a single institution with isolated symphyseal/parasymphyseal mandibular fractures. Patient data were abstracted from medical records and compared between patients of varying dentition stages. Results Fourteen patients met inclusion criteria during the study period, of whom 2 (14.3%) had deciduous dentition, 7 (50.0%) had mixed dentition, and 5 (35.7%) had permanent dentition. Patients with deciduous dentition were significantly more likely to receive soft diet or closed treatment with mandibulomaxillary fixation than open reduction and internal fixation when compared to patients with mixed or permanent dentition (p = 0.04). The post-treatment complication rate was 40% among all patients treated with open reduction and internal fixation, 16.7% among patients who underwent closed treatment with mandibulomaxillary fixation, and 75% amongst patients treated with soft diet (though 2 patients who received soft diet had permanent dentition and thus were inappropriately managed). The most common complication overall was malocclusion (20%). A treatment algorithm was proposed based on study data; adherence to the algorithm significantly decreased odds of complications (odds ratio: 0.03, 95% confidence interval:0.001-0.6). Conclusions The etiology, management, and outcomes of children with isolated symphyseal or parasymphyseal mandibular fractures at our institution varied by dentition stage. The authors proposed a treatment algorithm in order to optimize outcomes of symphyseal/parasymphyseal mandibular fractures in this patient population.

Purpose To assess maxillary occlusal plane correction in patients with hemifacial microsomia (HFM) after vertical vector mandibular distraction osteogenesis (vMDO) without orthodontic appliances. Methods A retrospective study was performed on consecutive patients with HFM and Kaban-Pruzansky type-II mandibular deformities who underwent unilateral vMDO by a single surgeon over an 18-month period. Patients with 12-months minimum clinical follow-up and postero-anterior (PA) cephalograms taken preoperatively and at a minimum of 3 months post-consolidation were included. Results Five patients met inclusion criteria, 3 were female, median age was 13 years, median distraction length was 21.3 mm. Median radiographic follow-up was 5 months (range 3-38) post-consolidation. Median correction of the ramus height differential (difference between non-diseased and diseased side) was 97.3%. Median maxillary height differential correction was 72.2%. Median maxillary occlusal plane angle correction (towards zero) was 84.2%. Relative and absolute maxillary bone growth was greater on the diseased side (median 7.4%, 3.5 mm versus 2.8%, 1.4 mm). Dentoalveolar height decreased bilaterally in 4 of the 5 patients. Median chin point correction (towards midline) was 31.4%. Conclusion Unilateral vMDO without orthodontic appliances effectively corrected mandibular ramus height, leveled the maxillary occlusal plane, and preferentially increased maxillary bone growth on the diseased side in patients with HFM.

The initial evaluation and treatment of the pediatric trauma patient require an organized, thorough approach. All patients must be assumed to have multiple injuries until proven otherwise. Resuscitation efforts should be early and aggressive to avoid the onset of irreversible shock. Adequate assessment and management of the ABCs described in this chapter will provide adequate treatment of the patient’s other injuries, leading to an overall improvement in morbidity and mortality. Thus, the ABCs play an essential role in the initial evaluation and treatment of the pediatric trauma patient. Beyond these primary goals, this chapter will discuss the methodical approach to diagnosing and addressing traumatic injuries rapidly in the pediatric population.

BACKGROUND Postoperative pain following open craniosynostosis repair has not been studied extensively and is sometimes thought to be inconsequential. The purpose of this study was to assess postoperative pain in this pediatric population. METHODS We performed a retrospective chart review of patients (n = 54) undergoing primary open craniosynostosis repair from 2010 to 2016. Demographics, length of stay (LOS), pain scores, emesis events, and perioperative analgesics were reviewed. Multivariable regression models were designed to assess for independent predictors of LOS and emesis. RESULTS A high proportion had moderate to severe pain on postoperative day 0 (56.5%) and day 1 (60.9%). Opioid administered in postoperative period was 1.40 mg/kg/d in morphine milligram equivalent (MME) (±1.07 mg/kg/d MME). Majority of patients transitioned to enteral opioids on postoperative day 1 (24.5%) or day 2 (49.1%). Ketorolac was administered to 11.1% (n = 6). Emesis was documented in 50% of patients. LOS revealed a positive association with age (P = 0.006), weight (P = 0.009), and day of transition to enteral opioids (P

Background Late treatment of scaphocephaly presents challenges including need for more complex surgery to achieve desired head shape. Virtual surgical planning for total vault reconstruction may mitigate some of these challenges, but has not been studied in this unique and complex clinical setting. Methods A retrospective chart review was conducted for patients with scaphocephaly who presented to our institution between 2000 and 2014. Patients presenting aged 12 months or older who underwent virtual surgical planning-assisted cranial vault reconstruction were included. Patient demographic, intraoperative data, and postoperative outcomes were recorded. Pre- and postoperative anthropometric measurements were obtained to document the fronto-occipital (FO) and biparietal (BP) distance and calculate cephalic index (CI). Virtual surgical planning predicted, and actual postoperative anthropometric measurements were compared. Results Five patients were identified who fulfilled inclusion criteria. The mean age was 50.6 months. One patient demonstrated signs of elevated intracranial pressure preoperatively. Postoperatively, all but one needed no revisional surgery (Whitaker score of 1). No patient demonstrated postoperative evidence of bony defects, bossing, or suture restenosis. The mean preoperative, simulated, and actual postoperative FO length was 190.3, 182, and 184.3 mm, respectively. The mean preoperative, simulated, and actual postoperative BP length was 129, 130.7, and 131 mm, respectively. The mean preoperative, simulated, and actual postoperative CI was 66, 72, and 71.3, respectively. Conclusions Based on our early experience, virtual surgical planning using a modified Melbourne technique for total vault remodeling achieves good results in the management of late presenting scaphocephaly.

Statement of the problem The clinical decision to pursue open reduction and internal fixation (ORIF) vs. closed treatment (CT) to treat mandibular condyle fractures has been long contested but predicated on understanding of absolute and relative indications and contraindications. This meta-analysis critically appraised the literature to compare and contrast clinical outcomes following these interventions. Materials and methods A systematic review and meta-analysis were performed to test the null hypothesis of no difference in clinical outcomes in ORIF vs. CT of mandibular condyle fractures. ORIF also was compared to endoscopically assisted open treatment. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database and ClinicalTrials.gov trial registries were accessed from 1946 to 2020. The quality of evidence was determined using Grading of Recommendations Assessment, Development and Evaluation methodology. No pediatric studies were included. The quality of evidence was downgraded due to risk of bias and imprecision in specific outcomes in observational studies. Data analysis Two authors extracted the following data from included studies: country of origin, study design, study period, number of patients, patient characteristics (i.e., age range, gender, ethnicity), fracture laterality (unilateral vs. bilateral), treatment used (CT vs. ORIF), and clinical outcomes. The study analyzed the data separately according to fracture location and study design (e.g., RCTs and observational studies). An experienced medical librarian was consulted on methodology and ran a medical subject heading (MeSH) analysis of known key articles provided by the research team to ensure complete capture of all articles pertaining to management of condylar fractures. In each database, the study ran scoping searches and used an iterative process to translate and refine the searches. Results and outcomes data Of 1507 screened articles, 14 met the inclusion criteria. There were 4 meta-analyses that were included, examining 7 randomized controlled (RCTs) trials and 31 non-randomized studies. Primary studies enrolled adults with displaced uni- or bilateral condylar fractures and did not report the results by fracture location (e.g., subcondylar or condylar) except with 2 RCTs that included all adults with subcondylar fractures. Primary studies compared the outcomes after open surgical procedure with those of fixation using 1 or 2 miniplates with various diameters. Open reduction and internal fixation were favored significantly when evaluating temporomandibular joint pain (RR 0.3; 95% CI 0.1-0.7) (NNTp 3; 2-6), laterotrusive movements of the mandible (MD 2.3; 1.7-3.0) (SMD 0.9; 0.4-1.3), and malocclusion (RR 0.5; 0.4-0.7) (NNTp 19; 10-200). However, open treatment yielded higher incidence of postoperative infection (RR 3.6; 95% CI 0.9-13.8). With respect to ORIF versus endoscopically assisted open treatment, no difference was seen in overall patient satisfaction with postoperative mandibular movement, disturbance to articulation, or occlusion. Conclusion Meta-analysis of high-level evidence in randomized controlled trial data suggests ORIF yields significantly superior clinical outcomes when evaluating restoration of translational and rotational mandibular movement, alleviation of pain, and restoration of occlusion and symmetry, although it is associated with higher risk of postoperative infection and facial nerve injury. These long-term benefits must be weighed against the increased risk of postoperative infection in ORIF; thus, treatment should be patient-specific. Future investigations with high-level evidence may further elucidate the relative effectiveness and safety of various open, endoscopic, and closed techniques in patients with facial trauma.

Cranial vault remodeling surgery for craniosynostosis carries the potential risk of dural venous sinus injury given the extensive bony exposure. Identification of the dural venous sinuses can be challenging in patients with craniosynostosis given the lack of accurate surface-localizing landmarks. Computer-aided design and manufacturing (CAD/CAM) has allowed surgeons to pre-operatively plan these complex procedures in an effort to increase reconstructive efficiency. An added benefit of this technology is the ability to intraoperatively map the dural venous sinuses based on pre-operative imaging. We utilized CAD/CAM technology to intraoperatively map the dural venous sinuses for patients undergoing reconstructive surgery for craniosynostosis in an effort to prevent sinus injury, increase operative efficiency, and enhance patient safety. Here, we describe our experience utilizing this intraoperative technology in pediatric patients with craniosynostosis. We retrospectively reviewed the charts of children undergoing reconstructive surgery for craniosynostosis using CAD/CAM surgical planning guides at our institution between 2012 and 2016. Data collected included the following: age, gender, type of craniosynostosis, estimated blood loss, sagittal sinus deviation from the sagittal suture, peri-operative outcomes, and hospital length of stay. Thirty-two patients underwent reconstructive cranial surgery for craniosynostosis, with a median age of 11 months (range, 7–160). Types of synostosis included metopic (6), unicoronal (6), sagittal (15), lambdoid (1), and multiple suture (4). Sagittal sinus deviation from the sagittal suture was maximal in unicoronal synostosis patients (10.2 ± 0.9 mm). All patients tolerated surgery well, and there were no occurrences of sagittal sinus, transverse sinus, or torcular injury. The use of CAD/CAM technology allows for accurate intraoperative dural venous sinus localization during reconstructive surgery for craniosynostosis and enhances operative efficiency and surgeon confidence while minimizing the risk of patient morbidity.

Improved nerve regeneration and functional outcomes would greatly enhance the utility of vascularized composite allotransplantation (VCA) such as hand and upper extremity transplantation. However, research aimed at achieving this goal has been limited by the lack of a functional VCA animal model. We have developed a novel rat midhumeral forelimb transplant model that allows for the characterization of upper extremity functional recovery following transplantation. At the final end point of 12 weeks, we found that animals with forelimb transplantation including median, ulnar and radial nerve coaptation demonstrated significantly improved grip strength and forelimb function as compared to forelimb transplantation without nerve approximation (grip strength: 1.71N ± 0.57 vs. no appreciable recovery; IBB scale: 2.6 ± 0.7? vs. 0.8 ± 0.40; p = 0.0005), and similar recovery to nerve transection-and-repair only (grip strength: 1.71N ± 0.57 vs. 2.03 ± 0.42.6; IBB scale: 2.6 ± 0.7 vs. 2.8 ± 0.8; p = ns). Moreover, all forelimb transplant animals with nerve coaptation displayed robust axonal regeneration with myelination and reduced flexor muscle atrophy when compared to forelimb transplant animals without nerve coaptation. In conclusion, this is the first VCA small-animal model that allows for reliable and reproducible measurement of behavioral functional recovery in addition to histologic evaluation of nerve regeneration and graft reinnervation.

PURPOSE The purpose of this study was to assess whether long-term outcomes were equivalent between computer-assisted design and manufacturing (CAD/CAM) -assisted cranial vault reconstruction performed by an inexperienced surgeon, with fewer years of surgical experience, and traditional reconstruction performed by senior surgeons with many decades of experience. METHODS An Institutional Review Board-approved retrospective cohort study was performed for all patients with nonsyndromic craniosynostosis between the ages of 1 month to 18 years who received primary, open calvarial vault reconstruction at the Johns Hopkins Hospital between 1990 and 2017. The primary outcome variable was the Whitaker category (I-IV) for level of required revision at the 2-year follow-up visit. Secondary outcomes included estimated blood loss, length of stay, operative time, and postoperative complications. CAD/CAM-assisted surgery was considered noninferior if the proportion of cases requiring any revision (Whitaker II, III, or IV) was no more than 10% greater than the proportion in the traditional surgery group with multivariate logistic regression analysis. t tests and fisher exact tests were used for secondary outcomes. RESULTS A total of 335 patients were included, with 35 CAD/CAM-assisted reconstructions. CAD/CAM-assisted reconstruction was noninferior to traditional after accounting for patient demographics, type of surgery, and experience level of the plastic surgeon. The traditional group required revision more frequently at 29.0% compared to CAD/CAM at 14.3%. Secondary outcomes were not significantly different between groups, but CAD/CAM had significantly longer average operative times (5.7 hours for CAD/CAM, 4.3 hours for traditional, P < 0.01). CONCLUSION CAD/CAM technology may lower the learning curve and assist less experienced plastic surgeons in achieving equivalent long-term outcomes in craniofacial reconstruction.

INTRODUCTION Maxillary hypoplasia after cleft lip and palate (CLP) repair can result in significant functional and aesthetic impairments. Le Fort I osteotomy & advancement and Le Fort I distraction osteogenesis are standard treatment options for individuals with CLP-associated midface retrusion. However, both of these modalities continue to be associated with a high relapse rate. This study describes surgical outcomes of a 2-stage technique utilizing distraction osteogenesis combined with bone grafting and rigid fixation, which may optimize skeletal stability by reducing relapse. METHODS A retrospective review of CLP patients with severe maxillary hypoplasia evaluated by a single surgeon from 2003 to 2014 was performed. Twenty-one subjects were identified that underwent maxillary advancement via a 2-stage technique: (1) Le Fort I external rigid distraction using a HALO device, followed by (2) autologous iliac crest bone graft application and plate-fixation. Post-operative cephalograms were taken on average 1-year following surgery. RESULTS Twelve subjects met the inclusion/exclusion criteria. A distraction rate of 1 mm/day was achieved with an average of 14 mm of maxillary advancement. Average increase in SNA was +9.03°, with an increase from 71.84° to 80.88° (normal = 82.0°, P value

This study investigates the efficacy of systemic growth hormone (GH) therapy in ameliorating the deleterious effects of chronic denervation (CD) injury on nerve regeneration and resulting motor function. Using a forelimb CD model, 4 groups of Lewis rats were examined (n = 8 per group): Group-1 (negative control) 8 weeks of median nerve CD followed by ulnar-to-median nerve transfer; Group-2 (experimental) 8 weeks of median nerve CD followed by ulnar-to-median nerve transfer and highly purified lyophilized pituitary porcine GH treatment (0.6 mg/day); Group-3 (positive control) immediate ulnar-to-median nerve transfer without CD; Group-4 (baseline) naïve controls. All animals underwent weekly grip strength testing and were sacrificed 14 weeks following nerve transfer for histomorphometric analysis of median nerve regeneration, flexor digitorum superficialis atrophy, and neuromuscular junction reinnervation. In comparison to untreated controls, GH-treated animals demonstrated enhanced median nerve regeneration as measured by axon density (p 2 vs 865.2 ± 48.33 µm2; p

In the general population, the incidence of cutaneous malignancies has been rising. However, a particular high-risk population—transplant recipients—suffer at an alarming rate from the incidence of aggressive cutaneous malignancies. The purpose of this review is to examine the latest literature on the epidemiology, risk factors, pathogenesis, prognosis, prevention, and management of highly aggressive cutaneous cancers in the transplant population. With innovations in immunosuppression, surgical technique, and perioperative care, organ transplant recipients are now living longer but now suffer from increasing morbidity secondary to the rising incidence of these aggressive cutaneous cancers. Currently, the three most common causes of delayed mortality following organ transplantation are complications associated with infectious diseases, cardiovascular disease and malignancy. Cutaneous malignancies have now become the most common malignancy in this unique population.

Gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) in newborns and children remain a significant cause of morbidity. Practice patterns and preferences among different institutions and among surgeons vary significantly. Controversial issues include the use of gastrostomy alone versus gastrostomy with Nissen fundoplication, laparoscopic versus open fundoplication, the role of the prophylactic Nissen fundoplication in newborns, Nissen fundoplication in neurologically intact versus neurologically impaired newborns, and the role as well as selection of investigations to evaluate the presence of gastroesophageal reflux in surgical decision making. A review of the recent literature as well as the senior author’s personal experience was used to evaluate the current state of GER surgery in the neonatal population. GER in newborns and young children is treated in various ways at different institutions and by different pediatric surgeons. The paucity of controlled studies of these diagnostic and treatment algorithms continues to be a source of controversy. There is general agreement that fundoplication is the preferred option in cases of severe refractory GER with comorbidities, especially when gastrostomy for feedings is indicated. Neurologically impaired children with GER benefit from antireflux surgery to prevent the complications of GERD. Risks and benefits of each treatment modality must be clearly explained to parents and caregivers early in the surgical decision-making process to ensure improved outcomes for these patients. Additional controlled studies are needed to further assess which practice patterns better serve this patient population.

Laparoscopic and thoracoscopic surgery have gradually become accepted diagnostic and therapeutic modalities in the management of neonatal surgical conditions. In the hands of experienced surgeons, minimally invasive surgery (MIS) has reduced the need for open procedures. In children younger than 1 year, the advantages of MIS are evident in avoiding the sequelae of open surgery. MIS has shown outcomes comparable to those with open surgery. The recent literature in the PubMed database was reviewed, using the keywords “minimally invasive surgery,” “neonatology,” “pediatric surgery,” “laparoscopy,” and “thoracoscopy.” The review included retrospective and institutional reports of MIS published since January 2000.The results were used to develop a review of the current state of MIS in the neonatal population. The use of minimally invasive techniques in neonatal surgical conditions was successful in the hands of experienced surgeons. Some procedures currently performed include gastrostomy, pyloromyotomy for hypertrophic pyloric stenosis, gastroesophageal reflux surgery, the Ladd procedure for intestinal malrotation, colonic pull-through procedures for Hirschsprung disease and other anorectal malformations, repair of diaphragmatic eventration and congenital diaphragmatic hernia, duodenal atresia, esophageal atresia/tracheoesophageal fistula, pulmonary lobectomy, surgery for necrotizing enterocolitis, and ligation of patent ductus arteriosus. Further formal training of surgeons in these techniques and the development of new and improved instrumentation can reduce the rates of open surgery and its sequelae in the neonatal population.

Background Relatively few reports have been published investigating the operative management of pediatric zygomaticomaxillary complex fractures. The purpose of this study was to assess pediatric zygomaticomaxillary complex fracture management and associated complications, and potentially describe a standard treatment paradigm for these cases. Methods A retrospective cohort review was performed of all patients younger than 15 years presenting to a single institution with zygomaticomaxillary complex fractures from 1990 to 2010. Patient demographics, concomitant injuries, management details, and complications were recorded. Complications were compared among patients by dentition stage, number of fixation points, and identity of fixation sites. Results A total of 36 patients with 44 unique zygomaticomaxillary complex fractures met the authors' inclusion criteria. Thirty-two fractures exhibited at least 2.0 mm of diastasis along at least one buttress (73 percent), and all but one of these were managed operatively. Among operatively managed patients with deciduous dentition, two-point fixation was associated with a lower overall complication rate compared with one- and three-point fixation (0 percent versus 75 percent and 75 percent; p = 0.01). Furthermore, rigid plate-and-screw fixation at the zygomaticomaxillary buttress was not associated with an increased complication rate in operatively managed patients with deciduous dentition (40 percent versus 50 percent; p = 0.76). Conclusions The authors' results suggest that two-point fixation is an effective management strategy for repair of displaced zygomaticomaxillary complex fractures in children. In addition, rigid plate-and-screw fixation at the zygomaticomaxillary buttress in children with deciduous dentition appears to be safe and effective when performed. Clinical question/level of evidence Therapeutic, III.

Post-traumatic arthritis is common in long-term follow-up of patients undergoing hemi-hamate arthroplasty (HHA). We hypothesize that anatomic mismatch could play a role in the development of arthritis. The purpose of this study is to establish a novel, computed tomography (CT)-based imaging technique for pre-operative assessment in HHA. With this technique, our group aims to identify digits with a high likelihood for anatomical mismatch between the donor graft and recipient interphalangeal joint. Using this technique to eliminate cases with high-likelihood of incongruent anatomy, we hypothesize the rates of arthritis could be reduced. We conducted a retrospective review of upper extremity CT scans from 2007 to 2014 at our institution. Those studies meeting our inclusion criteria were exported to a clinical radiology software suite. Subsequently, angular and linear measurements of the hamate and potential recipient proximal interphalangeal joints were collected. Angular and linear comparisons were then made between the donor hamate graft and the individual recipient sites. Using pre-established cutoff values, matches were deemed to be inconsistent or consistent. The study included 31 CT scans. The rate of anatomical consistency was low; the small finger was most often consistent (38.7 %) and the index finger was least often consistent (12.9 %). Linear inconsistency was common in all joints besides the small finger; angular inconsistency was most prevalent in the index and long fingers. This novel use of CT scans as a tool for pre-operative HHA planning is a crucial first step in trying to reduce the observed rates of arthritis after HHA.

Purpose Le Fort–type fractures are very rare in children, and there is a paucity of literature presenting their frequency and characteristics. The purpose of this study was to determine the etiology, frequency, and fracture patterns of children with severe facial trauma associated with pterygoid plate fractures in a pediatric cohort. Patients and Methods We performed a retrospective cohort study of all children aged younger than 16 years with pterygoid plate and facial fractures who presented to our institute between 1990 and 2010. Patient charts and radiologic records were reviewed for demographic and fracture characteristics. Patients were categorized into 2 groups as per facial fracture pattern: non–Le Fort–type fractures (group A) and Le Fort–type fractures (group B). Other variables including dentition age, frontal sinus development, mechanism of injury, injury severity, and concomitant injuries were recorded. Univariate methods were used to compare groups. Results We identified 24 children; 25% were girls, and 20.8% were of nonwhite race. Most presented with Le Fort–type fracture patterns (group B, 66.7%). Age was significantly different between group A and group B (mean, 5.9 years and 9.9 years, respectively; P = .009). No significant differences in Injury Severity Score, rate of operative repair, and length of stay were found between groups. Conclusions Most children with severe facial fractures and pterygoid plate fractures presented with Le Fort–type fracture patterns in our cohort. The mean age of children with Le Fort–type fractures was greater than in those with non–Le Fort–type patterns. However, Le Fort–type fractures did occur in younger children with deciduous and mixed dentition.

Facial skeletal reconstruction of patients with severe Treacher Collins syndrome (TCS) requires correction of both midface and mandibular deficiencies. Implementing virtual surgical planning can provide an accurate three-dimensional analysis of craniofacial abnormalities, creating calvarial donors that match the anatomy of the desired malar augmentation and facilitating bimaxillary movements, positioning, and fixation in orthognathic surgery. We present a case of an 18-year-old patient with TCS, who underwent staged zygomaticomaxillary reconstruction and double-jaw osteotomy with sliding genioplasty, using computer-assisted surgical planning. Following these operations, the patient achieved not only improved facial harmony but also class I occlusion.

While open carpal tunnel release provides excellent relief of median nerve compression, many patients complain of tenderness at the proximal palm incision for months after surgery. For over 25 years, endoscopic techniques have been available that move the incision off of the proximal palm to avoid or decrease this pillar pain. Proximal, distal, and two-portal techniques are reported, with varying learning curves associated with them. Multicenter trials have demonstrated safety of the procedure and improved patient experience with decreased postoperative pain and more rapid return to work. Endoscopic carpal tunnel release may be particularly appropriate for surgeons with a high volume of carpal tunnel syndrome in their practice and patients seeking to minimize their downtime after surgery.

Background Although conflicts of interest in biomedical research have received significant attention, the impact of conflicts of interest on surgical outcomes has not been fully explored. Methods A systematic electronic search of the literature was performed for studies that evaluated surgical outcomes in acellular dermal matrix and non-acellular dermal matrix implant-based breast reconstruction. Surgical complications, including infection, seroma, hematoma, necrosis, and explantation, were used as outcome metrics and extracted from studies. Surgical outcomes were then pooled and compared between studies that disclosed conflicts of interest and those that did not disclose conflicts of interest. Results A total of 776 abstracts were identified, of which only 35 fulfilled the authors' inclusion criteria. Conflicts of interest were reported in 14 of these abstracts (40 percent). The pooled data from studies that reported no conflicts of interest and studies that reported conflicts of interest included a total of 8241 and 5384 breasts and 2852 and 1864 patients, respectively. Considered collectively, surgical complications were less common in studies that reported a conflict of interest than in studies that reported no conflicts of interest. When surgical outcome data were further stratified by acellular dermal matrix use, surgical complications were less common in studies with conflicts of interest when acellular dermal matrix was used. However, when acellular dermal matrix was not used, surgical complications were similar between authors that reported a conflict of interest and those that did not report a conflict of interest. Conclusions Self-reported conflicts of interest are common in implant-based breast reconstruction research. Studies authored by groups with conflicts of interest are significantly associated with reporting lower surgical complications and therefore describing positive research findings, especially when industry-marketed products are being used in the study. Clinical question/level of evidence Therapeutic, III.

Vascularized composite allotransplantation may now be considered a viable treatment option in patients with complex craniofacial and limb defects. However, the field is still in its infancy, and challenges continue to exist. These challenges, most notably the adverse effects of lifelong immunosuppression, must be weighed against the benefits of the procedure. Improvements in this risk-benefit ratio can be achieved by achieving tolerance and preventing rejection. Five decades after Dr. Joseph E. Murray introduced the field of transplantation to the world, we now have a better understanding of the immunologic factors that may contribute to rejection and inhibit tolerance. In this article, we review emerging evidence that suggests that "danger signals" associated with ischemia-reperfusion injury contribute to innate immune activation, promoting rejection, and inhibiting tolerance. Based on this understanding, we also describe several strategies that may ameliorate the damaging effects of ischemia-reperfusion and the clinical implications of ischemia-reperfusion on the vascularized composite tissue allotransplantation outcome.

OBJECTIVE Due to the changing properties of the infant skull, there is still no clear consensus on the ideal time to surgically intervene in cases of nonsyndromic craniosynostosis (NSC). This study aims to shed light on how patient age at the time of surgery may affect surgical outcomes and the subsequent need for reoperation. METHODS A retrospective cohort review was conducted for patients with NSC who underwent primary cranial vault remodeling between 1990 and 2013. Patients' demographic and clinical characteristics and surgical interventions were recorded. Postoperative outcomes were assessed by assigning each procedure to a Whitaker category. Multivariate logistic regression analysis was performed to determine the relationship between age at surgery and need for minor (Whitaker I or II) versus major (Whitaker III or IV) reoperation. Odds ratios (ORs) for Whitaker category by age at surgery were assigned. RESULTS A total of 413 unique patients underwent cranial vault remodeling procedures for NSC during the study period. Multivariate logistic regression demonstrated increased odds of requiring major surgical revisions (Whitaker III or IV) in patients younger than 6 months of age (OR 2.49, 95% CI 1.05–5.93), and increased odds of requiring minimal surgical revisions (Whitaker I or II) in patients older than 6 months of age (OR 2.72, 95% CI 1.16–6.41). CONCLUSIONS Timing, as a proxy for the changing properties of the infant skull, is an important factor to consider when planning vault reconstruction in NSC. The data presented in this study demonstrate that patients operated on before 6 months of age had increased odds of requiring major surgical revisions.