Christopher R. Kinsella

Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients.

Background: Pediatric craniofacial fractures are anatomically distinct from their adult counterparts and must be managed with respect for future growth and development. These injuries must be approached as entities fundamentally different from adult craniofacial fractures. Here, the authors aim to provide context for practitioners managing pediatric facial fractures by augmenting presently available demographic, diagnostic, and treatment data. Methods: This is a retrospective review of demographics, diagnosis, and treatment of patients under 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with facial fractures. Patients were included regardless of treating specialty, treatment modality, or inpatient status. Results: A total of 772 consecutive patients met inclusion criteria. A significant majority (p < 0.001) of patients (68.9 percent) were male; older children were significantly more likely to sustain a facial fracture (p < 0.001). Fracture pattern, level of care, and cause of injury varied by age; 55.6 percent of patients had severe associated injuries. Male subjects, older patients, and patients of lower socioeconomic status were significantly more likely to sustain facial fractures secondary to violence (p ⩽ 0.001). Conclusions: Pediatric facial fractures may be associated with severe concomitant injuries. Injury patterns are significantly correlated with socioeconomic metrics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Custom porous polyethylene implants for large-scale pediatric skull reconstruction: early outcomes.

Background and Purpose Some of the most problematic craniofacial injuries in pediatric plastic surgery are large calvarial defects in children who have passed the age of maximal dural osteogenic potential and yet are too young to yield split calvarial grafts. Porous polyethylene (Medpor; Porex) is an alloplastic material that can be customized to precisely match a cranial defect. We present a clinical series that demonstrates successful use of porous polyethylene cranioplasties in large pediatric cranial defects. Methods From 2007 to 2009, 9 pediatric patients underwent custom-made porous polyethylene cranioplasties for large calvarial defects. Descriptive statistical analyses were performed on the cause of the defects, time to cranioplasty, size of defect, reconstruction technique, and postoperative healing. Results A total of 5 boys and 4 girls, with a mean age of 6.8 years, underwent 9 cranioplasties incorporating custom porous polyethylene implants. Initial pathologic findings included 7 patients with traumatic brain injuries, 1 patient with intractable seizures, and 1 patient with brain cancer. Initially, each patient had a craniectomy followed by replacement of the frozen bone “flap.” All patients experienced either infection or resorption of the bone leading to a permanent defect. The mean defect size was 152 cm2. The mean delay between the removal of failed bone “flap” and the final implant cranioplasty was 6.8 months. At the last follow-up, which averaged 3.6 months, all patients had stable wounds with acceptable cranial contour. Conclusions For pediatric large-scale calvarial defects, custom-made porous polyethylene implants can be safely used for cranioplasty. Tissue expansion and acellular dermal matrix were useful tools to help augment the soft tissues of the scalp before cranioplasty to prevent complications of implant extrusion and wound breakdown.

The psychological burden of idiopathic adolescent gynecomastia.

Background: For a population of adolescents, gynecomastia is a persistent problem. Occurring during a critical period in the formation of self-image and gender identity, this gender-incongruent process may disrupt normal psychological development. This study was designed to identify the prevalence of psychological disturbances in young male patients presenting with symptomatic gynecomastia to determine whether psychological examination should be included as a routine portion of this patient populations treatment. Methods: From 2002 to 2009, patients aged between 10 and 18 presenting to our institution for idiopathic adolescent gynecomastia were recruited to participate in a retrospective cohort study. All patients underwent psychological interviews conducted by the same clinical psychologist (C.W.) and were examined using the following metrics: the Childrens Depression Inventory, the Multidimensional Anxiety Scale for Children, and the Child Behavior Checklist. All patient scores were compared against population norms. Results: Twenty-four patients between the ages of 12 and 18 were observed. Compared with the general population, measures of anxiety, depression, and social phobia were significantly elevated in patients with gynecomastia; 100 percent of patients with gynecomastia received a Diagnostic and Statistical Manual of Mental Disorders–IV diagnosis. Conclusions: Idiopathic adolescent gynecomastia is a psychological threat to normal self-esteem and sexual identity. Patients presenting with this condition likely suffer an adjustment disorder subsequent to this anatomic stressor. Surgeons should strongly consider referring their patients with gynecomastia for psychological evaluation and treatment as an adjunct to successful surgical management of this condition. Future studies examining the postoperative effects on psychological health both with and without psychological treatment will be of great interest to treating physicians. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Scalp reconstruction: regeneration with acellular dermal matrix.

Background:Current methods of scalp reconstruction with complicating osteomyelitis of underlying bone require excision of deficient tissue and a staged reconstruction for ultimate coverage of the defect. Our group proposes a novel use of acellular dermal matrix (ADM) to preserve these deficient areas without the need for excision or staged management of osteomyelitic calvaria. Methods and Results:From 2003 to 2008, 3 patients underwent scalp reconstruction with ADM at our facility. Elevation of the scalp for secondary operations in each case showed full incorporation of the ADM. Follow-up ranging from 12 to 36 months showed a healed scalp with preserved hair-bearing skin in all cases. Conclusions:Scalp regeneration with ADM has specific advantages that include preservation of hair-bearing scalp, maintenance of distinct tissue planes for later reconstruction, absence of a donor site, and the alleviation of tissue expansion. This technology may represent an immediate solution for difficult scalp defects that would otherwise require staged complex reconstruction.

Recombinant human bone morphogenetic protein-2-induced craniosynostosis and growth restriction in the immature skeleton.

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered on an absorbable collagen sponge is a U.S. Food and Drug Administration–approved therapy effective at generating bone formation. In pediatric patients for whom other therapeutic options have been exhausted, rhBMP-2 is used off-label to address problematic bony defects. In the skeletally immature patient, the safety of rhBMP-2 therapy remains uncertain. Experiments are needed that investigate the effect of rhBMP-2 on growth and development in clinically relevant models. Methods: Ten juvenile rabbits underwent creation of a parietal skull defect that was treated with either 0.2 mg/cc rhBMP-2/absorbable collagen sponge or a neutral buffer solution/absorbable collagen sponge. Amalgam markers were placed at suture confluences to track suture separation and skull growth. Cranial growth was assessed radiographically at 10, 25, 42, and 84 days of age. Means and standard deviations for the various craniofacial growth variables were calculated and compared. Mean differences were considered significant for values of p < 0.05. At 84 days, sutures were analyzed by means of micro–computed tomographic scanning and histologic staining. Results: Treatment with rhBMP-2 resulted in fusion of the coronal sutures bilaterally, with variable fusion of the sagittal suture by cephalometric, radiographic, and histologic analysis. There were statistically significant changes to coronal suture growth, sagittal suture growth, skull height, craniofacial length, and intracranial volume (p < 0.05). Conclusions: The use of rhBMP-2 in this juvenile animal model resulted in skeletal changes that may be undesirable in a clinical setting. The appearance of these fused sutures suggested a direct effect of rhBMP-2. Further work is required to limit the effect of rhBMP-2 to the target defect when used in the immature skeleton.

Antibiotic duration and postoperative infection rates in mandibular fractures.

Background:Although the use of preoperative antibiotics has been proven effective, the value of postoperative antibiotics in the setting of mandibular fracture remains in question as does the appropriate duration of therapy. Methods:A retrospective study of all patients 18 years and older who presented with mandibular fractures to St Louis University Hospital between December 2001 and July 2006 was conducted. Collected variables included age, injury severity score, fracture type and location, preoperative antibiotic administration, antibiotic type, duration of antibiotic course, and postoperative infection. Infections were statistically compared with each. Results:Of 253 identified patients, 197 qualified for study inclusion. A total of 9 postoperative infections were documented. When comparing individuals with postoperative infection to those without, age was the only significant difference between infected and uninfected groups, with older patients more likely to acquire infection. Injury severity score, fracture type, duration of antibiotic course, and antibiotic type were not significantly different. Conclusions:Our findings suggest that patient factors make a greater contribution to postoperative infection when compared with iatrogenic factors in the treatment of mandibular fractures. We found no evidence to support prolonged postoperative antibiotic therapy. Our findings bring into question the need for postoperative antibiotics for the treatment of mandibular fractures.

Novel Animal Model of Calvarial Defect in an Infected Unfavorable Wound: Reconstruction with rhbmp-2

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered on an absorbable collagen sponge has been shown to induce the healing of acute, primary, large-scale calvarial defects in rabbits. However, clinical circumstances often require the reconstruction of a previously infected and chronically scarred wound. This study was designed to evaluate the efficacy of rhBMP-2/absorbable collagen sponge to improve healing in the previously infected, unfavorable calvarial defect model. Methods: Subtotal defects were made in the calvariae of 15 adult New Zealand White rabbits. The bone flap was inoculated with Staphylococcus aureus and replaced in situ. After a 2-week infection period, animals underwent bone flap removal and a 10-day course of antibiotic therapy. On postoperative day 42, the defect was exposed and treated with (1) no intervention/control (group 1; n = 5), or (2) absorbable collagen sponge with 0.43 mg/ml of rhBMP-2 (group 2; n = 10). Bone growth was analyzed with serial computed tomographic imaging and postmortem histology. Percentage bone healing was compared between groups using the t test. Results: The treatment group (group 2) demonstrated statistically more healing (55.6 percent) compared with the control group (group 1) (29 percent; p < 0.01). However, rhBMP-2–induced bone was not histologically or radiographically similar to native bone, lacking both continuity and a well-defined diploic space. Conclusions: These data suggest that rhBMP-2-treated collagen sponges may be useful for the repair of calvarial defects following infection. However, the osseous healing observed in this study was significantly less than previous reports in acute, noninfected models and was dissimilar to native bone. Further work is needed to optimize treatment of the previously infected calvarial wound with rhBMP-2.

An algorithm for application of furlow palatoplasty to the treatment of velocardiofacial syndrome-associated velopharyngeal insufficiency.

Treatment of velocardiofacial syndrome (VCFS)–associated velopharyngeal insufficiency is controversial. Palatoplasties have variable success, and pharyngeal flaps (PPF) increase the obstructive sleep apnea risk. Our center uses Furlow palatoplasties to treat overt clefts and kinetic submucous cleft palates. PPFs are employed to treat akinetic palates and recurrent/persistent velopharyngeal insufficiency after palatoplasty. A retrospective review was performed of patients with VCFS treated according to this algorithm. Twenty-seven patients with VCFS were included: 3.7% (n = 1) had overt clefts; 81.4% (n = 22) underwent Furlow palatoplasties for kinetic submucous cleft palates; 14.8% (n = 4) underwent primary PPFs for akinetic palates. The algorithm was successful in 21 patients (77.7%). Furlow palatoplasty achieved ultimate success in 45% of patients. Secondary PPF was successful in all 7 patients, as was primary PPF in all 4 patients. Furlow palatoplasty represents a first step in treating appropriate VCFS patients that avoids the risk of sleep apnea, but the potential for secondary pharyngoplasty must be considered.

Novel model of calvarial defect in an infected unfavorable wound: reconstruction with rhBMP-2. Part II.

BackgroundAnimal models of bone reconstruction have shown recombinant human bone morphogenetic protein 2 (rhBMP-2) to be an effective therapy in the acute calvarial defect wound. The purpose of this study was to compare the effectiveness of rhBMP-2 in a rabbit model of an unfavorable scarred calvarial wound with the criterion standard of autograft. MethodsNineteen adult New Zealand white rabbits underwent subtotal calvariectomy. After 6 weeks of healing and normal scar formation, these animals underwent reoperation for scar debridement and assignment to 1 of 4 therapeutic groups. Animals were assigned to an empty control group (no treatment, n = 3), vehicle control group (neutral buffered solution on an absorbable collagen sponge [ACS], n = 3), surgical control group (cryopreserved autograft, n = 3), or an experimental treatment group (rhBMP-2 on an ACS, n = 10). All animals underwent computed tomography imaging at 0, 2, 4, and 6 weeks after secondary reconstructive surgery. At 6 weeks, all animals were killed, and the defects were examined histologically. Percentage of healing of each defect was determined, and a 4 × 3 mixed-model analysis of variance was performed on healing as a function of time and therapy. ResultsBased on measures of defect radiopacity, the treatment group (rhBMP-2/ACS) and surgical control group (autograft) were statistically equivalent with 98% and 83% healing, respectively, at 6 weeks. The empty control and vehicle control groups were inferior to the treatment group (rhBMP-2/ACS) and surgical control (autograft) groups at each timepoint (P < 0.05). Histologically, bone in the surgical control (autograft) group was less trabecular and less cellular than the bone formed in the experimental treatment group (rhBMP-2/ACS). ConclusionsCompared with historical controls, rhBMP-2 therapy was as effective in reconstructing calvarial defects in the unfavorable scarred wound as in the acute favorable calvarial wound. When compared with cryopreserved autograft, rhBMP-2–regenerated bone showed equal defect coverage and similar bone thickness with varying bony architecture.

BMP-2-regenerated calvarial bone: a biomechanical appraisal in a large animal model.

AbstractRecombinant human bone morphogenetic protein-2 (rhBMP-2) is gaining popularity in craniofacial applications. Calvarial defects are, under normal circumstances, subjected to only minimal levels of the biomechanical stresses known to play an important role in osteogenesis, yet regenerated calvarial bone must be capable of withstanding traumatic forces such that the underlying neurocapsule is protected. The aim of this study is to, for the first time, assess the biomechanical properties of calvarial bone regenerated with derivations of a commercially available rhBMP-2–based system. Standardized calvarial defects were created in 23 adult male canines. These defects were treated with rhBMP-2 on one of several carriers. After 24 weeks, the biomechanical properties of the rhBMP-2–generated bone were compared to those of controls with a modified punch-out test (Bluehill 2; Instron, Norwood, Mass) and compared using a paired nonparametric analyses (SPSS, 17.0, Chicago, Ill). In a previously published report, defects across all the rhBMP-2 therapy groups were observed to have a mean rate of 99.5% radio-opacity at 24 weeks indicating nearly full bony coverage of the calvarial defect (compared to 32.7% in surgical controls). For ultimate load, ultimate energy, and first peak energy, there were significant differences (P < 0.05) with the control native bone having more robust biomechanical properties than the rhBMP-2–generated bone. We conclude from these findings that rhBMP-2–generated calvarial bone is significantly less protective against trauma than native bone at 6 months. Further investigation is required to assess the efficacy of rhBMP-2 in healing calvarial defects in the longer term.