Lorelei Grunwaldt

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.

Nonfatal sport-related craniofacial fractures: characteristics, mechanisms, and demographic data in the pediatric population

Background: Few reports exist on sport-related craniofacial fracture injuries in the pediatric population. Most patients with craniofacial injuries are adults, and most studies on pediatric sport injuries do not focus specifically on craniofacial fractures. The authors’ goal was to provide a retrospective, descriptive review of the common mechanisms of sport-related craniofacial injuries in the pediatric population, identifying the characteristics of these injuries and providing a description of the demographics of this population. Methods: The study population included children between the ages of 0 and 18 years who were seen in the emergency department at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center between 2000 and 2005. Of the 1508 patients identified, 167 had injuries caused by sport-related trauma (10.6 percent). Results: After evaluation in the emergency department, 45.5 percent were hospitalized, and 15.0 percent of these were admitted to the intensive care unit. The peak incidence of sport-related injuries occurred between the ages of 13 and 15 years (40.7 percent). Nasal (35.9 percent), orbital (33.5 percent), and skull fractures (30.5 percent) were most common, whereas fractures of the maxilla (12.6 percent), mandible (7.2 percent), zygomaticomaxillary complex (4.2 percent), and naso-orbitoethmoid complex (1.2 percent) were observed less frequently. Baseball and softball were most frequently associated with the craniofacial injuries (44.3 percent), whereas basketball (7.2 percent) and football (3.0 percent) were associated with fewer injuries. The most common mechanisms of injury were throwing, catching, or hitting a ball (34.1 percent) and collision with other players (24.5 percent). Conclusion: These data may allow targeted or sport-specific craniofacial fracture injury prevention strategies.

Safety of preoperative erythropoietin in surgical calvarial remodeling: an 8-year retrospective review and analysis.

Background: Calvarial remodeling is typically associated with significant blood loss. Although preoperative erythropoiesis-stimulating agents have proven to significantly decrease the need for blood transfusions, recent data in adults have raised concerns that elevating hemoglobin levels greater than 12.5 g/dl may increase the risk of thrombotic events. This study was designed to assess the risks of erythropoietin in the pediatric population. Methods: Records were retrospectively reviewed from 2000 to 2008 at three major metropolitan childrens hospitals of all children undergoing calvarial remodeling after receiving preoperative erythropoietin. Demographic and perioperative outcome data were reviewed, including transfusion reactions, pressure ulcer secondary to prolonged positioning, pneumonia, infection, deep vein thrombosis, cerebrovascular accident, pulmonary embolism, sagittal sinus thrombosis, pure red cell aplasia, and myocardial infarction. Results: A total of 369 patients met the inclusion criteria (mean age, 0.86 ± 1.1 years). On average, three preoperative doses of erythropoietin were administered (600 U/kg). Iron was also supplemented. No complications associated with dosing were noted, there were no thrombotic events identified, and no other major complications were seen (i.e., death or blindness). Thirty-one patients (8.40 percent) experienced one or more postoperative complications. There was no significant correlation between hemoglobin levels greater than 12.5 g/dl and the occurrence of any noted complication. Conclusions: With zero thrombotic postoperative complications, the authors estimate the risk of a thrombotic event in the pediatric population to be less than 0.81 percent (95 percent confidence). These data suggest that preoperative administration of erythropoietin in children undergoing calvarial remodeling does not appear to increase the incidence of thrombotic events or other significant complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Pediatric craniofacial fractures due to violence: Comparing violent and nonviolent mechanisms of injury

Background:This study examines the epidemiologic data of pediatric craniofacial fractures secondary to violence, comparing these data to craniofacial fractures sustained from all other causes. Methods:A retrospective review was completed on all patients who presented to the emergency department of a major urban childrens hospital from 2000 to 2005 with a craniofacial fracture. Data were compared between patients with fractures due to violent and nonviolent mechanisms. Socioeconomic analysis was performed using Geographic Information System mapping and 2000 US Census data by postal code. Results:One thousand five hundred twenty-eight patients were diagnosed with skull and/or facial fractures. Isolated skull fractures were excluded, leaving 793 patients in the study. Ninety-eight children were injured due to violence, and 695 were injured from a nonviolent cause. Patients with violence-related fractures were more likely to be older, male, and nonwhite and live in a socioeconomically depressed area. A greater number of patients with violence-related injuries sustained nasal and mandible angle fractures, whereas more patients with non-violence-related injuries sustained skull and orbital fractures. Those with violence-related craniofacial fractures had a lower percentage of associated multiorgan system injuries and a lower rate of hospital admissions and intensive care unit admissions. The rate of open reduction and internal fixation for craniofacial fractures was similar in both groups. Conclusions:Patients with violence-related fractures had fewer associated serious injuries and lower morbidity and lived in a more socioeconomically depressed area. The information gained from this descriptive study improves our ability to characterize this population of pediatric patients and to identify the associated constellation of injuries in such fractures.

Pediatric facial fractures: occurrence of concussion and relation to fracture patterns.

Background Children and adolescents with injuries resulting in facial fractures are a population that is potentially at risk for suffering concomitant concussion. Concussion results in a variety of physical symptoms and often affects cognition, emotion, and sleep. These effects can have a significant impact on academics and social functioning. Early recognition of concussion and active management have been shown to improve outcomes. The goal of this study was to describe the occurrence of concussion in patients sustaining facial fractures and to determine whether certain fracture types are associated with concussion. Methods We performed a retrospective review of patients aged 0 to 18 years who were evaluated in the emergency department of the Children’s Hospital of Pittsburgh from 2000 to 2005 with an International Classification of Diseases, Ninth Revision code indicative of facial fractures. Data included demographics, documentation of concussion, and facial fracture type. Patients with intracranial injury were excluded from the study. Univariate &khgr;2 analysis and logistic regression were performed to determine characteristics associated with concussion. Results Facial fracture was diagnosed in 782 patients. Ninety-one patients had an intracranial injury and were excluded, leaving 691 patients for evaluation. The mean age was 11.1 (SD, 4.6) years. Males made up 69.6% of patients, and 80.6% of patients were white. Concussion was diagnosed in 31.7% of patients. Age, sex, and race were not associated with concussion. Univariate analysis demonstrated that skull and orbital fractures were associated with higher rates of concussion, whereas maxillary fractures showed a trend toward higher rates of concussion, and nasal and mandible fractures showed a trend toward lower rates of concussion. Logistic regression analysis demonstrated the odds of having a concussion were higher in those with skull fractures (odds ratio, 2.3; confidence interval, 1.5–3.7). Conclusions Nearly one third of pediatric patients with facial fractures in this retrospective series were diagnosed with a concomitant concussion. Our data suggest that a higher index of suspicion for concussion should be maintained for patients with concomitant skull fractures and potentially orbital and maxillary fractures. Given the possibility of a worse outcome with delayed concussion diagnosis, patients with facial fractures may benefit from more active early concussion screening.

Complete Penile Amputation During Ritual Neonatal Circumcision and Successful Replantation Using Postoperative Leech Therapy

Circumcision is the most common surgical procedure in males in the United States, and minor complications are not uncommon. Major complications like partial penile amputations have been reported with successful replantation. Complete penile amputations in adult males have been described, and successful replantation has been reported with increasing success. We report a case of complete penile amputation at the penopubic junction using a Mogen clamp in a 7-day-old neonate with replantation using postoperative leech therapy. To our knowledge this is the first time leech therapy has been used postoperatively for neonatal penile amputation.

Acellular dermal matrix in the treatment and prevention of exposed vertical expandable prosthetic titanium ribs.

Study Design. Case series. Objective. To illustrate the use of acellular dermal matrix (ADM) in treatment and prevention of exposed vertical expandable prosthetic titanium rib (VEPTR) implants. Summary of Background Data. In the pediatric population with severe kyphoscoliosis, VEPTR is an effective tool during growth for the correction of ribcage deformity. Prolonged VEPTR therapy can result in wound breakdown, implant exposure, and infection. Treatment includes the use of prolonged antibiotics, muscle flaps, and, when salvage fails, removal of the VEPTR. The use of ADM in the treatment and prevention of VEPTR exposure has not been previously described. Methods. Between January 2002 and January 2010, eight patients who underwent placement of ADM for the treatment and prevention of exposed VEPTR devices were identified. Their records were reviewed for diagnosis, sex, age of patient at initial VEPTR placement, position of VEPTR placement, number of VEPTR expansions, wound complications, ADM use, adjunct procedures, and length of wound follow-up. Results. ADM was used in eight patients. In five patients ADM was used for compromised soft tissue overlying the VEPTR and threatened exposure of the hardware. In these cases, subsequent expansions occurred without incident and the wound remained stable with an average follow-up of 7.6 months. In three patients, ADM was used for exposed VEPTR hardware secondary to wound breakdown. Average follow-up was 3.3 months. In two of the three cases of exposed and contaminated hardware, stable soft tissue coverage was achieved and continued VEPTR therapy was achieved. One of the three cases of exposure involved infected and prominent hardware with purulence. This patient failed to clear the infection and required complete device removal. Conclusion. ADM can treat and prevent exposed VEPTR, allowing subsequent VEPTR expansions and minimizing the need for muscle flap coverage and/or implant removal and replacement.

Treatment for Infantile Hemangiomas: Selection Criteria, Safety, and Outcomes Using Oral Propranolol During the Early Phase of Propranolol Use for Hemangiomas.

Objective:Despite the increasing popularity of propranolol for treatment of infantile hemangioma (IH), there is need for further evidence of efficacy and safety. This study is a retrospective review of one institutions experience treating IH with propranolol using a standard protocol. Methods:Between 2009 and 2014, patients with IH were evaluated for treatment with propranolol. Exclusion criteria included a history of hypoglycemia, respiratory disorders, and cardiovascular disorders. Propranolol, 2 mg/kg/d, was initiated during 48-hour inpatient stay. Weight and complications were monitored. Appearance was assessed by Visual Analog Cosmetic Scale (VACS) via serial photography. Results:Twenty-three patients were treated with propranolol. Average age at initiation of therapy was 14.9 weeks. Twenty-two lesions were on the head and neck, and 1 was on the trunk. Average treatment duration was 54.3 weeks (range 24–148 wk). Treatment was confirmed to be complete in 23 patients at the time of review (91.3%). Two patients were lost to follow-up. Posttreatment color, size, and VACS improved significantly (P < 0.05). There was no significant difference between first and most recent weight. Two patients experienced hypoglycemia, 1 during a diarrheal illness and 1 during inpatient treatment initiation. Conclusion:The authors present a series of patients with IH safely treated with 2 mg/kg/d of propranolol. Using a strict protocol, few complications were observed. Patients achieved significant reduction in size and improvement of the overall appearance of IH.

Magnetic resonance imaging as a predictor of submucous cleft palate severity and guide for surgical intervention.

BackgroundDiagnosis of submucous cleft palate (SMCP) is frequently delayed, adversely affecting speech outcomes. Previous studies show that MRI reliably identifies structural abnormalities in velopharyngeal musculature. This information has potential to assist with diagnosis and treatment decisions. AimsThe objectives of this study were to (1) develop a clinician-friendly MRI grading scale of SMCP anatomy, (2) identify correlations between radiographic cleft severity and clinical severity using Pittsburgh Weighted Speech Scores (PWSS), and (3) determine if MRI is a predictor of surgical efficacy in improving PWSS. DesignThirty patients presenting to our Cleft Palate-Craniofacial Clinic for evaluation of velopharyngeal insufficiency (VPI) and suspected SMCP were reviewed. VPI severity was clinically graded using PWSS. All patients underwent MRI to grade palatal abnormalities, using a novel MRI grading scale. PWSS and cleft severity on MRI were compared. A subgroup of patients (n = 19) underwent palatoplasty. Preoperative and postoperative PWSS were compared. Degree of PWSS improvement was then correlated with the preoperative MRI grade. ResultsTwenty-nine out of 30 MRIs demonstrated abnormal palate anatomy. Of the 30 patients evaluated, 5 clinically improved with speech therapy alone. In this subgroup, MRI severity did not correlate with PWSS (P = 0.06–0.6). Nineteen patients underwent palatoplasty. Of these, 14 demonstrated improved postoperative PWSS. There were no significant correlations between severity of cleft on imaging and preoperative PWSS or score improvement (P = 0.056–0.65). ConclusionWhile MRI accurately identifies structural abnormalities of the soft palate, these abnormalities do not reliably correspond to clinical severity. Clinical examination including speech scores and dynamic speech testing, rather than static MRI, should guide treatment decisions and surgical indications.

Divided Parietal Bone in Plagiocephaly

Supernumerary cranial sutures represent a rare cause of plagiocephaly. In the case of an extra suture dividing the parietal bone, the presenting features are often inconsistent with the typical presentation of deformational or synostotic plagiocephaly. Disagreement exists as to how the presence of this suture affects the shape of the skull. We present a case of a supernumerary suture in the parietal bone leading to plagiocephaly and discuss the role this suture plays in cranial growth.