S. Alex Rottgers

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.

215 mandible fractures in 120 children: Demographics, treatment, outcomes, and early growth data

Background: Optimal management of pediatric mandible fractures demands that the practitioner balance reduction and fixation with preservation of growth potential and function. The ideal synthesis of these goals has not yet been defined. The authors catalogue their experience with pediatric mandible fractures at a major pediatric teaching hospital with reference to demographics, injury type, treatment, and outcomes to inform future management of these injuries. Methods: Demographics, management, and outcomes of pediatric mandible fractures presenting over 10 years at a pediatric trauma center were assessed. Cephalometric analysis was conducted. Relationships among demographics, fracture type, management, outcomes, and growth were explored. Results: Two hundred fifteen mandible fractures in 120 patients younger than 18 years were analyzed (average follow-up, 19.5 months). The condylar head and neck were fractured most frequently. Operative management was significantly more likely for children older than 12 years (p < 0.05). Operative management and multiple fractures were significantly associated with a higher rate of adverse outcomes (p < 0.05), but no adverse outcomes were considered to significantly affect mandibular function by patient or surgeon. No significant growth differences existed on cephalometric analysis between our cohort and age- and sex-matched controls (p > 0.05). Conclusions: This study reports the demographics, treatment, and early follow-up of a sizable cohort of pediatric mandible fractures. Management principles for these injuries are outlined. Although definitive recommendations must be withheld until longer follow-up is available, the data presented here show that the treatment protocols used at the authors’ center have yielded largely uncompromised mandibular function and growth thus far.

Outcomes in pediatric facial fractures: early follow-up in 177 children and classification scheme.

A comprehensive study of adverse outcomes after pediatric facial fractures has not been published. This study aimed to determine the incidence and classify adverse outcomes after facial fractures in children while reporting our early results. A retrospective chart review was performed on facial fracture patients identified in the Craniofacial Trauma Database of the Childrens Hospital of Pittsburgh and seen in follow-up from 2003 to 2007. An Adverse Outcome Classification Scheme was developed: type 1, outcomes resulting from the fracture; type 2, outcomes resulting from fracture treatment; and type 3, outcomes resulting from the interaction between the fracture, its treatment, and subsequent growth and development. Fisher exact or &khgr;2 analyses were completed. A total of 177 pediatric facial fracture patients were identified with 13.3 months of average follow-up. Mean age was 9.8 years (range, 0.4-18.7 y). Of these patients, 41.8% underwent surgery and 57 patients (32.2%) had adverse outcomes (type 1, 14.1%; type 2, 11.3%; and type 3, 15.8%); 26.3% of these had multiple adverse outcomes. Isolated fractures resulted in fewer adverse outcomes and fewer multiple adverse outcomes compared with combined fractures (26.6% versus 45.3%, P = 0.015; 4% versus 18.9%, P = 0.002). Patients treated operatively exhibited more types 1, 2, and 3 and multiple adverse outcomes compared to those treated conservatively (P < 0.01). In our pediatric cohort, 32.2% of patients had an adverse outcome. With longer follow-up and growth and development studies, we will likely see an increase in the incidence of type 3 adverse outcomes. We recommend, whenever possible, conservative treatment of pediatric facial fractures.

Precise Control of Osteogenesis for Craniofacial Defect Repair The Role of Direct Osteoprogenitor Contact in BMP-2-Based Bioprinting

BackgroundSuccess with bone morphogenetic protein-2 (BMP-2) has been widely reported in the osseous reconstruction of large calvarial defects. These efforts have required enormous doses of BMP-2 and are not sufficiently refined to facilitate the detail-oriented repair required for intricate craniofacial structures. We have previously shown that inkjet-based bioprinting technologies allow for precisely customized low-dose protein patterns to induce spatially regulated osteogenesis. Here, we investigate the importance of direct contact between bioprinted BMP-2 and the dura mater (a source of osteoprogenitors) in mediating calvarial healing. MethodsFive-millimeter osseous defects were trephinated in mouse parietal bones (N = 8). Circular acellular dermal matrix (ADM) implants were prepared such that 1 semicircle of 1 face per implant was printed with BMP-2 bio-ink. These implants were then placed ink-toward (N = 3) or ink-away (N = 5) from the underlying dura mater. After 4 weeks, osteogenesis was assessed in each of the 4 possible positions (BMP-2-printed area toward dura, BMP-2-printed area away from dura, unprinted area toward dura, and unprinted area away from dura) by faxitron. ResultsThe BMP-2-printed portion of the ADM generated bone covering an average of 66.5% of its surface area when it was face-down (printed surface directly abutting dura mater). By comparison, the BMP-2-printed portion of the ADM generated bone covering an average of only 21.3% of its surface area when it was face-up (printed surface away from dura). Similarly, the unprinted portion of the ADM generated an average of only 18.6% osseous coverage when face-down and 18.4% when face-up. ConclusionsWe have previously shown that inkjet-based bioprinting has the potential to significantly enhance the role of regenerative therapies in craniofacial surgery. This technology affords the precise control of osteogenesis necessary to reconstruct this region’s intricate anatomical architecture. In the present study, we demonstrate that direct apposition of BMP-2-printed ADM to a source of osteoprogenitor cells (in this case dura mater) is necessary for bio-ink-directed osteogenesis to occur. These results have important implications for the design of more complex bioprinted osseous structures.

Cranial vault remodeling for sagittal craniosynostosis in older children

OBJECT Sagittal craniosynostosis is the most common form of craniosynostosis and is commonly treated within the first year of life. Optimal treatment of patients older than 1 year of age is not well characterized. The authors reviewed cases of sagittal craniosynostosis involving patients who were treated surgically at their institution when they were older than 1 year in order to determine the rate of intracranial hypertension (ICH), potential to develop nonhealing cranial defects, and the need for various surgical procedures to treat the more mature phenotype. METHODS A retrospective chart review was conducted of all cases in the Childrens Hospital of Pittsburgh Neurosurgery Database involving patients who underwent cranial vault remodeling for scaphocephaly after 1 year of age between October 2000 and December 2010. RESULTS Ten patients were identified who met the inclusion criteria. Five patients underwent anterior two-thirds cranial vault remodeling procedures, 3 patients underwent posterior vault remodeling, and 2 patients underwent 2-staged total vault remodeling. All patients had improved head shapes, and mean cephalic indices improved from 65.4 to 69.1 (p = 0.05). Six patients exhibited signs of ICH. No patients with more than 3 months of follow-up exhibited palpable calvarial defects. CONCLUSIONS Patients with sagittal synostosis treated after 1 year of age demonstrate increased rates of ICH, warranting diligent evaluations and surveillance to detect it; rarely develop clinically significant cranial defects if appropriate bone grafting is performed at the time of surgery; and achieve acceptable improvements in head shape.

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.

Management of failed alveolar bone grafts: improved outcomes and decreased morbidity with allograft alone.

Background: This study demonstrates the safety and efficacy of allograft alone in revision alveolar bone graft surgery. Methods: A retrospective review of the authors’ institution’s alveolar bone graft experience (from 2004 to 2012) with open iliac crest bone graft, minimal-access iliac crest bone graft plus supplemental allograft, and revision allograft alone was performed. All patients (n = 47) were treated with alveolar fistula repair with primary closure. Results: Group 1 patients (12 male, 10 female; average age, 10 years) received iliac crest bone graft alone; 17 had unilateral and five had bilateral clefts. Group 2 (eight male, six female; average age, 9 years) received an iliac crest bone graft plus allograft; six clefts were unilateral and eight were bilateral. Group 3 (six male, five female; average age, 13 years) received revision allograft alone; seven clefts were unilateral and four were bilateral. Average operative time/alveolus was shortest in group 3 compared with groups 1 and 2 (p < 0.0005). Average engraftment was better in group 3 than in group 1 (p < 0.001) and similar to that in group 2 (p < 0.079). Revision alveolar bone graft with allograft alone improved Enemark scores from 3.7 preoperatively to 1.0 postoperatively (p < 0.0001). Hospital stay was shortest in group 3 compared with groups 1 and 2 (p < 0.0001). Bone graft extrusion occurred in six patients (27.3 percent) in group 1, no complications occurred in group 2, and a single necrotic central incisor was lost at the time of revision bone grafting in group 3 (9.1 percent). Conclusion: Allograft alone is safe and effective and provides a reliable alternative when traditional alveolar bone graft with iliac crest bone graft has failed. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Therapeutic, III.

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.

Novel animal model of calvarial defect: part III. Reconstruction of an irradiated wound with rhBMP-2.

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been shown to be an effective therapy in the acute calvarial defect wound and in calvarial defects complicated by chronic scar. The authors compared the effectiveness of rhBMP-2 with the accepted standard of autologous graft for repair of irradiated calvarial defects. Methods: Nineteen adult New Zealand White rabbits underwent subtotal calvariectomy. Four days postoperatively, animals received 15 Gy to their wound. Six weeks postoperatively, scars were débrided and defects reconstructed in one of four groups: empty (n = 3), vehicle (buffer solution/absorbable collagen sponge; n = 3), cryopreserved autograft, (n = 3), or rhBMP-2 repair (rhBMP-2/absorbable collagen sponge, n = 10). Animals underwent computed tomography imaging at 0, 2, 4, and 6 weeks, followed by euthanization and histological analysis. Percent healing was determined and a 4 × 3 mixed model analysis of variance was performed on healing versus treatment group/postoperative time. Results: According to radiopacity, rhBMP-2/sponge and autografts were statistically equivalent, with 99 and 89 percent healing at 6 weeks. Empty and vehicle treatment groups, with 35 and 34 percent healing, were inferior to the rhBMP-2/sponge and autograft groups (p < 0.05). Histologically, bone in the surgical control (autograft) group was less cellular and trabecular than bone formed after rhBMP-2/sponge treatment. Conclusions: rhBMP-2 therapy was as effective in reconstructing calvarial defects in the unfavorable irradiated wound as in the acute, favorable calvarial wound. Compared with cryopreserved autologous graft, rhBMP-2–regenerated bone resulted in equal defect coverage, similar thickness, and greater cellularity. Further studies are necessary to demonstrate the long-term viability and remodeling rhBMP-2/sponge–generated bone.