Sameer Shakir

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.

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.

Speech Outcomes After Clinically Indicated Posterior Pharyngeal Flap Takedown.

BackgroundVelopharyngeal insufficiency affects as many as one in three patients after cleft palate repair. Correction using a posterior pharyngeal flap (PPF) has been shown to improve clinical speech symptomatology; however, PPFs can be complicated by hyponasality and obstructive sleep apnea. The goal of this study was to assess if speech outcomes revert after clinically indicated PPF takedown. MethodsThe cleft-craniofacial database of the Childrens Hospital of Pittsburgh at the University of Pittsburgh Medical Center was retrospectively queried to identify patients with a diagnosis of velopharyngeal insufficiency treated with PPF who ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS), preoperative scores were compared to those after PPF takedown. Outcomes after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown with conversion to Furlow palatoplasty) were stratified and cross-compared. ResultsA total of 64 patients underwent takedown of their PPF. Of these, 18 patients underwent PPF takedown alone, and 46 patients underwent PPF takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43 (range, 3.0–22.0)(SD: 3.93) years of age at the time of PPF takedown, and 58% were men. Demographics between groups were not statistically different. The mean duration of follow-up after surgery was 38.09 (range, 1–104) (SD, 27.81) months. For patients undergoing PPF takedown alone, the mean preoperative and postoperative PWSS was 3.83 (range, 0.0–23.0) (SD, 6.13) and 4.11 (range, 0.0–23.0) (SD, 5.31), respectively (P = 0.89). The mean change in PWSS was 0.28 (range, −9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF with conversion to Furlow palatoplasty, the mean preoperative and postoperative PWSS was 6.37 (range, 0–26) (SD, 6.70) and 3.11 (range, 0.0–27.0) (SD, 4.14), respectively (P < 0.01). The mean change in PWSS was −3.26 (range, −23.0 to 4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range, 0.0–26) (SD, 6.60) and 3.39 (range, 0.0–27) (SD, 4.48), respectively (P < 0.05). The mean change in PWSS was −2.26 (range, −23.0 to 7) (SD, 5.7). There was no statistically significant regression in PWSS for either surgical intervention. Two patients in the PPF takedown alone cohort demonstrated deterioration in PWSS that warranted delayed conversion to Furlow palatoplasty. Approximately 90% of patients, who undergo clinically indicated PPF takedown alone, without conversion to Furlow Palatoplasty, will show no clinically significant reduction in speech. ConclusionsAlthough there is concern that PPF takedown may degrade speech, this study finds that surgical takedown of PPF, when clinically indicated, does not result in a clinically significant regression of speech.

Nonsyndromic Craniosynostosis and Associated Abnormal Speech and Language Development

Background: Although many metrics for neurodevelopment in children with nonsyndromic craniosynostosis have been analyzed, few have directly examined early language acquisition and speech development. The authors characterized language acquisition and speech development in children with nonsyndromic craniosynostosis. Methods: The authors’ institutional database was queried for nonsyndromic craniosynostosis from 2000 to 2014. Patients with an identified syndrome were excluded. Specific data elements included age, gender, velopharyngeal adequacy by means of the Pittsburgh Weighted Speech Scale, evaluation for anatomical motor delay, language acquisition delay/disorder, articulation or speech sound production delays/disorders, and whether speech therapy was recommended. Diagnosis of a submucous cleft palate was noted. Results: One hundred one patients met inclusion criteria, of which 57.4 percent were male. Average age at the time of the most recent speech evaluation was 6.1 years (range, 2.31 to 17.95 years); 43.6 percent had normal speech/language metrics and 56.4 percent had one or more abnormalities, including anatomical motor delay/disorder (29.7 percent), language acquisition delay/disorder (21.8 percent), articulation or speech production delay/disorder (4.0 percent), hypernasality (15.8 percent), and velopharyngeal insufficiency or borderline competency (23.8 percent). Average Pittsburgh Weighted Speech Scale score was 1.3 (range, 0 to 5), and 29.7 percent (n = 30) of patients were recommended to have speech therapy. In addition, 25.8 percent of patients were diagnosed with a submucous cleft palate. Conclusions: One in four patients with nonsyndromic craniosynostosis carried a diagnosis of submucous cleft palate. The authors found that abnormal speech and language development occurs in one in 1.7 patients with nonsyndromic craniosynostosis, and that speech therapy for such abnormal development is warranted in one in 3.4 of them—a prevalence two to five times higher compared with the general pediatric population.

Biomechanical Integrity in Craniofacial Surgery: Calvarial Reconstruction in Favorable and Infected Defects with Bone Morphogenetic Protein 2

Background: The limitations of autologous and alloplastic reconstruction for craniofacial bone defects have created a clinical need for viable tissue-engineering strategies. Recombinant human bone morphogenetic protein-2 (rhBMP-2) has shown promise in this setting. The aim of this study was to determine the long-term biomechanical properties of rhBMP-2–mediated calvarial reconstruction. Methods: Twelve-week-old New Zealand White rabbits underwent subtotal calvarectomy. Defects were repaired in one of several groups: immediate reconstruction with autologous graft, immediate reconstruction with cryopreserved bone graft, immediate reconstruction with rhBMP-2 (favorable), and delayed reconstruction with rhBMP-2 following infection and subsequent débridement (unfavorable). Cryopreserved reconstructions were measured at 6 weeks; autologous reconstructions were measured at 6 weeks and 6 months; and both favorable and unfavorable rhBMP-2 reconstructions were assessed at 6 weeks, 6 months, and 1 year after reconstruction. Healing was assessed with computed tomography. An unconfined compression test was performed for biomechanical analysis. Stress at 20 percent strain, percentage relaxation, tangent modulus, and final strain at 1800 N were compared between groups. Results: Nearly complete radiographic coverage was achieved by 6 months for autologous reconstruction and by 6 weeks for rhBMP-2 reconstruction. Favorable rhBMP-2 reconstruction demonstrated a larger final strain at 1800 N through 1 year compared with native bone. Bone in unfavorable rhBMP-2 reconstruction was more compressible than native bone, with a larger final strain at 1800 N at 1 year. There were no significant differences between favorable and unfavorable groups. Conclusions: Despite providing radiographic coverage, the biomechanical properties of rhBMP-2 bone differ from those of native bone. Further studies are warranted to determine how these properties affect overall strength and structural integrity.

Midcarpal and Scaphotrapeziotrapezoid Arthritis in Patients with Carpometacarpal Arthritis

Background: Carpometacarpal arthroplasty provides well-documented pain relief with preservation of thenar function in basal joint arthritis treatment. Nevertheless, some patients continue to have pain following surgery. The authors hypothesize that unrecognized midcarpal (capitolunate) arthritis is a contributor to persistent pain after carpometacarpal arthroplasty. The prevalence of midcarpal arthritis in patients with basal joint arthritis is unknown. This article establishes the radiographic prevalence of midcarpal arthritis in patients with carpometacarpal arthritis. Methods: Patients with basal joint arthritis were identified from a search using International Classification of Diseases, Ninth Revision code 716.94. Hand radiographs were reviewed and graded using the Eaton classification and Sodha classification for carpometacarpal arthritis. Scaphotrapeziotrapezoid arthritis and midcarpal arthritis were graded using the Sodha classification for arthritis as follows: grade 1, no or nearly no arthrosis; grade 2, definite arthrosis but not severe; and grade 3, severe arthrosis. Results: Eight hundred ninety-six radiographs were reviewed. The prevalence of scaphotrapeziotrapezoid arthritis in this population was 64 percent. The prevalence of midcarpal arthritis in this population was 23.5 percent. The prevalence of midcarpal arthritis in patients with radiologic evidence of carpometacarpal arthritis was 25.4 percent. The prevalence of severe midcarpal arthritis was 7 percent. Conclusions: The prevalence of midcarpal arthritis in patients with basal joint arthritis is 24 percent. The presence of two locations of arthritis may explain persistent hand and wrist pain in this population despite carpometacarpal arthroplasty. Clinically, these data will allow hand surgeons to better educate patients with basal joint arthritis regarding the possibility of incomplete pain relief following carpometacarpal arthroplasty.

Pediatric craniofacial fractures: trajectories and ramifications

Background:The pediatric craniofacial skeleton fractures in patterns distinct from those typical in adults; this has implications pertinent to management that may go unrecognized. The authors reviewed multilevel pediatric craniofacial fractures presenting to their institution, surmising that they would display an oblique trajectory of fracture patterns, and would be at increased risk of growing skull fractures (GSFs), compared with adults. Methods:A retrospective review was performed of pediatric patients presenting with multilevel craniofacial fractures between 2004 and 2010. Demographics, cause of injury, fracture patterns, associated injuries, management, and follow-up information were gathered. Computed tomography scans were reviewed to characterize fracture length, displacement, and trajectory. Adverse outcomes were documented, with particular attention to GSFs. Results:One hundred fifty-one patients met our inclusion criteria, which included a follow-up of >3 years. Average age at injury was 9.5 ± 4.7 years. Patterns of fracture displayed near consistent obliquity, with only 4 patients (2.6%) displaying a LeFort-type facial fracture. LeFort patterns were associated with older patients over the age of 12, but without statistical significance (P = 0.07). Five patients (3.3%) died as a result of their injuries. 3.3% of patients developed a GSF. All craniofacial fracture patients demonstrated radiographic and/or clinical evidence of healed fractures at their last follow-up. Conclusions:This series of pediatric craniofacial fractures near consistently demonstrated oblique fracture patterns, in contrast to the typical adult fracture patterns described by LeFort. Pediatric craniofacial fractures are also at increased risk of GSFs. Understanding of these principles is fundamental to successful therapy in this population.

Repair of a Complicated Calvarial Defect: Reconstruction of an Infected Wound With rhBMP-2.

BackgroundManagement of the previously infected craniofacial defect remains a significant clinical challenge, posing obstacles such as wound healing complications, lack of donor site availability, and predisposition to failure of the repair. Optimal therapy would reconstruct like with like, without donor site morbidity. The purpose of this study was to compare the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2)–mediated bone regeneration with the current standard of autologous bone graft for repair of previously infected calvarial defects. MethodsNineteen adult New Zealand white rabbits underwent subtotal calvariectomy. Bone flaps were inoculated with Staphylococcus aureus and replanted. After 1 week of infection, bone flaps were removed, and wounds were debrided, followed by 10 days of antibiotic treatment. After 6 weeks, animals underwent scar debridement followed by definitive reconstruction in 1 of 4 groups: empty control (n = 3), vehicle control (buffer solution on absorbable collagen sponge [ACS], n = 3), autologous bone graft (n = 3), or rhBMP-2 repair (rhBMP-2/ACS, n = 10). Animals underwent computed tomography imaging at 0, 2, 4, and 6 weeks postoperatively, followed by euthanization and histological analysis. Percent healing was determined by 3-dimensional analysis. A (time × group) 2-way analysis of variance was performed on healing versus treatment group and postoperative time. ResultsAt 6 weeks postoperatively, rhBMP-2/ACS and autologous bone graft resulted in 93% and 68% healing, respectively, whereas the empty and vehicle control treatment resulted in 27% and 26% healing (P < 0.001). Histologically, compared to autologous bone graft, bone in the rhBMP-2/ACS group was more cellular and more consistently continuous with wound margins. ConclusionsThe rhBMP-2 therapy is effective in achieving radiographic coverage of previously infected calvarial defects.

Wrong Turn From Right Quadrant

34 Question: A 35-yearold woman presented to the emergency department with a 1-day history of right lower quadrant pain. Her past medical historywasnotable foran omphalocele (requiring multiple abdominal surgeries as an infant) and antiphospholipid syndrome with multiple deep vein thromboses and pulmonary emboli. The patient described the abdominal pain as constant without radiation and unrelated to food intake. She denied any nausea, vomiting, fevers, chills, change in bowels, bleeding, or urinary symptoms. Laboratory data were unremarkable. Coronal and cross-sectional cuts from abdominal computed tomography (CT) are shown in Figures A and B, respectively. What is the diagnosis? Look on page 323 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Antibiotic Use in Primary Palatoplasty: A Survey of Practice Patterns, Assessment of Efficacy, and Proposed Guidelines for Use.

Background: The literature provides no guidelines for antibiotic use in palatoplasty. The authors sought to ascertain practice patterns; review a large, single-surgeon experience, and propose guidelines for antibiotic use in primary palatoplasty. Methods: A six-question survey was e-mailed to all surgeons of the American Cleft Palate-Craniofacial Association. A retrospective study was also conducted of the senior author’s 10-year primary palatoplasty series, and two groups were studied. Group 1 received no antibiotics. Group 2 received preoperative and/or postoperative antibiotics. Results: Three hundred twelve of 1115 surgeons (28 percent) responded to the survey. Eighty-five percent administered prophylactic antibiotics, including 26 percent who used a single preoperative dose. A further 23 percent gave 24 hours of postoperative therapy; 12 percent used 25 to 72 hours, 16 percent used 4 to 5 days, and 12 percent used 6 to 10 days. Five percent of surgeons administered penicillin, 64 percent administered a first-generation cephalosporin, 13 percent administered ampicillin/sulbactam, and 8 percent gave clindamycin. The authors reviewed 311 patients; 173 receive antibiotics and 138 did not. Delayed healing and fistula rates did not differ between groups: 16.8 percent versus 15.2 percent (p = 0.71) and 2.9 percent versus 1.4 percent (p = 0.47), respectively. A single patient treated without antibiotics developed a postoperative bacteremia. This case did not meet the Centers for Disease Control definition of a surgical site infection, but the patient developed a palatal fistula. Conclusions: Antibiotic use in primary palatoplasty varies widely. The authors’ data support a clinician’s choice to forego antibiotic use; however, given the significance of palatal fistulae and the single case of postoperative streptococcal bacteremia, the study group recommends a single preoperative dose of ampicillin/sulbactam. Current evidence cannot justify the use of protracted antibiotic regimens. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.