Congenital Deformities Research Articles

Syndactyly in the Pediatric Population: A Review of the Literature.

Syndactyly is one of the most common congenital upper extremity deformities. Syndactyly can be described as either simple, involving just the skin and soft tissue, or complex, involving the phalanges. Additionally, syndactyly can be categorized as complete, involving the entire digit (including the nail fold), or incomplete, which does not involve the nail fold. Multiple familial or spontaneous genetic abnormalities can cause syndactyly, and these mutations typically involve the canonical wingless-type (WNT) pathway. Surgical repair of syndactyly is typically done between six to 18 months of age, depending on the type of syndactyly. Regardless of the classification of the syndactyly, the repair is performed before school-going age (except in the case of extremely mild or rare, extremely complex syndactyly). One or more imaging modalities are used to aid the surgeon in deciding the surgical approach for the syndactyly repair. The surgical plan must be clearly communicated with parents to manage expectations of aesthetics and function of the digits post-surgery. In brief, a syndactyly release surgery involves the creation of the web space using a geometrical design of the surgeon's choice, defatting of finger flaps, separation of the digits, and closure with absorbable sutures. However, the approach may vary depending on the patient. A "best" approach for rectifying the difference in surface area of separated versus fused digits has not yet been determined. While this was typically done using a skin graft, the use of alternative methods (most notably, using a synthetic dermal substitute or not using a graft at all and allowing the skin to heal with secondary intention) has been on the rise given the undesirable side effects of a graft. Less commonly, an external fixator can be used to expand soft tissue and skin. In the case of complete syndactyly, the Buck-Gramcko technique is most commonly used for nail flap reconstruction. Complications of the surgery include contracture, web creep, and the need for a second surgery. Thus, parents must be counseled in recognizing signs of complications.

The etiology, clinical features, and treatment options of hemifacial microsomia.

The second most frequent craniomaxillofacial congenital deformity is hemifacial microsomia (HFM). Patients often accompany short mandible, ear dysplasia, facial nerve, and soft tissue dysplasia. The etiology of HFM is not fully understood. To organize the possible up-to-date information on the etiology, craniofacial phenotypes, and therapeutic alternatives in order to fully comprehend the HFM. Reviewing the potential causes, exploring the clinical features of HFM and summarizing the available treatment options. Vascular malformation, Meckel's cartilage abnormalities, and cranial neural crest cells (CNCCs) abnormalities are three potential etiology hypotheses. The commonly used clinical classification for HFM is OMENS, OMENS-plus, and SAT. Other craniofacial anomalies, like dental defects, and zygomatic deformities, are still not precisely documented in the classification. Patients with moderate phenotypes may not need any treatment from infancy through adulthood. However, patients with severe HFM require to undergo multiple surgeries to address facial asymmetries, such as mandibular distraction osteogenesis (MDO), autologous costochondral rib graft (CCG), orthodontic and orthognathic treatment, and facial soft tissue reconstruction. It is anticipated that etiology research will examine the pathogenic mechanism of HFM. A precise treatment for HFM may be possible with thoroughly documented phenotypes and a pathogenic diagnosis.

A Prospective Study on Functional Outcomes of Serial Cast Correction in Congenital Talipes Equinovarus (CTEV) by Ponseti Method.

Congenital talipes equinovarus (CTEV), often known as clubfoot, is one of the most common congenital deformities of the foot and ankle, affecting one in every 1,000 live births. The deformity has four components: ankle equinus, hindfoot varus, forefoot adductus, and midfoot cavus. The Ponseti casting technique of CTEV management has proven to be more effective, generating higher positive outcomes and lesser complications than conventional surgical methods. This study was conducted in a tertiary care teaching hospital centre in southern Rajasthan, India. Twenty cases with 31 feet of untreated clubfoot were included. The deformity was scored according to Pirani's scoring system. Manipulation and serial corrective casts were applied at weekly intervals according to Ponseti's method. Percutaneous tendoachilles tenotomy was done whenever required (guided by Pirani score). Final results were calculated using the Pirani score, noted before putting the patient on foot abduction orthosis. In our study, the average numberof casts required for full correction was 6.5. Heel cord tenotomy was required in 27 feet (87%) to achieve full correction. Final Pirani score significantly improved from an average of 4.8 on presentation to 0.055 after completion of casting. We conclude that the Ponseti technique of CTEV correction significantly reduces the need for invasive surgical procedures along with being exceedingly safe, effective, and affordable. The Ponseti technique of cast correction is crucial and provides a painless, plantigrade, cosmetically acceptable foot with higher functional outcomes and minimal complications.

Congenital duodenal windsock deformity simulating midgut volvulus and treated with innovative minimal invasive technique and duodenoplasty

We present a 3200 gm female term neonate born by spontaneous vaginal delivery with uneventful antenatal scans and perinatal period who had passed normal meconium, breast fed for 6 days and presented with bilious vomiting simulating neonatal midgut volvulus

Abnormal mechanical stress on bicuspid aortic valve induces valvular calcification and inhibits Notch1/NICD/Runx2 signal.

Bicuspid aortic valve (BAV) is a congenital cardiac deformity, increasing the risk of developing calcific aortic valve disease (CAVD). The disturbance of hemodynamics can induce valvular calcification, but the mechanism has not been fully identified. We constructed a finite element model (FEM) of the aortic valve based on the computed tomography angiography (CTA) data from BAV patients and tricuspid aortic valve (TAV) individuals. We analyzed the hemodynamic properties based on our model and investigated the characteristics of mechanical stimuli on BAV. Further, we detected the expression of Notch, NICD and Runx2 in valve samples and identified the association between mechanical stress and the Notch1 signaling pathway. Finite element analysis showed that at diastole phase, the equivalent stress on the root of BAV was significantly higher than that on the TAV leaflet. Correspondingly, the expression of Notch1 and NICH decreased and the expression of Runx2 elevated significantly on large BAV leaflet belly, which is associated with equivalent stress on leaflet. Our findings indicated that the root of BAV suffered higher mechanical stress due to the abnormal hemodynamic environment, and the disturbance of the Notch1/NICD/Runx2 signaling pathway caused by mechanical stimuli contributed to valvular calcification.

Pediatric Insurance Coverage Variation of Orthognathic Surgery and Orthodontic Treatment for Congenital Craniofacial Abnormalities

Introduction: Orthognathic surgery and associated orthodontic treatment are necessary parts of care for children who have congenital craniofacial deformities. Inconsistencies in insurance coverage across the U.S. have led to serious barriers to care for many families. In an effort to describe common patterns of coverage, we report craniofacial coverage criteria for both medical and dental insurances. Methods: In this study, we analyzed medical policies of the top 50 market share insurance providers, as well as all dental policies available in the U.S., for a total of 776 policies. Included in this analysis are Medicaid and Children’s Health Insurance Program (CHIP). Results: A total of 94.1% of both private medical and dental policies provide up-front limited coverage of congenital-related treatments, along with 98.0% of Medicaid plans covering oral surgery for cleft palate. Almost all states (n = 47) offered at least one private medical plan that covered orthognathic surgery for congenital and craniofacial anomalies, while n = 3 states (Colorado, Ohio, West Virginia) did not offer any. Coverage for oral surgery and orthodontic treatment by private dental and standalone dental plans were consistent, with 80.9% (n = 518) plans offering (52 ± 14)% in-network coverage of costs for oral surgery and 55.6% (n = 356) offering a similar (49 ± 12)% out-of-network coverage. Forty-six Medicaid and 44 CHIP programs offered coverage of “oral surgery for cleft palate.” Of these plans, 8.8% (n = 9) covered oral surgery as a medical benefit and 2.9% (n = 3) required that the surgery be “medically necessary.” Fifty Medicaid and 48 CHIP plans offered coverage for orthodontia. Conclusion: Many systemic barriers remain in the way of consistent access to affordable care in the United States. Coverage for patients with congenital anomalies remains highly variable and greater efforts are needed to ensure consistent, comprehensive coverage.

The advantages of domestic ear molding system in molding bilateral neonatal congenital auricular deformities

BackgroundThere are different types of ear molding devices on the market. However, due to high cost, the wide application of the ear molding is hindered, especially for children with bilateral congenital auricular deformities (CAD). This study is designed to correct the bilateral CAD with the flexible use of Chinese domestic ear molding system.MethodsNewborns diagnosed with bilateral CAD were recruited in our hospital from September 2020 to October 2021. For each subject, one ear wore a set of domestic ear molding system, while the contralateral ear used only matching Retractor and Antihelix Former. Medical charts were reviewed to collect data on the types of CAD, the incidence of complications, the initiation and duration of treatment, as well as the satisfaction after treatment. Treatment outcomes were graded into three levels: excellent, good, and poor, according to the improvement of auricular morphology evaluated by both doctors and parents, respectively.ResultsA total of 16 infants (32 ears) were treated with the Chinese domestic ear molding system, which contains 4 cases with Stahl’s ear (8 ears), 5 cases with Helical rim deformity (10 ears), 3 cases with Cup ear (6 ears), 4 cases with Lop ear (8 ears). All infants accomplished the correction completely. Both parents and doctors were satisfied with the outcomes. No obvious complication was observed.ConclusionsEar molding is an effective nonsurgical treatment for CAD. Molding with Retractor and Antihelix Former is simple and effective. Domestic ear molding system can be flexibly used in correcting bilateral CAD. With this approach, infants with bilateral CAD will benefit more in the near future.

Nonsurgical Creation of an Auriculocephalic Sulcus in Children With Congenital Auricular Deformities.

Nonsurgical correction of congenital auricular deformity is known to be effective in newborns. In this study, the authors investigated factors influencing the outcome of nonsurgical or surgical correction of the auriculocephalic sulcus, an important auricular structure and one that is necessary for wearing glasses or a mask. A total of 80 ears (63 children) were splinted using a metallic paper clip and thermoplastic resin in our outpatient clinic between October 2010 and September 2019. The ears were divided into a group, in which the auriculocephalic sulcus was formed nonsurgically (n =5 6) and a group, in which surgery was needed (n = 24). The authors compared the clinical characteristics of the deformities, whether cryptotia affected the superior or inferior crus, and whether constricted ears were Tanzer group IIA or IIB between the two study groups by retrospective chart review. There was a significant correlation between the age, at which ear-molding treatment was initiated and outcome ( P < 0.001). The optimal cutoff value for age, before which ear-molding treatment should be initiated was 7 months. Inferior crus-type cryptotia was corrected adequately by splinting, but all Tanzer group IIB constricted ears needed surgical treatment. Earlier initiation of ear-molding treatment is recommended, preferably before 6 months of age. Nonsurgical treatment is an effective intervention for the creation of the auriculocephalic sulcus in ears with cryptotia and Tanzer group IIA constricted ears but cannot correct for an inadequate amount of skin over the auricular margin or a defect in the antihelix.

PMMA Teeth-Pedicle Screw Spacers in Revision Spinal Surgery: A Technical Note

BACKGROUND Pedicle screw instrumentation was first described by Boucher in 1959 and subsequently popularised by Camille et al. in 1963. It has since become the most prevalent spinal fixation technique with indications for pedicle screw and rod constructs including congenital disease, trauma, infection, and spinal deformity including scoliosis. Initially used in lumbar spine surgery, the use of pedicle screws has since been extended to the thoracic spine where, because of the narrow pedicle corridor and proximity of critical structures, there is less margin for error in screw placement.1 Pedicle screw misplacement has been described in up to 40% of lumbar spine cases and up to 55% in thoracic spine cases.2 Complications associated with pedicle screw placement include damage to spinal cord, neural elements, nerve roots, pedicle fractures, wall cut out, and difficulty fitting instrumentation to the pedicle. Pedicle screw placement techniques can be grossly divided into freehand and image-guided techniques, with freehand techniques including drill assisted and pedicle gearshift (probe) methods while image-guided techniques incorporate fluoroscopic assisted, navigation assisted and robotic-assisted means. Pedicle screw placement into previously fused spines can be challenging with vital anatomic landmarks altered or obscured by the fusion mass.3 PMMA (Polymethyl methacrylate) was first introduced by Charnley in 1960 for cemented total hip arthroplasty. In spine surgery, PMMA has been used in numerous forms including kyphoplasty, disk substitution, and pedicle screw augmentation. In 1972 Bucholz and colleagues began combining PMMA with antibiotics to achieve high local antibiotic concentration in the setting of osteomyelitis; as such PMMA antibiotic loaded spacers have been well described in revision arthroplasty. Staged revision spinal surgery has been advocated by some authors in the setting of deep infection.4 Our senior author has noted that identification of pedicle screw tracts during second stage surgery can be challenging. Rationale We describe a novel surgical technique for the use of PMMA Teeth in the setting of staged revision spinal surgery to maintain the patency of pedicle screw tracts, permitting prompt identification on proceeding surgery stages and achieving local antibiotic delivery when necessary. Surgical Technique A standard posterior approach to the spine is performed identifying the in situ instrumentation. After removal of the in situ spinal rods and pedicle screws, the pedicle screw tracts are examined evaluating the medial, lateral, superior, and inferior walls of the tract. Residual fibrous tissue is debrided. A standard mix of Palacos R cement (Heraeus Medical, Newbury, UK) with the addition of 2 g vancomycin is performed. The PMMA teeth are subsequently fashioned from the Palacos R cement (Fig. 1). Similar to the technique described by Tsung et al.5 in revision hip arthroplasty, the principle for fixation is that of macroscopic fit as opposed to microscopic interlock of the cement; therefore, the PMMA teeth are inserted once the cement has cured.FIGURE 1: PMMA Teeth.PMMA indicates Polymethyl methacrylate.Expected Outcomes The PMMA teeth technique can assist the spinal surgeon in identifying the pedicle screw tract promptly and safely in staged revision spinal surgery with the added benefit of local antibiotic delivery. Complications Potential complications include PMMA Teeth fracture in situ, however, given the PMMA Teeth are inserted once the cement has cured, removal should be uncomplicated. DISCUSSION & CONCLUSION The incidence of revision spinal fusion has a reported range of 8 to 45%, with the revision rate increasing with follow-up; 21% of patients undergoing revision spinal surgery will require further spinal surgery.6 The rate of pedicle screw perforation has been reported to be as high as 28%, and 19% with a perforation greater than 2mm. This poses a significant challenge with considerable potential for pedicle screws to be misplaced in the revision spinal surgery setting.

Management of orofacial clefts in Africa, insufficient management centers, and workforce.

Management of orofacial clefts in Africa, insufficient management centers, and workforce.

National Mortality Tendencies of Population in Ukraine and the Kharkiv Region

The purpose of the study was to determine national tendencies of mortality in Ukraine and the Kharkiv region. Materials and methods. Data from official sources of statistical information of Ukraine were used and systematic analysis and generalization of the obtained data was performed and tendencies of mortality in Ukraine were calculated. Results and discussion. According to the dynamics of mortality rates of the population of Ukraine in 2010–2019, there was a decrease in almost all nosological forms of disease. For some groups of diseases there was a tendency of increasing mortality per 100 thousand population with tendencies for the general population +3.0% and +3.9%, for men +3.4% and +1.1% and women +2.2% and 8.3%. Obtained results on the overall dynamics of declining tendencies in mortality due to major diseases in recent years and their growth due to some nosologies and structural characteristics of the main causes of mortality are in complete agreement with other studies. The study noted an increase in tendencies of mortality of population of Ukraine in 2010–2019 (per 100 thousand population) in several disease groups: neoplasms (tendency +3.0%: males +3.4 %, females +2.2%) and diseases of digestive system (respectively +3.9%: +1.1% and +8.3%). The Kharkiv region leads among other regions in 2019 in such classes: overall – 3rd place (40,611 cases), diseases of the circulatory system – 2nd (28,079), coronary heart disease – 2nd (21,154), diseases of the digestive system – 2nd (1,624), external causes of death – 2nd (2,225), neoplasms – 3rd (5,714), cerebrovascular disease – 4th (5,009), diseases of the respiratory system – 4th (810), diseases of the genitourinary system – 4th (196) and congenital malformations, deformities and chromosomal abnormalities – 4th (69). Significant increase in tendencies found in the Kharkiv region during 2018–2019 both in absolute counts and per 100 thousand: complications of pregnancy, childbirth and postpartum period (+300.0 and +293.8%), certain conditions that occur in the perinatal period (+14.3 and +24.3%), other causes (+13.8 and +14.5%) and urolithiasis (+12.0 and +12.9%) with defined structural characteristics of mortality in diseases of the circulatory system (69.09%), neoplasms (14.04%) and accidents and trauma (5.26%). Conclusion. The obtained results of the general dynamics of decreasing mortality tendencies due to major diseases and their growth due to some nosologies and structural characteristics of the main causes of mortality in Ukraine completely coincide with the data of other studies

Modified dual osteotomy for Madelung’s deformity

Madelung’s deformity is one of the rare congenital deformities of the forearm and wrist, typically seen as positive ulnar variance and increased volar tilt due to the “Vickers” ligament. Different corrective surgical methods for this have been done in the literature. In this case of a 9-year-old Madelung’s like deformity, we have performed a modified dual osteotomy with periosteal preservation allowing natural articulation and bone to be modified, especially in a younger child. This article gives the surgical option to orthopedics for the future, especially in a younger child with severe deformity. This is a level V evidence-based therapeutic study.

Resection of cervical hemivertebra with occipitocervical - fusion: report on two torticollis cases and literature review

ABSTRACT The objective of this study is to present the two cases of cervical hemivertebra and torticollis, and To describe technique and result of cervical hemivertebra resection and torticollis correction via a anterior–posterior surgical approach and occipitocervical fusion. Cervical hemivertebra, accompanied by abipartite atlas, agenesis of odontoid and C2 segmental type of vertebral artery (VA), is a rare, but complex congenital anomalies, associated with cervical scoliosis and occipitocervical instability. To the best of our knowledge, this is the first report on such congenital anomaly and deformity correction via anterior–posterior hemivertebra resection with occipitocervical fusion. Two patients were presented with torticollis due to congenital cervical hemivertebra accompanied by abipartite atlas, agenesis of odontoid and C2 segmental type of VA. Deformity correction was executed by an anterior–posterior hemivertebra resection and occipitocervical fusion with segment instrumentation. The treatment course was uneventful and clinical outcomes was favorable. The radiographs showed a satisfactory deformity correction with a well-balanced coronal and sagittal alignment. Hemivertebra resection with occipitocervical fusion could correct torticollis with satisfactory clinical and radiographical outcome.

Prevalence of congenital malformations and deformities of the osteomuscular system in live newborns in Mexico, 2008-2017

Prevalence of congenital malformations and deformities of the osteomuscular system in live newborns in Mexico, 2008-2017

An algorithmic approach of reconstruction for cranioplasty failure: A case series.

Cranioplasty is a surgical procedure used to repair cranial defects for both cosmetic and functional reasons. The complication rate of cranioplasty is between 10% and 50%. The failure of cranioplasty is associated with various factors, including etiologies, types of material, and the timing of cranioplasty. In this study, a case series of managing cranioplasty complications at a single institution. Eighteen patients were identified who underwent craniofacial defect reconstruction due to the failure of their initial cranioplasty between January 2010 and May 2020. Five men (27.78%) and thirteen women (72.22%) were included. The mean age was 39.61 years old. The average follow-up duration was 5.94 years. The indication for initial cranioplasty included previous decompressive craniectomy (77.78%, n = 14), traumatic cranial defects (16.67%, n = 3), and congenital cranial deformity (5.56%, n = 1). The reported complications were infection (50%, n = 9), implant exposure (50%, n = 9), wound dehiscence (22.22%, n = 4) and cranial deformity (11.11%, n = 2). More than half of the materials used for initial cranioplasty were synthetic [titanium mesh: 44.44%, n = 8; polymethyl metacrylate: 5.56%, n = 1; titanium mesh and polymethyl metacrylate: 5.56%, n = 1], while 44.44% of the patients received autologous bone graft. Of all reconstructive procedures for cranioplasty failure, 55.56% was local flap with or without skin graft (n = 10), 16.67% was free flap (n = 3), 11.11% was skin graft only (n = 2), 5.56% was regional flap (n = 1). The free flap survival rate was 100% (3/3), and implant removal with sebsquent second cranioplasty was performed on 27.78% (n = 5) of the patients. Management of cranioplasty failure can be challenging due to infection, refractory implant exposure, and wound dehiscence. The principles of management are based on adequate infection control and reconstructive ladder. Meanwhile, collaboration with plastic surgery and neurosurgery should be strengthened in order to achieve the best clinical outcomes.

Complications and Outcomes of the Nuss Procedure in Adult Patients: A Systematic Review.

Pectus excavatum is a congenital chest wall deformity, commonly identified in early childhood, creating a "sunken chest" appearance. Over time, the deformity can worsen, thus impacting cardiopulmonary function and creating significant body image disturbance in patients. The Nuss procedure is a minimally invasive technique in which a curved steel bar is introduced underneath the sternum through small bilateral thoracic incisions to correct the deformity. Most studies regarding the procedure to date focus on outcomes and complications in pediatric patients, however, few studies discuss these results in adult patients. This systematic review aims to analyze common complications and outcomes in patients over the age of 18 who have not undergone any prior intervention for pectus excavatum. The most common complications experienced in adult patients were displacement of the implanted steel bar, infection of the surgical site, pneumothorax, pleural effusion, and chronic postoperative pain. Reoperation was common in patients with a displacement of the bar, chronic pain, and bleeding. Additionally, adult patients routinely required a higher number of steel bars to be placed to correct the deformity. Despite evidence that the rate of complications increases with age, the majority of adult patients in our included studies were satisfied with the outcome of the procedure with indications of improved self-image and reduced preoperative symptoms such as dyspnea on exertion, palpitations, chest pain, and depression.

Comparison of Different Surgical Techniques in Correction of Congenital Vertical Talus Deformity: A Systematic Review and Meta-Analysis of the Literature.

Congenital Vertical Talus (CVT) is a rare form of congenital rigid flatfoot. Numerous surgical techniques have been developed over the years in an attempt to definitively correct this deformity. We performed a systematic review and meta-analysis of the existing literature to compare the outcomes of children with CVT treated with different methods. A detailed systematic search was conducted in accordance with PRISMA guidelines. Radiographic recurrence of the deformity, reoperation rate, ankle arc of motion, and clinical scoring was compared between the following 5 methods: Two-Stage Coleman-Stelling Technique, Direct Medial Approach, Single-Stage Dorsal (Seimon) Approach, Cincinnati Incision, and Dobbs Method. Meta-analyses of proportions were performed, and data were pooled through a random effects model using the DerSimonian and Laird approach. Heterogeneity was assessed using I^2 statistics. The authors used a modified version of the Adelaar scoring system to assess clinical outcomes. An alpha of 0.05 was used for all statistical analysis. Thirty-one studies (580 feet) met the inclusion criteria. The reported incidence of radiographic recurrence of talonavicular subluxation was 19.3%, with 7.8% requiring reoperation. Radiographic recurrence of the deformity was highest in the children treated with the direct medial approach (29.3%) and lowest in the Single-Stage Dorsal Approach cohort (11%) ( P <0.05). The reoperation rate was significantly lower in the Single-Stage Dorsal Approach cohort (2%) compared with all other methods ( P <0.05). There was no significant difference in the reoperation rates between the other methods. The highest clinical score was seen in the Dobbs Method cohort (8.36), followed by the group treated with the Single-Stage Dorsal Approach (7.81). The Dobbs Method resulted in the largest ankle arc of motion. We found the lowest radiographic recurrence and reoperation rates in the Single-Stage Dorsal Approach cohort, while the highest rate of radiographic recurrence was seen in those treated with the Direct Medial Approach. The Dobbs Method results in higher clinical scores and ankle arc of motion. Future long-term studies focusing on patient-reported outcomes are needed. Level III.

Coexistence of proboscis lateralis and multiple craniofacial, neurological, cardiac and spinal deformities: a one-of-a-kind case report

BackgroundProboscis lateralis (PL) is an uncommon congenital facial deformity marked by the protrusion of a primitive tubular structure made up of skin and soft tissue that generally emerges from the eye's medial canthus and is associated with some craniofacial deformities. We report the first case of PL with multiple craniofacial, neurological, cardiac, and spinal anomalies.Case presentationA full-term female baby delivered by cesarean section cried immediately at birth. The mother reported having a normal pregnancy but has a history of x-ray during her first trimester. The baby was born with a rare presentation of proboscis lateralis which was accompanied by multiple anomalies, including but not limited to bilateral colpocephaly, corpus callosum agenesis, complex cyanotic congenital heart disease, and hemivertebra of the T10 body.ConclusionPL is an uncommon congenital condition that causes a variety of craniofacial abnormalities. Multiple additional defects affecting various organ systems should also be evaluated in a person diagnosed with PL.

Insights and trends review: the role of three-dimensional technology in upper extremity surgery.

The use of three-dimensional (3-D) technology in upper extremity surgery has the potential to revolutionize the way that hand and upper limb procedures are planned and performed. 3-D technology can assist in the diagnosis and treatment of conditions, allowing virtual preoperative planning and surgical templating. 3-D printing can allow the production of patient-specific jigs, instruments and implants, allowing surgeons to plan and perform complex procedures with greater precision and accuracy. Previously, cost has been a barrier to the use of 3-D technology, which is now falling rapidly. This review article will discuss the current status of 3-D technology and printing, including its applications, ethics and challenges in hand and upper limb surgery. We have provided case examples to outline how clinicians can incorporate 3-D technology in their clinical practice for congenital deformities, management of acute fracture and malunion and arthroplasty.

43. Trends in Craniofacial Fellowship Career Outcomes: A Call for Expanding Professional Opportunities in Craniofacial Surgery

Background: Limited available pediatric plastic surgery positions fail to accommodate the increasing number of craniofacial fellows trained annually. However, many adult indications have increased the demand for craniofacial expertise. Given new opportunities available to craniofacial surgeons, the authors aim to evaluate career prospects for recent craniofacial graduates and explore additional career opportunities. Methods: Upon approval from the American Society of Craniofacial Surgeons (ASCFS), an anonymous online survey invitation was sent to craniofacial fellows who graduated from 2016 to 2021. Respondents were queried regarding their craniofacial fellowship and subsequent career prospects. Results: A total of 124 eligible participants were identified, of which 30 (24.2%) responded. Craniomaxillofacial case distribution at respondents’ current practices varied, with 42.3% reporting a 50-75% craniofacial case load and 38.5% reporting less than 25%. Craniofacial trauma reconstruction was performed most at current positions (92.3%), followed by general reconstruction (92.3%) and breast surgery (69.2%); least commonly performed was facial feminization (23.1%). Most respondents desired an increased craniomaxillofacial case load (65.4%). 26.9% were unable to secure their current position prior to fellowship completion, and 80.0% cited limited craniofacial job availability. Recommendations to improve fellowship comprehensiveness and increase candidate competitiveness included increased facial feminization, facial aesthetic, and microsurgical experience. Conclusion: To adapt to trends in craniomaxillofacial surgery, ASCFS should encourage developing fellowships that increase exposure to gender-affirming, adult craniofacial reconstruction, orthognathic, and skeletal facial aesthetic surgery. Expanding training beyond congenital deformities can provide additional employment opportunities while maintaining excellence and innovation in facial plastic surgery.