Reconstruction In Pediatric Patients Research Articles

The Effect of Insurance Type on Time to Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Critically Appraised Topic

Clinical Scenario: Delay in surgery for anterior cruciate ligament (ACL) injuries increases the risk of complications including secondary injuries. Previous research has shown individuals with public insurance have greater delays in care for a variety of health conditions. Clinical Question: In pediatric patients with ACL injuries, is the time from injury to surgery longer for patients with public insurance than patients with private insurance? Summary of Key Findings: Four studies met the inclusion criteria. All studies reported a greater wait time for surgery in pediatric patients with public insurance. Clinical Bottom Line: There is moderate evidence indicating that there is a delay in ACL surgery for pediatric patients with public insurance compared to those with private insurance. Strength of Recommendation: Grade B evidence exists that there is a delay in surgery for ACL injuries in pediatric patients with public insurance compared to those with private insurance.

The Forgotten Flap: The Pedicled Trapezius Flap's Utility in Pediatric Head and Neck Reconstruction-A Systematic Review.

When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction. A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted. A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (n = 11) and case series (n = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (n = 46, 73.0%) and chronic wounds secondary to H&N masses (n = 9, 14.3%). Defects were most commonly located in the neck (n = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm2 and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (n = 48, 71.6%) and based on the dorsal scapular artery (n = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (n = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years. This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.

Evaluation of T2W FLAIR MR image quality using artificial intelligence image reconstruction techniques in the pediatric brain

BackgroundArtificial intelligence (AI) reconstruction techniques have the potential to improve image quality and decrease imaging time. However, these techniques must be assessed for safe and effective use in clinical practice.ObjectiveTo assess image quality and diagnostic confidence of AI reconstruction in the pediatric brain on fluid-attenuated inversion recovery (FLAIR) imaging.Materials and methodsThis prospective, institutional review board (IRB)-approved study enrolled 50 pediatric patients (median age=12 years, Q1=10 years, Q3=14 years) undergoing clinical brain MRI. T2-weighted (T2W) FLAIR images were reconstructed by both standard clinical and AI reconstruction algorithms (strong denoising). Images were independently rated by two neuroradiologists on a dedicated research picture archiving and communication system (PACS) to indicate whether AI increased, decreased, or had no effect on image quality compared to standard reconstruction. Quantitative analysis of signal intensities was also performed to calculate apparent signal to noise (aSNR) and apparent contrast to noise (aCNR) ratios.ResultsAI reconstruction was better than standard in 99% (reader 1, 49/50; reader 2, 50/50) for overall image quality, 99% (reader 1, 49/50; reader 2, 50/50) for subjective SNR, and 98% (reader 1, 49/50; reader 2, 49/50) for diagnostic preference. Quantitative analysis revealed significantly higher gray matter aSNR (30.6±6.5), white matter aSNR (21.4±5.6), and gray-white matter aCNR (7.1±1.6) in AI-reconstructed images compared to standard reconstruction (18±2.7, 14.2±2.8, 4.4±0.8, p<0.001) respectively.ConclusionWe conclude that AI reconstruction improved T2W FLAIR image quality in most patients when compared with standard reconstruction in pediatric patients.

Pericranial Flap Reconstruction in Pediatric Patients Undergoing Neuromodulatory Surgery: Impact on Wound Healing

Background: Pediatric patients with medically-intractable epilepsy may require modulation of seizure foci to reduce frequency and severity of seizures. These neuromodulatory procedures, which include responsive neurostimulator (RNS) and deep brain stimulator (DBS), involve the implantation of high-profile and long-term cranial hardware, placing patients at risk of wound healing complications, hardware exposure and infection. A multidisciplinary neurosurgical and plastic surgical approach utilizing pericranial flap coverage of hardware may decrease wound healing complications in these cases. This study compares the wound-healing outcomes in patients undergoing RNS/DBS insertion with and without pericranial flap coverage. Methods: A retrospective chart review was conducted of all patients who underwent RNS and DBS insertion with or without pericranial flap coverage at a level 1 pediatric medical center between 2014 and 2022. Wound healing outcomes at 60 days were evaluated. Data were compared using Fisher’s exact test. Results: Twenty-seven patients underwent 29 neuromodulatory epilepsy procedures (14 DBS, 15 RNS). Twenty of the procedures included a pericranial flap to cover hardware. Median length of stay was 2.0 days for both cohorts. Two subjects without pericranial flap reconstruction had a wound healing complication (22.2%), compared to none of the procedures that included a pericranial flap ( P = .09). Conclusion: In pediatric patients undergoing insertion of responsive neurostimulators and deep brain stimulators for medically-intractable epilepsy, a multidisciplinary neurosurgery and plastic surgery approach utilizing pericranial flap reconstruction may reduce the risk of postoperative wound complications.

Reconstructive Techniques in Pediatric Congenital Microtia: A Systematic Review and Meta-analysis.

Autografts and allografts are commonly used in microtia reconstruction. We aimed to systematically review and compare these reconstructive materials in pediatric congenital microtia reconstruction. A systematic review of the literature was performed. MEDLINE, Embase, PubMed, Web of Science, and CINAHL databases were searched for original studies on congenital microtia reconstruction in pediatric patients since database inception to 2021. Microtia grade was stratified as high or low. Meta-analysis of pooled proportions and continuous variables was performed using inverse variance weighting with a random effects model to compare between the autograft and allograft groups. Sixty-eight studies with a total of 5,546 patients used autografts (n = 5,382) or alloplastic implants (n = 164). Four other studies used prosthesis, cadaveric homografts, or tissue engineering. The allograft group was on average younger than the autograft group (8.4 vs. 11.1 years). There were no syndromic patients in the allograft group, compared to 43% in the autograft group. Patients treated with allografts had higher microtia grade than those treated with autograft (98 vs. 72%). Autografts were more commonly utilized by plastic surgeons and allografts by otolaryngologists (95 vs. 38%). No autografts and 41% of allografts were done concurrently with atresiaplasty or bone conduction implant. Satisfaction rates were similarly high (>90%) with similar complication rates (<10%). Microtia reconstruction using autografts and allografts had similar satisfaction and complication rates. Allografts were preferred for younger patients and concurrent hearing restoration. Further large-scale studies are required to evaluate the long-term efficacy of these reconstructive techniques.

Single-port robotic extraperitoneal pediatric pyeloplasty using low anterior access: Description of technique and initial experience

IntroductionWe aim to report our surgical technique, functional and radiological outcomes of single port (SP) extraperitoneal robotic pediatric pyeloplasty through a low anterior (3cm) access using a da-Vinci single-port (SP) robotic surgical system in the pediatric population. Material and methodsWe present our initial series of 6 pediatric patients that underwent robotic SP extraperitoneal pyeloplasty between 2022 - 2023. Patient clinicopathologic variables and perioperative outcomes were collected prospectively. ResultsAll cases of SP extraperitoneal pyeloplasty were completed without any intraoperative complications or conversion to an open, laparoscopic, or multi-port robotic pyeloplasty. Total operative times including cystoscopy ranged from 178 mins to 240 mins. All patients tolerated the surgery with minimal postsurgical pain and no narcotic requirement. No intraoperative or immediate postoperative complications were recorded in the cohort. There were no readmissions after discharge at a median follow-up of 12 months (6-18 months) in our series. ConclusionsSingle port extraperitoneal pyeloplasty is a safe and feasible option for upper tract reconstruction in pediatric patients. All patients had complete resolution of symptoms and improvement of hydronephrosis on follow-up imaging.

Characterization of cranial growth patterns using craniometric parameters and best-fit logarithmic growth curves

Few studies have reported a complete quantitative database of cranial growth, from infancy to adulthood, as a reference through three-dimensional analysis. Our study aimed to characterize cranial growth patterns using craniometric parameters by establishing sex- and age-specific norms.In total, 1009 Korean patients (male-to-female ratio, 2:1; age range, 0–18 years) who underwent thin-slice computed tomography (CT) scans for head trauma were divided into 20 age groups, with a 6-month interval for those under 2 years and a 1-year interval for those over 2 years. After four reference planes [Frankfurt horizontal (FH), midsagittal, and two coronal planes passing the sella (S) and basion (B)] had been established, intracranial volume (ICV), anteroposterior diameter (APD), biparietal diameter (BPD), cranial heights (CHs), cephalic index (CI, BPD/APD), and height index (HI, CH–B/APD) were measured using Mimics software. Best-fit logarithmic curves were derived using a linear regression model.The best-fit curves for ICV (cm3) were y = 785.6 + 157*ln(age) for males (R2 = 0.5752) and y = 702 + 150.5*ln(age) for females (R2 = 0.6517). After adjustment for age, males had higher values of ICV, APD, BPD, and CHs than females (all p < 0.0001). ICV, APD, BPD, and CHs demonstrated a rapid increase during the first few months of life, reaching 90–95% of the adult size by 5–6 years of age, while CI and HI showed a continuous decline by 4%, regardless of sex.This study presented cranial growth references for more than 1000 of the Korean population aged up to 18 years. This might help to provide guidelines for diagnosis and treatment (including timing, amount, and direction) for cranial reconstruction in pediatric patients with craniosynostosis.

Poster 324: Complications following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Case Series

Objectives: The purpose of this study was to analyze the rate and type of complications and subsequent procedures encountered with soft tissue quadriceps tendon autograft (QTA) for anterior cruciate ligament reconstruction (ACLR) in pediatric patients ≤ 18 years old. Methods: After institutional review board approval, operative records of all pediatric patients ≤ 18 years old who underwent ACLR from June 2015 to December 2021 were retrospectively reviewed. A consecutive series of patients who underwent ACLR with a QTA with minimum 6 month-follow up were included in the study. Skeletally immature patients underwent an all-epiphyseal (AE) technique while patients nearing skeletal maturity or that were skeletally mature underwent a complete transphyseal (CT) procedure. All patients underwent ACLR by utilizing a full thickness soft tissue QTA without a bone plug. Additionally, patients who were determined to be at high risk of re-tear underwent a concomitant a lateral extra-articular tenodesis (LET) with a modified Lemaire technique. Preoperative demographic information, surgical details, associated diagnosis, and subsequent injuries and complications were collected. Complications associated with the quadriceps tendon harvest site and use of QTA including removal of non-absorbable sutures from the autograft donor site, quadriceps tendon rupture, and the subsequent development of a superior patellar osteochondritis dissecans lesions (OCD) were reported. Results: A total of 143 pediatric patients ≤ 18 years old underwent an ACLR with a soft tissue QTA during the study period. Of the 143 eligible patients, 137 patients had minimum 6-month follow-up and were included in the study. After 3 attempted contacts, six patients (4%) were deemed lost to follow-up and excluded from the study. The mean age was 14.8±1.6 (range 11-18 years) and 60% were male. The average follow-up time was of 2.0 ± 1.1 years (range 0.5-4.9 years). Of the 137 patients included in the study, 11 (8%) had a subsequent complication associated with the use a of a QTA. Baseline demographic characteristics of this cohort are summarized in (Table 1). Of the 11 patients with QTA related complications, 8 (6%) had a subsequent procedure to remove non- absorbable sutures used for the donor site closure. When we first began to perform QTA ACLR, non- absorbable sutures were used to close the donor site defect. We encountered a subset of patients that developed persistent donor site irritation and pain associated to the use of such sutures, and consequently changed our technique to use absorbable sutures. Interestingly, 2 (1%) patients developed OCD-like lesions in the superior aspect of the patella 1.2 ± 0.8 years on average following surgery (Fig 1). We speculate that the QTA harvest could have compromised the vasculature of the patella, thus resulting in the development of OCD and subsequent chondromalacia. Finally, 2 (1%) patients had quadriceps tendon ruptures following QTA ACLR. The first patient aged 16, slipped and fell onto a hyperflexed left knee 6 weeks after QTA ACLR and sustained a small boney avulsion injury of the superior pole of the patella. During repair, cultures were taken, and rare Staphylococcus aureus were identified. The patient was placed on Keflex for 4 weeks, however 2 weeks after finishing treatment they presented with sudden limited range of motion, increased pain, and a yellow appearing scab. An ultrasound guided aspirated was positive for Staphylococcus aureus, and the patient subsequently underwent an infection and debridement procedure. The second patient, aged 14, sustained a non-contact injury while playing football 7 months post- operatively prior to being cleared to return to sports. They sustained a complete tear of the distal quadriceps tendon, adjacent to the donor site. Of note, 1 patient underwent a concomitant removal of non-absorbable sutures and patellar chondromalacia debridement and is thus represented twice. In addition, 5 (4%) patients had a graft failure and underwent subsequent revision ACLR, 6 (4%) had a second meniscus related surgery, 8 (6%) had a subsequent lysis of adhesions procedure and 13 (9%) underwent ACLR for injuries sustained on the contralateral knee. Conclusions: In this study, we report complications encountered with soft tissue QTA for ACLR. The complication rate for quadriceps tendon graft harvest was 8%. However, given that the removal of non- absorbable sutures from the donor site was caused by the surgical technique used, the revised complication rate for quadriceps tendon graft harvest was 3%. To the authors’ knowledge, this is the first study to raise the suspicion that quadriceps tendon graft harvest could lead to the development of super patellar OCD as this occurred in two patients from this cohort. Although the use of a QTA has recently gained popularity due to its high return to sports and low graft failure rate, surgeons must be aware of the complications and risk associated with quadriceps tendon graft harvest. [Table: see text]

Use of Peripheral Nerve Blocks Is Not Associated With Decreased Postoperative Opioid Prescription After ACL Reconstruction in Adolescents.

The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P<.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P<.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P<.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P<.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [Orthopedics. 2024;47(2):83-88.].

Complications Following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Case Series

Complications Following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Case Series

Long-Term Outcomes after Pediatric Mandibular Reconstruction Using Vascularized Free Fibula Flap.

The purpose of this study was to evaluate the long-term outcomes of mandibular reconstruction with vascularized free fibula flap in pediatric patients. Consecutive cases of mandibular reconstruction with vascularized free fibula flaps in pediatric patients at Peking University School and Hospital of Stomatology between 1999 and 2019 were reviewed. Postoperative computed tomography (CT) data of all patients were collected at each postoperative follow-up point, and after the age of 18 years. The length and height of the grafted fibula and the length of the remaining mandible were evaluated by measuring the three-dimensional CT data using ProPlan CMF 3.0 software. Lower limb function was evaluated using the Enneking evaluation scale. Facial symmetry was self-evaluated and scored. Statistical analysis was performed on the data obtained. Fourteen patients were included in this study. All flaps were successful. The CT measurement results showed growth in the length of the grafted fibula that reconstructed the mandibular ramus and the residual mandible ( P < 0.05). The height of the grafted fibula remained stable ( P > 0.05). Eight patients were followed up until they were older than 18 years, and the CT measurement results after 18 years showed an essentially symmetric mandible profile ( P > 0.05). All patients were satisfied with their postoperative facial symmetry. Enneking evaluation scores showed good recovery of lower limb functions. The vascularized free fibula flap for mandibular reconstruction in pediatric patients is safe and reliable. It also provides good cosmetic and functional outcomes, as it demonstrated positive growth. Therapeutic, IV.

V01-03 SINGLE-PORT MINI PFANNENSTIEL ROBOTIC EXTRAPERITONEAL PEDIATRIC PYELOPLASTY: INITIAL EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023V01-03 SINGLE-PORT MINI PFANNENSTIEL ROBOTIC EXTRAPERITONEAL PEDIATRIC PYELOPLASTY: INITIAL EXPERIENCE Jaya Sai Chavali, Brendan Frainey, Albert Geskin, Ethan Ferguson, Roxana Ramos, Audrey Rhee, and Jihad Kaouk Jaya Sai ChavaliJaya Sai Chavali More articles by this author , Brendan FraineyBrendan Frainey More articles by this author , Albert GeskinAlbert Geskin More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Audrey RheeAudrey Rhee More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aim to report our technique and functional and radiological outcomes of extra peritoneal robotic pediatric pyeloplasty through a mini-pfannenstiel (3 cm) incision using da-Vinci single-port (SP) robotic surgical system in pediatric population. METHODS: We present our initial series of 8 pediatric patients that underwent robotic SP pyeloplasty between 2020 - 2022. The case presented in current video is 1 year old male with known history antenatal hydronephrosis that presented with worsening postnatal hydronephrosis and renal function on split function and renal ultrasound imaging studies. The patient underwent cystoscopy, stent placement that confirmed severe ureteropelvic junction (UPJ) obstruction prior to proceeding with robotic surgery. He was placed in relaxed lateral position, extra peritoneal space was developed through mini pfannenstiel incision before docking the SP surgical system. The following robotic surgical steps were described: (1) development of extra peritoneal space, (2) identification of ureter and ureteropelvic junction, (3) dismemberment and reduction of redundant renal pelvis, (4) ureteropelvic junction anastomosis using running 5-0 Vicryl sutures. RESULTS: Overall operative time was 120 minutes and associated with minimal blood loss. No complications and patient discharged on POD1 and stent removed in 4 weeks as outpatient. The attached tables describe our study patient demographics, indications (Table 1) and outcomes among our study population (Table 2). All patients tolerated the surgery with minimal postsurgical pain and no narcotic requirement. CONCLUSIONS: Single port extra peritoneal pyeloplasty is a safe and feasible option for upper tract reconstruction in pediatric patients. All patients had complete resolution of symptoms both clinically and based on imaging upon follow up. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e79 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jaya Sai Chavali More articles by this author Brendan Frainey More articles by this author Albert Geskin More articles by this author Ethan Ferguson More articles by this author Roxana Ramos More articles by this author Audrey Rhee More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of clinical outcomes between anterior cruciate ligament reconstruction with over-the-top route procedure and anatomic single-bundle reconstruction in pediatric patients

The purpose of this study is to evaluate the clinical results of over-the-top route (OTTR) reconstruction for pediatric anterior cruciate ligament (ACL) injuries and compare them with results of anatomic single-bundle reconstruction (SBR), which used the bone tunnel technique and was performed early after epiphyseal closure (age ≤15 years). This study included pediatric patients aged 11-15 years who underwent ACL reconstruction. The mean age at surgery was 13.4 years (11-15 years), including 14 men and 29 women. Operative procedures were determined according to growth plate closure. In all cases, the tibial side was reconstructed using a bone tunnel procedure. On the femoral side, we selected the OTTR procedure (group O) with open physis. Where the physis was closed, we selected the anatomical SBR (group B). The clinical results were evaluated with manual examination, the side-to-side difference (SSD) in tibial anterior translation using the Kneelax 3, and knee function score. There were no significant differences in the Lachman and pivot-shift tests, SSD in tibial anterior translation with Kneelax 3, or knee function score between the two groups before or after the surgery. Growth disturbance was not observed on either the femoral or tibial side in group O. The OTTR method provided comparable results with the bone tunnel anatomical method in manual examination, Kneelax 3, and knee clinical function scores, suggesting that the OTTR method is very useful for pediatric ACL reconstructions. Level of evidence: III; retrospective study.

Posterior Cruciate Ligament and Patellar Tendon Can Predict Anterior Cruciate Ligament Size for Planning During ACL Reconstruction in Pediatric Patients

To establish correlations between the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and patellar tendon in normal pediatric knees to inform surgical planning for ACL reconstruction graft size. Magnetic resonance imaging scans of patients ages 8 to 18 years were assessed. Measurements included ACL and PCL length, thickness, and width, and ACL footprint thickness and width at the tibial insertion. Interrater reliability was assessed with a random set of 25 patients. Pearson correlation coefficients were used to assess the correlation between ACL, PCL, and patellar tendon measurements. Linear regression models were used to test whether the relationships differed by sex or age. Magnetic resonance imaging scans of 540 patients were assessed. Interrater reliability was high for all measurements except PCL thickness at midsubstance. Sample equations for estimating ACL size are as follows: ACL length= 22.61+ 1.55∗PCL origin width (R2= 0.46; 8- to 11-year-old male patients), ACL length= 12.37+ 0.58∗PCL length+ 2.29∗PCL origin thickness - 0.90∗PCL insertion width (R2= 0.68; 8- to 11-year-old female patients), ACL midsubstance thickness= 4.95+ 0.25∗PCL midsubstance thickness+ 0.04∗PCL insertion thickness - 0.08∗PCL insertion width (R2= 0.12; 12- to 18-year-old male patients), and ACL midsubstance width= 0.57+ 0.23∗PCL midsubstance thickness+ 0.07∗PCL midsubstance width+ 0.16∗PCL insertion width (R2= 0.24; 12- to 18-year-old female patients). We found correlations between ACL, PCL, and patellar tendon measurements that can be used to create equations that predict ACL size in various dimensions based on PCL and patellar tendon measurements. There is a lack of consensus on the ideal ACL graft diameter for pediatric ACL reconstruction. The findings from this study can assist orthopaedic surgeons to individualize ACL graft size for specific patients.

Surgical outcomes of robotic-assisted cyst excisions and hepaticojejunostomies in patients with perforated choledochal cysts: a single-centerretrospective study.

Perforated choledochal cysts is usually treated by open approach through a one- or two-stage procedure. Laparoscopic procedures are gradually being used more commonly with advancements in minimally invasive technology, while the level of difficulty and conversion rate are still high due to adhesions and deranged anatomy. Robot-assisted choledochal cyst excisions have been proposed as another minimally invasive procedure that is thought to improve operability and precision compared with laparoscopic surgery. However, there is still a lack about the use of robotic assistance for bilio-enteric reconstruction in pediatric patients with perforated choledochal cyst excisions. The aim of this current study was to investigate the safety and effectiveness of robotic-assisted procedures in pediatric perforated choledochal cyst excisions. Patients suffering from perforated choledochal cysts and treated with surgical procedures including open, laparoscopic, and robotic procedures between January 2009 and December 2021 were retrospectively analyzed. Robotic cyst excisions and hepaticojejunostomies were mainly used to a one-stage procedure (the pseudocyst formation or intra-mural perforation) or in stage 2 of two-stage procedures (complete perforation). Data collection included patient characteristics, intraoperative outcomes, and postoperative complications. There were a total of 64 patients suffering from perforated choledochal cysts were treated at our institution. Thirty-one cases of cyst excisions and hepaticojejunostomies were completed by open procedures. Twenty-two cases of cyst excisions and hepaticojejunostomies were completed by laparoscopic procedures and 11 cases were completed by robotic procedures. The operating times were significantly longer in the laparoscopic procedures group (214.32 ± 51.33min) than found with either the open procedures group (130.55 ± 10.51min) or the robot-assisted procedures group (188.82 ± 16.55min) (p < 0.001). The time to oral intake, total complication, and hospital stay were similar among all three groups (3.53 ± 0.28days vs 3.47 ± 0.30days vs 3.46 ± 0.29days, 19.35% vs 27.27% vs 18.18%, 11.48 ± 1.29days vs 11.95 ± 2.75days vs 11.55 ± 2.38days, respectively) (p > 0.05). The number of biliary complications was higher in the laparoscopic procedures group (18.18%) than in both the open procedures and robot-assisted procedures groups (0.00%) (p = 0.016). Robotic-assisted cyst excision and hepaticojejunostomy procedures in patients with perforated choledochal cysts are both safe and feasible. What is more, they can achieve the same results as open procedures and also reduce the level of difficulty of operations and bring fewer biliary complications compared with laparoscopic procedures.

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction in Pediatric Patients: Surgical Technique

Anterior cruciate ligament (ACL) rupture is a common affliction in the athletic population. In pediatric patients, the immature skeleton with active growth plates is an issue that makes ACL reconstruction surgery technically challenging. The rerupture rate after ACL reconstruction is higher in the pediatric population than in the adult population. The addition of anterolateral ligament (ALL) reconstruction has been shown to be an effective way to reduce the rate of graft rupture and to control rotatory instability (pivot shift). Therefore, it appears necessary to combine ACL and ALL reconstruction in the pediatric population. We describe the surgical steps for combined ACL and ALL reconstruction adapted for young patients with active growth plates.

Peripheral Nerve Blockade for Medial Patellofemoral Ligament Reconstruction in Pediatric Patients: The Addition of a Proximal Single-Injection Sciatic Nerve Block Provides Improved Analgesia.

PurposeWe tested the hypothesis that the addition of a single-injection proximal sciatic nerve block to an adductor canal block would significantly reduce pain scores and opioid requirements compared to a group of patients that received only an adductor canal or femoral nerve block for medial patellofemoral ligament reconstruction in pediatric patients. The primary end-point is the number of patients achieving a Patient Acceptable Symptom State (PASS) (pain score less than four) for the entire 24-hour postoperative period in patients with and without a proximal sciatic block.Patients and MethodsThis is a retrospective cohort study of 144 consecutive pediatric patients, ages 10 to 18 years, undergoing medial patellofemoral ligament reconstruction with peripheral nerve blockade for postoperative analgesia from 2016–2020 at a pediatric orthopedics children’s hospital. Patients were divided into 2 cohorts with and without a proximal sciatic nerve block: group A/F: adductor canal or femoral CPNB and group AS: adductor canal CPNB and a proximal single-injection sciatic nerve block.ResultsThere was strong evidence for an increase in the number of patients who reported a pain score less than four for the entire 24-hour postoperative period in the group that received the additional proximal sciatic block. (PASS: A/F 13/62 (21%) vs AS 43/82 (52%), p<0.001) There was strong evidence for a reduction in mean and maximum pain scores and opioid requirements in the first 24-hours after surgery in the proximal sciatic group.ConclusionThe addition of a proximal sciatic nerve block was associated with significantly reduced mean and maximum pain scores and opioid requirements after medial patellofemoral ligament reconstruction in pediatric patients and supports a randomized clinical trial to confirm these findings. Based on the results of this study we recommend the addition of a proximal sciatic nerve block, anterior or posterior, to an adductor canal block to provide improved analgesia and reduced opioid requirements in the 24-hours after MPFLR in pediatric patients.

Rates of Infection After Pediatric ACL Reconstruction: A Marketscan Database Study of 44,501 Patients

Introduction:Anterior cruciate ligament reconstruction (ACL-R) is increasingly performed in pediatric patients. Infection after ACL-R is among the most serious complications. The use of administrative data has been validated for the assessment of infection after ACL reconstruction. While infection after ACL-R has been well investigated in adults, the literature is limited for ACL reconstruction in pediatric patients.Purpose:Describe and analyze the rates of infection after ACL-R among pediatric patients, compared to young adult patients, utilizing the MarketScan database.Methods:The Truven Health Analytics MarketScan Commercial Claims and Encounters database was assessed to access health care utilization data for privately insured individuals aged 5-30 years old. ACL-R records performed between 2006 and 2018 were obtained using Current Procedures Terminology (CPT) and International Classification of Diseases Ninth Revision (ICD-9) and Tenth (ICD-10) codes. The presence of postoperative infection requiring reoperation was assessed utilizing previously published algorithms. All patients had at least 180 days of insurance coverage after intervention.Results:The ACL-R cohort included 44,501 individuals under 18 years old and 53,915 individuals aged 18-30 years old. The rate of infection after ACL-R in patients under 18 years of age was 0.52%, and was similar to patients 18-30 years old (0.47%, p=0.213). Among patients <18 years old, patients <15 years old had a significantly lower rate of infection at 0.37% compared to adolescents (15.0-17.9 years old) at 0.55% (p=0.039). For those less than 18 years old, males were significantly more likely to have an infection after ACL-R (0.73%) compared to females (0.53%, p=0.008).Discussion:Utilizing an insurance database, this study demonstrated that rates of infection after an ACL-R are relatively low (0.52%) and are similar to rates in young adults, despite the differences in graft utilization. Both age less than 15 and female sex were associated slightly lower rates of infections in pediatric patients.Figure 1.Rates of infection after ACL-Reconstruction (ACLR) in each age group over the study time period. There was significant difference in rate of infection in those <18 years old, Adolescents (15.0-17.9 years old) had significantly higher rate of infection than Pediatric patient (<15.0 years old). No differences were observed for those older than 18 years old (Young Adult [18.0-24.9 years old] and those >18 years old.

Isolated Lateral Release is Inferior to Medial Patellofemoral Ligament Reconstruction for Surgical Management of Patella Instability in Pediatric Patients

Background:The optimal treatment for chronic patella instability remains controversial. Medial patellofemoral ligament reconstruction (MPFLR) has emerged as the “gold standard” for soft tissue stabilization. However, isolated lateral release (ILR) is still commonly performed to treat chronic patella instability despite growing evidence against this approach.Hypothesis/Purpose:Our purpose is to evaluate long-term revision rates and short-term post-operative complications in pediatric patients undergoing either MPFLR or ILR for recurrent patellar instability. The hypothesis is that MPFLR is a superior treatment option with reduced long term revision rates and comparable short-term complications.Methods:The MarketScan database was queried from 2007-2015 to identify patients who underwent MPFLR or ILR as their primary surgical treatment of their chronic patellar instability. Patients were excluded if they had incomplete records up to 5 years or if they underwent concomitant osteotomy or cartilage restoration during their index stabilization procedure. Baseline demographic data and patient co-morbidities were documented. Two and five year revision surgical stabilization rate and post-operative complications were reported. Results were analyzed statistically.Results:This study identified 471 patients (mean age 15.6 years, female 56.9%) who underwent MPFLR and 528 patients (mean age 15.5 years, female 70.5%) who underwent ILR for chronic patellar instability. Patients were stratified into two mutually exclusive groups: 1) MPFLR only or 2) ILR only. Patients who underwent MPFLR experienced higher rates of overall complications within 90 days of surgery (8.7% vs 4.9%, p = 0.0171). MPFLR had a higher rate of early wound complications (0.8% vs. 0%, p <.033) There was no difference in revision stabilization rate between MPFLR and ILR at 2 year follow-up. However, at 5 years of follow-up, 8.9% of patients who underwent ILR underwent revision surgery compared to 3.0% of patients who underwent MPFLR as their index surgery (p < 0.0001).Conclusions:Isolated lateral release is an inferior treatment option for surgical stabilization of chronic patella instability as compared to medial patellofemoral ligament reconstruction in pediatric patients. Despite slightly higher rate of short term complications in the MPFLR group and similar revision rates at 2 years, MPFLR has significantly decreased risk of revision stabilization at 5 year follow-up.Table 1.Postoperative Complications - within 90 daysTable 2.Quality Outcomes

Mechanical Properties of Pediatric Knee Ligaments and The Iliotibial Band

Background:Substantial research about the mechanical properties of adult knee ligaments exists, but comparatively little is known about the pediatric knee. Choosing a graft for ligament reconstruction in pediatric patients is limited by the lack of knowledge of the mechanical properties of those ligaments and potential graft options in the skeletally immature.Purpose:Describe the mechanical properties of the ACL, PCL, MCL, LCL, and iliotibial band (ITB) in pediatric patients.Methods:Skeletally immature fresh frozen whole knees from 18 human cadavers (mean specimen age = 10.4 years) were thawed and the ligaments grossly dissected with bone block attachments intact, and length, width, and thickness were measured. Specimens were tested as a single unit (for those containing multiple bundles) and hydrated throughout testing. Each specimen was secured in an MTS machine and underwent a tensile loading protocol to measure ultimate tensile strength, ultimate tensile strain, and linear modulus.Results:Under testing, the ACL exhibited ultimate tensile strength (8.7 +/- 4.1 MPa), ultimate tensile strain (54.4 +/- 20.8%), and linear modulus (31.0 +/- 22.8 MPa) that were similar to the PCL (9.8 +/- 6.6 MPa, 48.6 +/- 22.1%, and 47.9 +/- 53.5 MPa, respectively). The LCL ultimate tensile strength was 18.7 +/- 6.5 MPa, ultimate tensile strain was 57.2 +/- 22.2%, and linear modulus was 68.7 +/- 50.8 MPa, compared to the MCL (19.5 +/- 13.9 MPa, 38.9 +/- 15.7%, and 93.3 +/- 75.1 MPa, respectively). Finally, the ITB demonstrated an ultimate tensile strength of 11.8 +/- 4.4 MPa, ultimate tensile strain of 42.6 +/- 14.9%, and linear modulus of 55.5 +/- 27.7 MPa.Conclusion:The ITB demonstrated greater ultimate tensile strength and a higher linear modulus than the ACL and PCL, with a lower ultimate tensile strain. Conversely, the ITB demonstrated lower values for ultimate tensile strength and linear modulus than the LCL and MCL. The ITB may serve as a reasonable substitute for native ACL and PCL reconstruction due to similar ultimate tensile strengths. The ITB may be less well-suited to reconstruct the LCL and MCL due to more significant differences in ultimate tensile strength.Table 1.Demographics and select results of Pediatric Cadaver Specimens (n=18). MPa = megapascals.Figure 1.Biomechanical Strength of Ligaments in Pediatric Cadaver Specimens (n=18). Error bars indicate standard deviation.