Reconstruction In Pediatric Patients Research Articles

Pediatric Wound Closure by a Tension-Relief System.

Surgical reconstruction in pediatric patients can often be complex. Primary wound closure is almost always the preferred technique in the reconstructive ladder; however, it is not always possible in pediatric patients. We report the pediatric use of the TopClosure Tension-Relief System, an innovative skin-stretching technique for secure primary wound closure of large defects. We modified the technique by fixating it to a protective dressing instead of the patient's skin, thus avoiding both staple scars and pain. A retrospective review of 112 patients aged 7 days to 18 years who underwent Tension-Relief System-assisted surgery at a tertiary medical center from 2010 to 2020 was conducted. Cases included congenital deformities, traumatic wounds, burn scars, and complicated-wounds, with or without hardware or deep tissue exposure. The use of the system avoided the need for multiple surgical sessions and for local or regional flaps. The technique was simple to use, with few complications, and led to satisfactory aesthetic and functional outcomes. The findings support using the technique in children and adolescents with challenging tension wounds. Herein, we report on our experience with the Tension-Relief System and detail four cases in which early or immediate closure was successfully achieved.

The Impact of Concomitant Meniscus Repair on Functional and Patient Reported Outcomes at Return to Activity in Paediatric Patients Undergoing ACL Reconstruction

Background:Paediatric patients undergoing Anterior Cruciate Ligament (ACL) reconstruction often present with a repairable meniscus tear. When a conservative early post-operative rehabilitation protocol is used to protect the meniscus repair, some have wondered whether this has an effect on functional and subjective outcomes, or time required, at return to activity.Purpose:The goal of this study was to compare the quantitative lower limb functional measures and subjective patient reported outcome scores at Return to Activity (RTA) in paediatric patients undergoing ACL reconstruction, with or without meniscus repair.Methods:This study was performed as a retrospective comparative cohort analysis of prospectively collected data in paediatric patients undergoing ACL reconstruction. Inclusion criteria for this study included a full data set and a visit to our biomechanics lab post-operatively, after being cleared for RTA by their attending surgeon. If a repairable meniscus injury was present, it was repaired concurrently with ACL reconstruction. Patients with a meniscus repair were provided rehabilitation guidelines that included partial weightbearing and limited range of motion (ROM) for six weeks, whereas full weightbearing and unrestricted ROM was recommended for the non-meniscal repair group. Postoperative quantitative knee functional outcome variables (drop vertical jump ground reaction forces, isometric knee extension/flexion strength, and hip abduction strength) were expressed as limb symmetry indices (LSIs; reconstructed limb/uninjured limb). Patient reported subjective knee outcome scores (Tegner and HSS Pedi-FABS) were also obtained. Differences in outcome measures were assessed using Mann-Whitney U-test and independent T-tests.Results:Twenty-four paediatric ACL reconstruction patients met criteria for inclusion in this study. Thirteen patients had a meniscus repair (median age 15 (13-17)) and 11 patients did not (median age 15.8 (14-17)). The median days between surgery and follow-up was 267 (168-460) days for the meniscus repair group and 251 (167-435) days for the non-meniscus repair group. There were no differences between the groups for the postoperative drop vertical jump test (p=0.21), knee extension/flexion strength (p=0.88/0.46) and hip abduction strength (p=0.46). Both groups also displayed similar Tegner (6.1/6.2) and Pedi-FABS (12.5/12.8) scores.Conclusion:Despite conservative weight-bearing and range of motion restrictions, repair of the meniscus in combination with ACL reconstruction in pediatric patients does not appear to induce a meaningful strength deficit at the return-to-activity evaluation phase, and is therefore not expected to influence return to activity in comparison with non-meniscus repair patients. This is important guidance for paediatric patients, families, and rehabilitation professionals involved in the care of young athletes.Table 1.Patient characteristicsTable 2.Post-operative patient reported outcome scores

Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients.

The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes. Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively. A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL. Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size. Level IV: case series.

The microvascular reconstruction in children with maxillofacial defects: A Systematic Review

Background: Facial bones trauma in the pediatric population is linked to severe damage and impairment, particularly in maxillofacial, particularly in area. In addition, reconstruction of maxillofacial in pediatric patients has some unique considerations. Therefore, this study described the effectiveness of microvascular reconstruction in children with maxillofacial defects.Methods: The relevant literature from PubMed and Science Direct databases. The strategic search is using the keywords such as "Pediatric" OR "Children" OR "Under-eighteen years" AND "microvascular reconstruction" OR "microvascular surgery" AND "maxillofacial defect". We used a PRISMA method to the selection of those articles. The inclusion criteria were related to microvascular reconstruction in children with maxillofacial defects from 2000-2021.Result: Total of six studies entries with inclusion criteria. These studies show that most free flaps or microvascular reconstruction procedures carried on pediatric patients to resolve maxillofacial defects gave successful functional, and clinical outcomes. In addition, a few complications, mainly infections, occurred following the surgery, however successfully managed with antibiotics.Conclusion: A microvascular reconstruction is a good option for maxillofacial defects reconstruction in pediatric patients due to a shorter surgical time and faster recovery.

Wharton’s Jelly–Mesenchymal Stem Cell–Engineered Conduit for Pulmonary Artery Reconstruction in Growing Piglets

Surgical treatment of congenital heart defects affecting the right ventricular outflow tract often requires complex reconstruction and multiple reoperations. With a randomized controlled trial, we compared a novel tissue-engineered small intestine submucosa-based graft for pulmonary artery reconstruction (seeded with mesenchymal stem cells derived from Wharton's Jelly) with conventional small intestine submucosa in growing piglets. Six months after implantation, seeded grafts showed integration with host tissues at cellular level and exhibited growth potential on transthoracic echocardiography and cardiovascular magnetic resonance. Our seeded graft is a promising biomaterial for pulmonary artery reconstruction in pediatric patients with right ventricular outflow tract abnormalities.

Image quality and diagnostic accuracy of reduced-dose computed tomography enterography with model-based iterative reconstruction in pediatric Crohn\u2019s disease patients

This study assessed the image quality and diagnostic accuracy in determining disease activity of the terminal ileum of the reduced-dose computed tomography enterography using model-based iterative reconstruction in pediatric patients with Crohn’s disease (CD). Eighteen patients were prospectively enrolled and allocated to the standard-dose (SD) and reduced-dose (RD) computed tomography enterography (CTE) groups (n = 9 per group). Image quality, reader confidence in interpreting bowel findings, accuracy in determining active CD in the terminal ileum, and radiation dose were evaluated. Objective image quality did not show intergroup differences, except for image sharpness. Although reader confidence in detecting mural stratification, ulcer, and perienteric fat stranding of the RD-CTE were inferior to SD-CTE, RD-CTE correctly diagnosed active disease in all patients. The mean values of radiation dose metrics (SD-CTE vs. RD-CTE) were 4.3 versus 0.74 mGy, 6.1 versus 1.1 mGy, 211.9 versus 34.5 mGy∙cm, and 4.4 versus 0.7 mSv mGy∙cm for CTDIvol, size-specific dose estimation, dose-length product, and effective dose, respectively. RD-CTE showed comparable diagnostic accuracy to SD-CTE in determining active disease of the terminal ileum in pediatric CD patients. However, image quality and reader confidence in detecting ulcer and perienteric fat stranding was compromised.

Forecasting the flap: predictors for pediatric lower extremity trauma reconstruction.

BackgroundPredicting the need for post-traumatic reconstruction of lower extremity injuries remains a challenge. Due to the larger volume of cases in adults than in children, the majority of the medical literature has focused on adult lower extremity reconstruction. This study evaluates predictive risk factors associated with the need for free flap reconstruction in pediatric patients following lower extremity trauma.MethodsAn IRB-approved retrospective chart analysis over a 5-year period (January 1, 2012 to December 31, 2017) was performed, including all pediatric patients (<18 years old) diagnosed with one or more lower extremity wounds. Patient demographics, trauma information, and operative information were reviewed. The statistical analysis consisted of univariate and multivariate regression models to identify predictor variables associated with free flap reconstruction.ResultsIn total, 1,821 patients were identified who fit our search criteria, of whom 41 patients (2.25%) required free flap reconstruction, 65 patients (3.57%) required local flap reconstruction, and 19 patients (1.04%) required skin graft reconstruction. We determined that older age (odds ratio [OR], 1.134; P =0.002), all-terrain vehicle accidents (OR, 6.698; P<0.001), and trauma team activation (OR, 2.443; P=0.034) were associated with the need for free flap reconstruction following lower extremity trauma in our pediatric population.ConclusionsOur study demonstrates a higher likelihood of free flap reconstruction in older pediatric patients, those involved in all-terrain vehicle accidents, and cases involving activation of the trauma team. This information can be implemented to help develop an early risk calculator that defines the need for complex lower extremity reconstruction in the pediatric population.

Evaluation of Complication Rates of Free Flap Reconstruction in Pediatric Patients.

Introduction:While there is extensive literature investigating surgical outcomes in free flaps for adults, there is a dearth of information on the efficacy of flap use in the pediatric population. This study is the first to measure complication rates following pediatric free flap reconstruction on a national level.Methods:All pediatric free flap cases between 2012 and 2018 were identified and stratified by type of flap using current procedural terminology codes assigned to the primary procedure in the National Surgical Quality Improvement Program database. Each entry included the recipient location of the flap, postoperative complications, and demographics. Chi-square analysis was used to compare complication rates across various flap groupings. In addition, univariate and multivariate analyses were used to identify independent predictors of flap complications or failure.Results:Multivariate regression analysis demonstrated that compared to bone flaps, there is increased risk of nonbleeding complications in skin (Odds Ratio (OR) =7.7, P = 0.029), muscle (OR = 10.6, P = 0.012), and osteocutaneous flaps (OR = 10.8, P = 0.018). Flap of the trunk (OR = 40.9, P = 0.003) and upper extremities (OR = 32.9, P = 0.041) had a higher odds of bleeding complications compared to head-and-neck flaps. Regression analysis also showed that older age is associated with bleeding complications, with patients aged 5–11 years (OR = 38.5, P = 0.027) and 12–17 years (OR = 30.6, P = 0.038) having greater rates compared to patients under the age of 2. The pediatric flap reoperation rate was found to be 3.6%–4.7%, with the highest flap anastomotic complication rate in the head-and-neck region (6.9%–8.0%).Conclusion:Free flap reconstruction across flap type, anatomic location, and age ranges are safe and efficacious in the pediatric population.

Safety of Contemporary Resorbable Fixation Systems for Craniofacial Reconstruction in Pediatric Patients.

Resorbable hardware allows adequate strength for maintaining the relative position of the craniofacial skeleton during osseous healing, and allowing subsequent growth in pediatric patients. The purpose of this study was to determine the complication profile of the latest copolymer of resorbable plates for craniofacial reconstruction in pediatric patients. Retrospective query of the operative billing record was performed for use of the DePuy Synthes Rapidsorb Fixation System at the authors' tertiary children's hospital from 2015 to 2019. Three hundred twenty-five patients were randomly selected for analysis of complications within the first postoperative year. Median age at craniofacial reconstruction was 3.0 years, with 127 procedures (39.9 percent) performed for an intracranial mass and 141 procedures (44.3 percent) performed for craniosynostosis. Overall, 7.9 percent patients had a postoperative wound complication. The most common complications were dehiscence (3.8 percent), hematoma/seroma (3.5 percent), and infection (2.5 percent). There were no instances of extrusion, plate fracture, or screw loosening. Hardware complications in the temporoparietal region were more likely to occur at incision sites (p = 0.001), whereas wound complications at the frontal region were more likely to occur away from incision sites (p < 0.001). There were no differences in complications between plates secured with resorbable screws or with the resorbable injectable polymer system (p ≥ 0.161 for all). Radiotherapy was significantly implicated in development of clinical infection (p = 0.001), culture-positive infection (p < 0.001), readmission (p = 0.007), reoperation (p = 0.003), and plate removal (p = 0.007). Resorbable cranial hardware has an overall favorable complication profile for craniofacial reconstruction in pediatric patients undergoing surgical intervention for craniosynostosis or intracranial mass resection.

Pediatric Mandibular Reconstruction Using the Vascularized Fibula Free Flap: Functional Outcomes in 34 Consecutive Patients.

The vascularized fibula free flap is a workhorse flap in pediatric mandibular reconstruction. This study aimed to address functional outcomes, complications, and morbidity associated with the fibula resection in a consecutive series of mandibular reconstruction using this technique in skeletally immature patients. Functional outcomes in terms of maximal mouth opening capacity, patient-reported eating ability, occlusion, and gait were retrospectively reviewed in 34 consecutive pediatric patients (18 males, 16 females) who underwent mandibular reconstruction using the vascularized free fibula flap. Data regarding donor and recipient site complications were also retrieved. The mean follow-up period was 50.6 months (range, 12-108 months). The average age was 10.3 years (range, 2-15 years). Underlying pathologies included ossifying fibroma, ameloblastoma, mandibular arteriovenous malformation, fibrous dysplasia, Goldenhar syndrome, dentigerous cyst, mandibular lymphoma, odontogenic fibroma, adenomatoid odontogenic tumor, aneurysmal bone cyst, neurogenic sarcoma, and central giant cell granuloma. Defect length ranged from 8 to 17 cm. Mean return to normal ambulation was achieved 12 days postoperatively. All patients reported ability to eat solids and liquids, with 29 of 34 achieving normal mouth opening. Normal or minimally disturbed occlusion was maintained postoperatively in most patients. Temporomandibular joint ankylosis and condylar displacement were each developed in one patient. Two patients reported gait disturbances that receded after physical therapy. No other major donor site complications, including flexion contracture of the great toe, were identified. The vascularized fibula free flap is reaffirmed to be the criterion standard for mandible reconstruction in pediatric patients, providing satisfactory functional results and adequate adaptation to the growing facial skeleton with minimal sequelae. Complications regarding hallux function may be prevented by assessing the vascularity of the flexor hallucis longus intraoperatively and ensuring tension-free closure of the donor site.

Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review.

We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes. PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized. Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low. Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.

Donor-Site Morbidity Following Free Fibula Flap Harvest for Mandibular or Maxillary Reconstruction in Pediatric Patients.

The morbidity at the donor-site in the free fibula flap is a well-studied fact in the adult population, but in children, there are few reports of the long-term adverse effects at the donor site. In this study, we evaluate donor-site morbidity, complications, and functional outcome in pediatric patients undergoing free fibula flap harvest for mandibular or maxillary reconstruction, and the relation between pain and walking abilities. A retrospective study of 22 pediatric patients undergoing free fibula flap harvest for mandibular and maxillary reconstruction between 2003 and 2014 was conducted. A certified point evaluation system was used, analyzing several factors like pain, walking ability, restriction in activities, gait alteration, paresthesia, and cosmetic appearance, and the relationship between variables. Mean age follow up of patient was 8.5 years (range 2-13 years). Pain was reported in 27% (n = 6), paresthesia and numbness 9% (n = 2), walking ability alteration in 50% (n = 11), restriction in activities in 18% (n = 4), gait alteration in 23% (n = 5), and cosmetic appearance alteration in the 14% (n = 3). We compare the pain and the gait alteration and did not find any relation between pain and gait alteration (P = 0.6016) and there was no relation between restriction in activities and walking ability (P = 0.1455). Free fibula flap is the gold standard for head and neck reconstruction, but the morbidity at the donor site, especially in a growing child, should not be ignored or minimized when counseling patients and their families.More studies, with more population and with a long-term follow-up should be carried out to determine the impact on the daily activities on the pediatric population.

Pedicled Anterolateral Thigh Flap

Background: Once it has been first described by Song et al., in 1984, anterolateral thigh (ALT) flap gains wide popularity as a free flap with only a few reports in the literature regarding its application as a pedicled flap in regional soft-tissue reconstruction in pediatric patients. Materials and Methods: The author describes his experience about the role of pedicled ALT flap in reconstruction of different local defects in pediatric patients. Representative cases are presented for illustration. Results: Nine patients with ischial, trochanteric, and groin defects have been reconstructed by pedicled ALT flap between January 2018 and January 2019. The patients were between 7- and 15-year-old. The size of the flaps measured from 4 cm × 6 cm to 19 cm × 17 cm. The type of the flap was myocutaneous flaps in six cases and as perforator flaps in three cases. Primary closure of the donor site has been done in seven cases while split-thickness skin grafts were done in two cases. Eight flaps have been totally survived while partial necrosis has been occurred in the distal end of one case. Conclusion: Pedicled ALT flap provide a reliable and versatile option for plastic surgeons in reconstruction of difficult regional soft-tissue defects in pediatric patients especially when bulkiness and resistance of infection is indicated, with accepted functional and cosmetic results.

Modification of the Hybrid Anatomic Technique for Anterior Cruciate Ligament Reconstruction in Pediatric Patients

The incidence of anterior cruciate ligament (ACL) lesions with Tanner stage ≤4 has been increasing in children. To stabilize the knee, different surgical techniques have been developed for ACL reconstruction in the pediatric population. The use of a hybrid anatomic technique, intra-epiphyseal in the femur and transphysis in the tibia, has been recommended as the technique of choice to reconstruct the ACL in these patients. Despite the favorable results, this technique is not exempt from complications. The aim of this study was to present a simple and reproducible modification of the hybrid anatomic technique for ACL reconstruction in pediatric patients.

Pediatric Mandible Reconstruction: Controversies and Considerations.

SummaryMandibular reconstruction in pediatric patients has some unique considerations. The method of reconstruction has to factor in the growth potential of the neo-mandible, the native mandible, and the donor site. The condyle is considered the main growth center of the mandible. Current literature indicates that fibula, iliac crest, and scapula osseous flaps do not have the ability to grow. Costochondral grafts exhibit growth because of the costal cartilage component, although the growth is unpredictable. Preservation of the mandibular periosteum can result in spontaneous bone regeneration. Fibula bone harvest in a child mandates close follow-up till skeletal maturity, to monitor for ankle instability and valgus deformity. Dental rehabilitation maintains occlusal relationships, which promotes normal maxillary development. Elective hardware removal should be considered to facilitate future dental implant placement and possible revision procedures. After completion of growth, if occlusion or symmetry is not satisfactory, secondary procedures can be performed, including distraction osteogenesis, orthognathic-type bone sliding operations, and segmental ostectomy.

Incidence of Medial and Lateral Meniscal Tears After Delayed Anterior Cruciate Ligament Reconstruction in Pediatric Patients.

Background:The treatment of pediatric anterior cruciate ligament (ACL) injuries is controversial, and no clear management guidelines have been established.Purpose:To evaluate the association between elapsed time from ACL injury to surgery and the incidence of meniscal tears and chondral injuries in patients aged ≤16 years.Study Design:Cohort study; Level of evidence, 3.Methods:Between December 2012 and April 2019, a total of 207 consecutive knees in 207 patients aged ≤16 years underwent primary ACL reconstruction and were included in this study. Patients were divided into 1 of 2 groups (early group [≤150 days] and delayed group [>150 days]) based on the time between injury and surgery. Patient records, including arthroscopic findings identified by 2 experienced knee surgeons at the time of surgery, were reviewed for demographic information, incidence and types of medial and lateral meniscal tears, and chondral injuries and their locations in each group.Results:There were 180 knees in the early group and 27 knees in the delayed group. The delayed group showed a significantly higher rate of medial meniscal tears than the early group: 16 of 27 (59.2%) and 46 of 180 (25.6%), respectively (odds ratio [OR], 4.24 [95% CI, 1.83-9.33]; P = .0011). The delayed group had a significantly lower rate of lateral meniscal tears than the early group: 6 of 27 (22.2%) and 90 of 180 (50.0%), respectively (OR, 0.29 [95% CI, 0.11-0.70]; P = .007). The delayed group had significantly higher rates of chondral injuries in the medial femoral condyle and the medial tibial plateau than the early group: 8 of 27 (29.6%) and 25 of 180 (13.9%), respectively (OR, 2.61 [95% CI, 1.03-6.62]; P = .049), and 2 of 27 (7.4%) and 1 of 180 (0.6%), respectively (OR, 14.32 [95% CI, 1.58-208.10]; P = .045).Conclusion:Delayed ACL reconstruction was associated with an increased incidence of medial chondral injuries and medial meniscal tears but with a decreased incidence of lateral meniscal tears.

Outcomes following Microvascular Mandibular Reconstruction in Pediatric Patients and Young Adults.

Background:The etiology and treatment of complex mandibular defects in children differ markedly from those of adults, although treatment with free bone flaps is historical in both groups. While adult outcomes and complication rates are well known, few pediatric data exist, especially for patients with congenital deficiencies. This study reports early and late outcomes from a cohort of young, primarily syndromic patients undergoing microvascular mandibular reconstruction.Methods:This is a retrospective case series of patients who underwent microvascular mandibular reconstruction between 1995 and 2016.Results:Thirteen patients received a total of 13 fibula transfers and 1 medial femoral condyle transfer. Most patients carried a congenital diagnosis (77%), and the average age during surgery was 11.7 ± 5.7 years. The median (interquartile range) [IQR] length of follow-up was 6.3 (5.7) years. There was a 100% flap survival rate, although 86% of all patients experienced at least one complication. Half of all procedures resulted in an early complication. Nine patients (69%) developed late complications, of which temporal mandibular joint ankylosis was the most common (n = 5; 38%).Conclusions:This study is one of few detailing outcomes following mandibular reconstruction by free flap transfer in pediatric patients. These patients were primarily syndromic with appreciable complication rates higher than in other adult and pediatric studies. Some complications are manageable or self-resolving, but others lead to functional problems that may require late operative interventions to correct. Microsurgical treatment should be reserved for children with large, complex mandibular defects when other options are unavailable or have been exhausted.

Femoral nerve catheters and limb strength asymmetry at 6 months after primary anterior cruciate ligament reconstruction in pediatric patients.

The postoperative implications of single-injection femoral nerve blockade and femoral nerve catheter placement for anterior cruciate ligament reconstruction are not well defined among pediatric patients. Femoral nerve blockade may be associated with deficits in quadriceps symmetry at 6months postoperative. We compared outcomes after primary anterior cruciate ligament reconstruction surgery in pediatric patients who received either a single-injection femoral nerve block or femoral nerve catheter and a single-injection popliteal nerve block. We conducted a retrospective chart review of patients 10-19years of age who underwent anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft by a single orthopedic surgeon at two of our locations. Of 88 patients analyzed, 31 received single-injection femoral nerve blockade (52% female, mean age=15.6±1.8years) and 57 received femoral nerve catheter (53% female, mean age=15.6±1.7years). Time from surgery to return-to-sport clearance and movement symmetry were compared between groups at approximately 6months postoperatively. The single-injection femoral nerve blockade group exhibited significantly greater single-leg squat symmetry than did the femoral nerve catheter group (95.5±6.7% vs 88.3±9.3%; P= 0.02; mean difference=7.2%, 95% CI=-1.1, 13.3) 6months postoperatively. There was no difference in time from surgery to return-to-sport clearance between groups (median=247 [interquartile range=218-295] days vs 268 [241-331] days; P= 0.22; mean difference=40days; 95% CI=-23, 102). Though time to return to sport did not differ, patients in the femoral nerve catheter group exhibited greater single-leg squat asymmetry than did those in the femoral nerve blockade group approximately 6months postoperatively. Persistent functional deficits may be important to consider when treating pediatric patients undergoing anterior cruciate ligament reconstruction.

Wharton's Jelly-Mesenchymal Stem Cell-Engineered Conduit for Pediatric Translation in Heart Defect.

The materials available for the right ventricular outflow tract (RVOT) reconstruction in patients with tetralogy of fallot (TOF)/pulmonary atresia come with the severe limitation of long-term degeneration and lack of growth potential, causing right ventricular dysfunction, aneurysm formation, and arrhythmias, thus necessitating several high-risk reoperations throughout patients' lives. In this study, we evaluated the capacity of mesenchymal stem cells (MSCs) derived from the Wharton's Jelly (WJ-MSCs), the gelatinous inner portion of the umbilical cord, to grow and recellularize an extracellular matrix (ECM) graft in our optimized xeno-free, good manufacturing practice-compliant culture system. WJ-MSCs were phenotypically and functionally characterized by flow cytometry and multilineage differentiation capacity, respectively. The typical MSC immunophenotype and functional characteristics were retained in our xeno-free culture system, as well as the capacity to grow and engraft onto a naturally occurring scaffold. WJ-MSCs, from both human and swine source, showed excellent capacity to recellularize ECM graft producing a living cell-seeded construct. In addition, we have provided an in vivo proof of concept of feasibility of the cellularized conduit, engineered with swine WJ-MSCs, to be used in a novel porcine model of main pulmonary artery reconstruction, where it showed good integration within the host tissue. Our study indicates that the addition of WJ-MSCs to the ECM scaffold can upgrade the material, converting it into a living tissue, with the potential to grow, repair, and remodel the RVOT. These results could potentially represent a paradigm shift in pediatric cardiac intervention toward new modalities for effective and personalized surgical restoration of pulmonary artery and RVOT function in TOF/pulmonary atresia patients. Impact Statement The materials available for pulmonary artery reconstruction in pediatric patients with Congenital Heart Defect come with the limitation of long-term degeneration and lack of growth, thus necessitating several reoperations. Here, we describe a novel approach combining perinatal stem cells and naturally occurring scaffold to create a living tissue engineered conduit that showed good growth potential in a pulmonary artery reconstruction porcine model. We envision this approach is of great interest and relevance in tissue engineering field applied to cardiovascular regenerative medicine, as it may open up new avenues for correction of congenital cardiac defects, with remarkable medical and social benefits.

Does Immediate Inferior Alveolar Nerve Allograft Reconstruction Result in Functional Sensory Recovery in Pediatric Patients?

Ablative mandibular resection may result in neurosensory loss and decreased quality-of-life, yet nerve reconstruction is not performed routinely for various reasons, including increased operative time. This study aimed to determine whether immediate inferior alveolar nerve (IAN) allograft reconstruction provides functional sensory recovery (FSR) in the pediatric age group. This multicenter retrospective cohort study included pediatric patients who underwent mandibular resection with IAN discontinuity and a nerve allograft greater than 45mm. A positive control group also was included, comprising pediatric patients who underwent mandibular resection without nerve reconstruction. The primary predictor variable was the use of a nerve allograft; a secondary variable was the time to achieve FSR using the Medical Research Council Scale. Comparisons were made to historical adult data. Statistical analysis of the comparison of neurosensory outcomes over time was measured by weighted values, repeated-measures analysis of variance, and the McNemar test. The study group consisted of 32 patients, 18 in the graft group and 14 in the non-graft group, without significant differences in age, gender, or nerve gap length. By 1year, FSR was achieved in 100% in the study group and 0% in the control group (P<.00001). The median time to FSR was 75days in the study group and 110days in the historical adult study group. In comparison to historical adult data, there was a significant difference at 1year, with adults at 87% FSR (P=.01562). Long-span nerve allografts were effective in restoring sensation to the lip and chin in pediatric patients, with 100% reaching FSR, whereas no patients without nerve reconstruction achieved FSR. Pediatric patients recovered to a higher level of FSR than adults at 1year. Immediate IAN reconstruction in pediatric patients should be considered strongly when the mandible requires resection with sacrifice of the IAN.