Targeted Muscle Reinnervation for Limb Amputation to Avoid Neuroma and Phantom Limb Pain in Patients Treated at a Pediatric Hospital.

Amputees frequently experience chronic neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) transfers transected nerves to nearby motor nerves to promote healing and prevent neuroma formation and PLP. The purpose of this study was to report outcomes of TMR in a series of children and young adults treated at a pediatric hospital. Methods: Patients undergoing major limb amputation with TMR were included with minimum one year follow-up and completed questionnaires. Primary clinical outcomes included incidence of symptomatic neuromas, PLP, residual limb pain, narcotic use, and neuromodulator use. A follow-up phone survey was conducted assessing five pediatric Patient Reported Outcomes Measurement Information System (PROMIS) metrics adapted to assess residual limb and PLP. Results: Nine patients (seven male and two female patients, avg. age = 16.83 ± 7.16 years) were eligible. Average time between surgery and phone follow-up was 21.3 ± 9.8 months. Average PROMIS Pediatric t-scores for measures of pain behavior, interference, quality-affective, and quality-sensory for both PLP and residual limb pain were nearly 1 standard deviation lower than the United States general pediatric population. One patient developed a symptomatic neuroma 1 year after surgery. Conclusions: Compared with an adult patient sample reported by Valerio et al, our TMR patients at Nationwide Children's Hospital (NCH) showed similar PLP PROMIS t-scores in pain behavior (50.1 versus 43.9) and pain interference (40.7 versus 45.6). Both pediatric and adult populations had similar residual limb pain including PROMIS pain behavior (36.7 adult versus 38.6 pediatric) and pain interference (40.7 adult versus 42.7 pediatric). TMR at the time of amputation is feasible, safe, and should be considered in the pediatric population.

Local Anesthesia Alone for Postaxial Polydactyly Surgery in Infants.

BACKGROUND: Surgical excision for postaxial polydactyly type B is advocated to avoid long-term complications. Excision with local anesthesia (LA) in infancy represents a safe and effective treatment for this condition, although general anesthesia (GA) is employed by many surgeons. We present a comparison of surgical outcomes, cost, and time between LA and GA to support widespread change in management. METHODS: A retrospective review of patients under 12 months of age undergoing surgical polydactyly excision by a single surgeon was performed. Anesthesia type, patient demographics, and complications were recorded. Comparisons were made between LA and GA groups on procedure cost, operating time, length of stay (LOS), and time from procedure end to discharge. Stepwise forward regression was used to identify the best model for predicting total costs. RESULTS: Ninety-one infants with a mean age of 3 months (±1.9) were examined; 51 (56%) underwent LA alone, 40 (44%) underwent GA. Mean operating time was 11.53 ± 4.36 minutes, with no difference observed between anesthesia groups (P = .39). LA infants had a significantly shorter LOS (2.5 vs 3.5 hours; P < .05), quicker postoperative discharge (32 vs 65 minutes, P < .05), and fewer overall expenses, 2803 vs 6067 U.S. dollars (USD), P < .05. Two minor surgical complications (1 in each group) were reported. CONCLUSIONS: This study demonstrates significantly decreased cost, LOS, and time to discharge using LA alone for surgical excision of postaxial polydactyly type B. Results suggest the approach is quick, economical, and avoids the risks of GA in early infancy.

Surgical Innovations to Restore Function in Pediatric Peripheral Nerve Conditions.

Peripheral nerve injuries in children can result in devastating lifelong deficits. Because of the time-sensitive nature of muscle viability and the limited speed of nerve regeneration, early recognition and treatment of nerve injuries are essential to restore function. Innovative surgical techniques have been developed to combat the regenerative length and speed; these include nerve transfers. Nerve transfers involve transferring a healthy, expendable donor nerve to an injured nerve to restore movement and sensation. Nerve transfers are frequently used to treat children affected by conditions, including UE trauma, brachial plexus birth injury, and acute flaccid myelitis. Pediatricians play an important role in the outcomes of children with these conditions through early diagnosis and timely referrals. With this review, we aim to provide awareness of state-of-the-art surgical treatment options that significantly improve the function of children with traumatic nerve injuries, brachial plexus birth injury, and acute flaccid myelitis.

Pediatric Lawnmower Injuries: a 25-year Review.

BACKGROUND: Despite regulations currently in place, the incidence of lawnmower injuries in children has not decreased for several decades in the United States. In fact, studies in several countries show that the incidence of riding lawnmower injuries are actually on the rise worldwide. Those injuries tend to be devastating and limb-threatening. The purpose of this study was to evaluate a pediatric trauma center's experience with those injuries over the past 25 years. METHODS: All patients who presented to a level I pediatric trauma center with injuries from lawnmowers between 1994 and 2019 were reviewed. Date of birth, gender, date of injury, mechanism of injury, type of lawnmower, and type of injury (including whether an open fracture, soft tissue defect, and/or amputation were present) were recorded. RESULTS: A total of 142 pediatric patients were treated over the study period. The average age was 7.5 years. The three most common mechanisms of injury were being hit by a riding lawnmower moving forward, falling off a riding lawnmower, and being hit by a riding lawnmower moving backward. Of all patients, 68.3% sustained an open fracture and 38% required an amputation. Riding lawnmowers resulted in more operative procedures, longer hospital stays, and more soft tissue defects that require reconstruction than push mowers. Younger patients were at a higher risk to sustain proximal amputations (wrist/ankle or proximal) than older patients. CONCLUSION: Lawnmower injuries are devastating and largely avoidable. There are currently recommendations and regulations in the United States, which if followed, would prevent the vast majority of pediatric lawnmower injuries. Unfortunately, the incidence of these injuries has not decreased despite the current regulations. Broader public education is essential to decrease the incidence of serious lawnmower injuries in children.Level of Evidence: IV.

A Hand Call Curriculum for Plastic Surgery Residents.

BACKGROUND: The ability to diagnose and manage patients with acute hand injuries is an essential component of plastic surgery residency. This study proposes an innovative and feasible curriculum to improve hand surgery education for plastic surgery residents and ensure optimal care for patients with hand injuries. METHODS: A hand call curriculum for plastic surgery residents (n = 29) from two institutions was implemented from 2018 to 2020. In 2018 and 2019, a hand call boot camp was conducted, while additional curricular sessions for anatomy and didactic learning were added in 2019-2020. Pre and post test assessments, as well as confidence assessments were conducted in 2018 and 2019. RESULTS: In 2019, after having completed the boot camp, residents indicated significantly more confidence in identifying hand emergencies and formulating a basic treatment plan, including when to enlist help (P = 0.0313). Overall, residents in earlier years (PGY 1-3) demonstrated steeper changes in confidence and readiness to take hand call than those in more senior years (PGY 4-8). Knowledge test scores improved amongst residents in both PGY groups following boot camp in both 2018 and 2019. CONCLUSION: Findings from our study will be used to optimize the hand call curriculum following limitations with COVID-19 and consider wider implementation across other plastic surgery programs nationally.

Branching hypopigmentation following intralesional corticosteroid injection: Case report and review of the literature.

Intralesional corticosteroid injections are frequently used to treat various musculoskeletal and dermatologic conditions, including keloid scarring. While a number of adverse events may be associated with these injections, hypopigmentation without atrophy is rare. We report a case of a pediatric patient with temporary cutaneous hypopigmentation without atrophy following intralesional corticosteroid injection in a keloid scar.

Establishing Validity Evidence for an Operative Performance Rating System for Plastic Surgery Residents.

OBJECTIVE: The aim of this study was to describe an operative performance rating system for plastic surgery residents and provide validity evidence for the instrument. METHODS: Three plastic surgery residents (PGY levels 1, 5, and 6) from Southern Illinois University School of Medicine (SIUSOM) performed a carpal tunnel release with audio video recording. The 3 videos were reviewed by 8 expert hand surgeons and 3 SIUSOM faculty using the operative performance rating system instrument to assess resident operative performance. Validity evidence including content, internal structure, and relationship to other variables was collected. RESULTS: Inter-rater reliability was consistently fair to moderate (weighted Cohen's Kappa 0.44-0.84 for experts, 0.24-0.55 for SIUSOM raters), and all assessment items were highly correlated (Cronbach's alpha of 0.9867). Local SIUSOM faculty routinely demonstrated higher overall scores for PGY 1 and PGY 6 residents compared to expert raters. CONCLUSIONS: Although limited by small numbers, this pilot study suggests that potential bias based upon PGY year, identity, and performance history may exist and independent assessment by unbiased raters or comparison to national operative norms may be valuable. Our study provides baseline validity evidence for a resident operative performance assessment tool that can be integrated into practice in plastic surgery training programs.

Pediatric Digital Necrosis Secondary to Dressing Application: A Case Series.

BACKGROUND: Pediatric digital necrosis resulting in revision amputation is a devastating outcome following digital dressing application. METHODS: We report a series of 4 pediatric patients (age: 21 months-11 years) who presented for surgical consultation related to digital ischemia and irreversible necrosis following the application of Coban digital dressings. A review of the literature demonstrated that such injuries had not previously been described. RESULTS: In our case series, Coban dressing was utilized as a deterrent for thumb sucking, fingertip tuft fractures with nail bed lacerations, and a phalanx fracture secondary to crush injury. All 4 children suffered digital necrosis secondary to Coban dressings and ultimately required revision amputation. CONCLUSIONS: We discuss risks factors, application practices, and strategies to minimize complications with digital dressings in the pediatric population with the intent of creating awareness among hand surgeons to help promote safe practices and improve patient outcomes.

Mandibular Body Resection and Setback for Severe Malocclusion in Lymphatic Malformations.

Extensive lymphangiomas of the facial skeleton result in deforming forces leading to ongoing masticatory, speech, oral hygiene, and airway problems. This paper presents a small series of patients with severe mandibular overgrowth secondary to lymphatic malformations. Following debulking of the malformations and tongue reductions, the authors describe the results of their treatment with bilateral mandibular body resections and setback. The authors' results suggest that severe functional impairment from deforming malformations can be addressed in childhood with orthognathic surgery. Improved occlusion, oral closure, and airway opening can be achieved using this procedure.

Medical Trainee Continuity of Care Following Emergency Department Consultations in a Pediatric Hospital.

BACKGROUND: The importance of continuity of care in training is widely recognized; however, a broad-spectrum assessment across all specialties has not been performed. OBJECTIVE: We assessed the continuity of care provided by trainees, following patient consultations in the emergency department (ED) across all specialties at a large pediatric tertiary care center. METHODS: Medical records were reviewed to identify patients seen in consultation by a resident or fellow trainee in the ED over a 1-year period, and to determine if the patient followed up with the same trainee for the same condition during the next 6 months. RESULTS: Resident and fellow trainees from 33 specialties participated in 3400 ED consultations. Approximately 50% (1718 of 3400) of the patients seen in consultation by a trainee in the ED followed up with the same specialty within 6 months, but only 4.1% (70 of 1718) followed up with the same trainee for the same condition. Trainee continuity of care ranged from 0% to 21% among specialties, where specialties with resident clinics (14.4%) have a greater continuity of care than specialties without resident clinics (2.7%, P < .001). Continuity of care did not differ between fellows (4.2%) and residents (4.0%, P = .87), but did differ between postgraduate years for residents (P < .001). CONCLUSIONS: Trainee continuity of care for ED consultations was low across all specialties and levels of training. If continuity of care is important for patient well-being and trainee education, efforts to improve continuity for trainees must be undertaken.

Regional anesthesia alone for pediatric free flaps.

Microvascular surgery plays an important reconstructive role in the pediatric population. Successful outcomes rely on surgical technique as well as anesthesia. Regional anesthesia contributes to successful free tissue transfer through sympathetic blockade, postoperative pain control, and elimination of risks and costs associated with general anesthesia. While regional anesthesia in microsurgery is discussed in the literature for adult and elderly patients, no studies focus on the pediatric population. Accordingly, this paper reviews 20 pediatric patients undergoing microvascular surgery (anterolateral thigh, n = 9; gracilis, n = 3; toe transfer, n = 6; and fibula, n = 2) with regional anesthesia and sedation. All patients underwent spinal epidural anesthesia, and seven also received brachial plexus blocks. The average duration of anesthesia was 3-4 h (anterolateral thigh (ALT) and gracilis) and 6-8 h (toe transfer and fibula). No anesthesia-related complications or flap failures occurred. We conclude that regional anesthesia has important benefits in pediatric microsurgery and it is a safe and cost-effective alternative to general anesthesia.