ACTA2 Mutation: Microsurgeon Beware!

Patients with the alpha actin 2 genetic mutation suffer early onset aneurismal and vascular-occlusive conditions due to dysfunctional smooth muscle contractility. Outcomes of free flap reconstruction in this patient population are unknown. Here we report the case of a 21-year-old woman with alpha actin 2 mutation who required decompressive hemicraniectomy following an acute stroke. The entire Cushing flap underwent necrosis, requiring debridement and exposing dura. This condition was treated with a free latissimus myocutaneous flap. The patient's post-operative course was complicated by venous thrombosis, requiring intra-flap tPA and revision of the venous anastomosis with a saphenous vein graft. Ultimately the distal 75% of the flap was lost, leaving the dura exposed. The patient's course was further complicated by multiple wound healing complications: large areas of necrosis of the latissimus and saphenous vein donor sites, the neck vessel recipient site, and the right hand after IV infiltration. She ultimately healed with a regenerative tissue matrix strategy. Reconstructive options with no or minimal donor site morbidity should be considered in patients with the alpha actin 2 mutation. We encourage further reporting of outcomes in these patients.

TMRpni: Combining Two Peripheral Nerve Management Techniques.

Amputee patients suffer high rates of chronic neuropathic pain, residual limb dysfunction, and disability. Recently, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are 2 techniques that have been advocated for such patients, given their ability to maximize intuitive prosthetic function while also minimizing neuropathic pain, such as residual and phantom limb pain. However, there remains room to further improve outcomes for our residual limb patients and patients suffering from symptomatic end neuromas. "TMRpni" is a nerve management technique that leverages beneficial elements described for both TMR and RPNI. TMRpni involves coaptation of a sensory or mixed sensory/motor nerve to a nearby motor nerve branch (ie, a nerve transfer), as performed in traditional TMR surgeries. Additionally, the typically mismatched nerve coaptation is wrapped with an autologous free muscle graft that is akin to an RPNI. The authors herein describe the "TMRpni" technique and illustrate a case where this technique was employed.

Pulley Release and Reconstruction With Acellular Dermal Matrix After Zone 2 Flexor Tendon Injury.

Zone 2 flexor tendon repair has been historically associated with poor outcomes, mainly due to stiffness. In an effort to minimize adhesions, accommodate flexor digitorum profundus and flexor digitorum superficialis bulk, and prevent bowstringing, we have developed a novel approach to flexor tendon repair that relies on aggressive flexor tendon pulley release and pulley reconstruction with acellular dermal matrix. This technique leverages the antiadhesive properties and high tensile strength of acellular dermal matrix to maximize gliding and prevent bowstringing. Here we describe the details of our technique and illustrate a case where this technique was employed.

Adolescent Kienböck's Disease: A Comparison between Lunate Offloading and Revascularization Procedures.

Objective To evaluate the outcomes and complication rate of surgical management in adolescent patients with Kienböck's disease and compare lunate offloading and revascularization procedures. Methods We performed a retrospective chart review to evaluate adolescent patients with Kienböck's disease between 1990 and 2016 who were surgically managed. Charts were reviewed for demographic information, presence of trauma, range of motion, grip strength, and radiographic parameters pre- and postoperative. Results We assessed 21 wrists in 20 patients. All had failed conservative management and required surgery. Seven patients underwent lunate offloading procedures, most commonly radial-shortening osteotomy, whereas 13 patients had an attempt at revascularization. All patients had either minimal or no pain at a clinical mean clinical follow-up of 63.4 months. Postoperatively, grip strength and radial deviation improved, with no difference between the two groups. Those that underwent joint offloading procedures had less ulnar variance. Eight of 11 patients with a postoperative MRI (magnetic resonance imaging) had evidence of lunate revascularization after a revascularization procedure. Conclusion Surgical management of Kienböck's disease in adolescent patients can yield satisfactory outcomes in those that fail conservative management. Level of Evidence/Type of study This is a Level IV, therapeutic study.

The Index Finger Metacarpal Tubercle.

Purpose: The region of the index finger metacarpophalangeal joint is a common source of hand pain with variable, well-known etiologies. We have identified the tubercle at the dorsoradial neck of the index finger metacarpal as a distinct and specific site of pain in a subset of patients who presented with a chief report of index finger pain. Although experienced hand surgeons may recognize this clinical entity, we found no previous description within the literature. Methods: After institutional review board approval, we performed a retrospective review of all patients presenting to a single surgeon practice with severe pain at the dorsoradial tubercle of the index finger metacarpal unattributable to known etiologies. Patients underwent initial management of steroid injection followed by surgical excision if conservative measures failed. Results: Steroid injection was administered as initial management in 9 of 10 afflicted hands. Five of these hands experienced complete resolution of pain at 4 weeks after injection whereas 4 developed recurrence at an average of 3 months after injection. Among patients with recurrence, one patient opted for a second injection that led to pain resolution 4 weeks later, whereas the remaining 3 hands had surgical excision. All patients who underwent surgical excision reported minimal discomfort and marked improvement in pain after surgery. Conclusions: We identified the tubercle at the dorsoradial neck of the index finger metacarpal as a distinct and specific site of pain in a subset of patients. We postulate that the pathophysiology of pain at the prominent index finger metacarpal tubercle may be related to a subacute radial collateral ligament injury. Steroid injection to the tubercle is a reasonable initial treatment option and satisfactory results may also be obtained with surgical excision. Type of study/level of evidence: Therapeutic IV.

Comparison of Vickers' Physiolysis With Osteotomy for Primary Correction of Clinodactyly.

Background: The purpose of this study was to compare the Vickers physiolysis procedure with osteotomy for correction of digital clinodactyly and determine which method provides better correction at final follow-up or whether the patient's age, preoperative angulation, or presence of syndactyly affects final outcomes. Methods: All patients of skeletal immaturity who underwent surgical correction of clinodactyly were evaluated with clinical examination and radiographs to determine the percentage and absolute change in the degree of clinodactyly pre- versus postoperatively, in addition to stratification based on the degree of deformity, age, and presence of syndactyly. Results: Vickers' physiolysis and osteotomy were undertaken in 30 and 11 digits, respectively. The angulation significantly improved from 43.0° to 23.9°, with a 46.2% correction of deformity in the Vickers group at 46.3 months. The angulation decreased from 39.2° to 22.4° in the osteotomy group, with a 55.3% correction of deformity at 55.3 months. There was better correction in those with isolated clinodactyly compared with those with concomitant syndactyly and better percentage of correction in patients with lesser deformity in the Vickers group. There were more reoperations in the osteotomy group. Conclusions: The use of osteotomy may lead to more revision cases, whereas the Vickers procedure has minimal complications and need for revision. The Vickers physiolysis procedure is more effective in those with angulation <55°.

Outcomes of the Adams-Berger Ligament Reconstruction for the Distal Radioulnar Joint Instability in 95 Consecutive Cases.

Objective The objective of this article is to evaluate the outcomes and complication rate for Adams-Berger anatomic reconstruction of the distal radioulnar joint (DRUJ), in addition, to determine the role of sigmoid notch anatomy on failure. Methods We conducted a retrospective chart review to evaluate adult patients that had undergone reconstruction of the DRUJ for instability with the Adams-Berger procedure between 1998 and 2015 within our institution with > 24 months follow-up. Charts were reviewed for patient demographics, mechanism of injury, outcome, and complications. Results Ninety-five wrists in 93 patients were included. Mean age at surgery was 37.3 years with 65.2 months follow-up. At the last follow-up, 90.8% had a stable DRUJ, 5.3% did not, and 3.4% had some laxity. Postoperatively, 75.9% described either no pain or mild pain. Grip strength increased while pronosupination decreased. Procedure success was 86.3%, as 12 patients underwent revision at 13.3 months postoperatively. Reconstructive failure was more common in females when an interference screw was utilized for tendon fixation. Age, timing of surgery, type of graft, sigmoid notch anatomy, and previous surgery did not affect revision or failure rate. Conclusion Our findings demonstrate that Adams-Berger reconstruction of the DRUJ provides reliable long-term results with an overall success of 86% at > 5 years follow-up. Level of evidence/Type of study This is a Level IV, therapeutic study.

Outcomes of shoulder abduction after nerve surgery in patients over 50 years following traumatic brachial plexus injury.

PURPOSE: There is controversy regarding the effectiveness of brachial plexus reconstruction in older patients, as outcomes are thought to be poor. The aim of this study is to determine the outcomes of shoulder abduction obtained after nerve reconstruction in patients over the age of 50 years and factors related to success. METHODS: Forty patients over the age of 50 years underwent nerve surgery to improve shoulder function after a traumatic brachial plexus injury. Patients were evaluated pre- and postoperatively for shoulder abduction strength and range of motion (ROM); Disability of the Arm, Shoulder and Hand (DASH) scores; pain; age bracket; gender; body mass index (BMI); delay from injury to operation; concomitant trauma; severity of trauma; and type of reconstruction. RESULTS: The average age was 58.2 years (range 50-77 years) with an average follow-up of 18.8 months. The average modified British Medical Research Council (BMRC) shoulder abduction grade improved significantly from 0.23 to 2.03 (p < 0.005). Fourteen patients achieved functional shoulder abduction of ≥ M3 postoperatively. There was no correlation between age or age range stratification and BMRC grade or those obtaining useful shoulder abduction ≥ M3. Active shoulder abduction improved significantly from 18.25° to 40.64°, with no difference on the basis of age or age stratification. There were improved modified BMRC grades with nerve transfers versus nerve grafts. Less patients achieved ≥ M3 function if surgery was delayed > 6 months. The mean DASH score decreased from 45.3 to 40.7 postoperatively, and the average pain score decreased from 3.7 to 3.0. Patients with a higher postoperative BMRC grade for shoulder abduction had improved postoperative DASH scores and VAS for pain (p = 0.011 and 0.005, respectively). CONCLUSION: Brachial plexus nerve reconstruction for shoulder abduction in patients over the age of 50 years can yield useful BMRC scores and ROM, and age should not be used to exclude nerve reconstruction in these patients.

Outcomes of Elbow Flexion Reconstruction in Patients Older than 50 with Traumatic Brachial Plexus Injury.

BACKGROUND: There is controversy regarding the effectiveness of brachial plexus reconstruction for elbow function in older patients, as reported outcomes are generally poor. The purpose of this study was to evaluate elbow function outcomes in patients older than 50. METHODS: Fifty-eight patients older than 50 years underwent nerve grafting, transfers, or free functioning muscle transfer to improve elbow function after traumatic brachial plexus injury. Patients were evaluated preoperatively and postoperatively for elbow flexion strength and range of motion; Disabilities of the Arm, Shoulder and Hand scores; pain; concomitant trauma; severity of trauma; and type of reconstruction. RESULTS: The average age of the patients was 57.8 years, and the average follow-up was 24.0 months. The average modified British Medical Research Council elbow flexion grade improved significantly from 0.26 to 2.63. Thirty-three patients (60 percent) achieved functional flexion greater than or equal to M3 postoperatively, compared to zero patients preoperatively. There was no correlation between age and modified British Medical Research Council grade. Active elbow range of motion improved significantly postoperatively, with no effect of age on flexion motion. More patients achieved greater than or equal to M3 flexion with nerve transfers (69 percent) compared to free functioning muscle transfer (43 percent). Patients had worse outcomes with high-energy injuries. The mean Disabilities of the Arm, Shoulder and Hand score decreased from 51.5 to 49.6 postoperatively, and the average pain score decreased from 5.0 to 4.3. CONCLUSION: Brachial plexus reconstruction for elbow function in patients older than 50 can yield useful flexion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Redefining the Rectus Sheath: Implications for Abdominal Wall Repair.

BACKGROUND: The abdominal wall is frequently manipulated in a variety of reconstructive procedures, and its anatomy is well described. The authors' clinical observations, however, contradict the standard depiction of the components of the abdominal wall at various levels-particularly regarding the course of the transversus abdominis muscle. Therefore, the authors sought to characterize the components of the rectus sheath at various surgical landmarks to define anatomic points important to abdominal wall repair. METHODS: The authors analyzed the abdominal computed tomographic studies of 100 healthy, young (age, 18 to 35 years; body mass index, 20 to 40 kg/m) patients with suspected renal calculi. Coordinates of key landmarks were recorded at vertebral levels T12 to L5 using a specially designed computer program that scaled all values and calculated distances between various points. RESULTS: All subjects had significant presence of the transversus abdominis within the rectus sheath (the overlap between the abdominis rectus and transversus abdominis muscles) at the costal margin plane (T12-L1, 4.2 cm). Ninety-nine percent had transversus abdominis presence within the rectus sheath at L1-L2 (3.2 cm), 86 percent at the level of the twelfth rib (L2-L3, 1.4 cm), 36 percent at the umbilicus (L3-L4), and 2 percent slightly above the posterosuperior iliac spine (L5-S1). CONCLUSIONS: These findings contradict classic teachings of abdominal wall structure and highlight the need for a cautious revisiting of the various permutations of component separation, particularly posterior component release. Furthermore, these anatomical landmarks may help predict the development or recurrence of ventral hernias, thus guiding patient selection and informing surgical technique.

#Cleft: The use of Social Media Amongst Parents of Infants with Clefts.

INTRODUCTION: Many societies and organizations are using social media to reach their target audience. The extent to which parents of patients with craniofacial anomalies use social media has yet to be determined. The goal of this study is to characterize and describe the use of social media by the parents of children with cleft lip and palate as it pertains to the care of their child. MATERIALS AND METHODS: Parents or guardian of all patients presenting for initial consultation regarding a child's congenital cleft anomaly were contacted by phone or mail to complete a survey regarding their use of social media vis-à-vis their child's cleft anomaly. Participants were asked to answer a 19-question survey. RESULTS: Thirty-two families were contacted and 25 surveys were completed. Ninety-two percent of respondents used social media to learn about their child's diagnosis. Facebook (76%) and blogs (24%) were the most commonly accessed social media outlets, followed by Instagram (8%). Education about the diagnosis and treatment of cleft pathology (87%) was the most common reason for accessing social media, followed by companionship and support (56%), and advice about perioperative care (52%). Almost half (43%) of parents used social media to obtain information on their caregiver and treatment team, and 26% of parents used information gained on social media to guide their decision on where to seek care. CONCLUSION: Social media is a readily available resource, one that will certainly shape the experiences of our patients and families for years to come.

Management of Scaphoid Fractures.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the epidemiology, classification, and anatomy pertinent to the scaphoid. 2. Appropriately evaluate a patient with suspected scaphoid fracture, including appropriate imaging. 3. Understand the indications for operative treatment of scaphoid fractures, and be familiar with the various surgical approaches. 4. Describe the treatment options for scaphoid nonunion and avascular necrosis of the proximal pole. SUMMARY: The goal of this continuing medical education module is to present the preoperative assessment and the formation and execution of a surgical treatment plan for acute fractures of the scaphoid. In addition, secondary surgical options for treatment of scaphoid nonunion and avascular necrosis are discussed.

Pedicled Flap Closure as an Adjunct for Infected Ventricular Assist Devices.

PURPOSE: End-stage cardiac disease has resulted in an increased utilization of cardiac transplantation or long-term mechanical assistance to sustain life. Though left ventricular assist devices (LVAD) have revolutionized the treatment algorithm for these patients, these devices carry a substantial infection rate, ranging from 30% to 50%. We report our institution's experience with attempted flap salvage for infected and exposed LVADs. METHODS: A retrospective review for all LVAD-related infections treated with flaps at our institution from 2010 to 2015. RESULTS: Twenty flaps were performed in 15 patients during the study period. Average age was 54 years. There were 4 women and 11 men with average body mass index of 30.6. Surgery was indicated for LVAD motor or drive line exposure in the setting of infection in all cases. Rectus abdominus (n = 10), omentum (n = 6), pectoralis major (n = 3), and intercostal (n = 1) were used for coverage. Complications resulted in approximately 67% of cases including hematoma (n = 4), seroma (n = 3), cellulitis (n = 1), and total flap loss (n = 1). CONCLUSIONS: Left ventricular assist devices are lifesaving interventions for patients with severe cardiac disease but are associated with a high rate of infectious complications over time. Although device coverage carries a high rate of complications, no devices required exchange due to infection or failed attempts at salvage.

Distal metaphyseal ulnar shortening osteotomy: technique, pearls, and outcomes.

Background Ulnar sided wrist pain is a commonly encountered complaint of the hand surgeon, and ulnar impaction is a common cause. Surgical treatment aims to reduce the force transmitted through the ulna and traditionally includes diaphyseal ulnar shortening osteotomy and the "wafer" procedure. These procedures have known shortcomings. We describe an alternative option known as the distal metaphyseal ulnar shortening osteotomy (DMUSO). Materials and Methods Retrospective review of eight procedures was undertaken to assess radiographic healing, objective measurements of wrist and forearm motion, grip and pinch strength, and subjective measures of Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and Michigan Hand Outcomes Questionnaire (MHQ) at a minimum of 12 months following surgery. Description of Technique A wedge osteotomy is made in the osteochondral region of the distal metaphysis of the ulna, and a headless compression screw is used for fixation. Results Five women and three men underwent DMUSO with average follow up at 13 months; the dominant wrist was affected in 7 of 8 patients. The affected wrist had less motion in all planes, and grip and pinch strength was also less in the affected wrist, but only wrist extension was significantly different from the contralateral side. These findings likely did not have an effect on the clinical outcome. Subjective outcomes included average DASH score of 13 (0-35), PRWE 19 (40-11), and MHQ score of 88 (85-100). Conclusions DMUSO is a viable option for patients with ulnar impaction syndrome. It requires intra-articular exposure of the distal radioulnar joint (DRUJ) but is less invasive then diaphyseal shortening. It permits early and reliable return of joint motion and function while avoiding the potential need for hardware removal by using a buried screw.

Current concepts in the evaluation and treatment of mallet finger injury.

The mallet finger is a frequently encountered fingertip injury that leads to extensor lag of the distal phalanx. Classification systems stratify these injuries as ranging from soft-tissue disruption of the extensor mechanism alone to those that have articular involvement and volar subluxation. The management of mallet finger injuries varies based on injury pattern and surgeon preference. These treatment options include splinting regimens, closed reduction and percutaneous pinning, and open reduction and internal fixation. Although the final goal of treatment is to establish a congruent joint, the efficacy of each treatment modality has been shown to vary.

Current trends in the management of proximal interphalangeal joint injuries of the hand.

Injuries to the proximal interphalangeal joint are commonly encountered by the hand surgeon. Proper diagnosis and treatment are vital for optimal outcomes. Proper treatment of these injuries requires a working knowledge of the anatomy of the joint and an appreciation for principles for reduction, stabilization, and early rehabilitation to provide the best outcomes possible. Injuries can include fractures of the head of the proximal phalanx, dislocations, fracture dislocations, and fractures of the base of the middle phalanx. Similar to other aspects of plastic surgery, there is little high-level evidence guiding treatment and thus most treatment is based on level III or IV evidence. The goal for treatment of any injury around the proximal interphalangeal joint is to establish a congruent joint and allow for early motion. Stiffness and posttraumatic arthritis are common following these injuries. Salvage procedures are limited to arthrodesis and arthroplasty, neither of which can restore the normal function of the hand.

The keystone island flap: use in large defects of the trunk and extremities in soft-tissue reconstruction.

BACKGROUND: Microsurgical perforator flaps are useful in an array of reconstructive scenarios, but their technical complexity, steep learning curves, and prolonged operative times may limit their widespread adoption. Alternatively, the keystone island flap combines perforator-based vascularity with relative simplicity of nonmicrosurgical tissue rearrangement. This article reviews the authors' reconstructive experience using the keystone flap to reconstruct large trunk and extremity defects. METHODS: The authors performed a retrospective chart review of patients undergoing keystone flap reconstruction between 2002 and 2008. Patient demographic data, medical histories, comorbidities, surgical indications, defect characteristics and locations, hospitalization, complications, and follow-up care were evaluated and are presented in this article as an uncontrolled case series. RESULTS: Twenty-eight patients underwent keystone flap reconstruction. The average wound size measured 15.0 ± 11.7 × 13.0 ± 7.9 cm (250.5 ± 379.4 cm2). The average length of stay, including tumor resection, was 6.36 ± 6.68 days. A 35.7 percent overall complication rate was noted; partial and total flap loss was observed in only 7 percent of patients. One patient (3 percent) failed reconstruction and required alternative wound closure. CONCLUSIONS: The keystone flap can be applied to large defects of the trunk and extremities, obviating the need for either microsurgical techniques or extensive operative time while achieving primary wound healing. Despite minor complications, the 97 percent reconstructive success rate compares well to published rates of microsurgical tissue transfers but has several advantages: short operative times, high reproducibility, ease of use, and favorable aesthetic outcome. The authors conclude that the keystone flap is a reliable and effective reconstructive surgical technique for reconstruction of soft-tissue defects.

Right-sided congenital diaphragmatic hernia: high utilization of extracorporeal membrane oxygenation and high survival.

PURPOSE: The purpose of the study was to assess the treatment strategies and outcome of right-sided congenital diaphragmatic hernia (R-CDH), particularly extracorporeal membrane oxygenation (ECMO). METHODS: We reviewed the cases of 42 patients treated for R-CDH at our institution from 1991 to 2006. We gathered demographic information, documented ECMO use and the type of surgical repair, and compared outcomes with predicted survival as calculated by the CDH Study Group's equation. RESULTS: Of the 35 patients included in our statistical analysis (7 were excluded), 12 (34%) were born at our institution, all of whom were prenatally diagnosed with R-CDH. Nineteen patients (54%) required ECMO therapy. Extracorporeal membrane oxygenation was initiated after repair of the R-CDH in 2 patients (11%). Of those patients who went on ECMO before repair, 4 patients (21%) were repaired on ECMO, 9 patients (47%) underwent repair after ECMO, and 4 patients (21%) underwent ECMO but died before their R-CDH could be repaired. Primary repair of the diaphragm was possible in 15 cases (56%), and primary closure of the abdominal incision was possible in 15 of the 23 open repairs (65%). The mean predicted survival for all 35 patients was 63%, whereas 28 (80%) actually survived. Logistic regression showed a significant association between the presence of cardiac defects and mortality (odds ratio = 0.008, P = .014). CONCLUSIONS: Our data suggest that patients with R-CDH have high ECMO utilization and may experience greater relative benefit from ECMO as evidenced by their higher-than-expected overall survival. Extracorporeal membrane oxygenation may be found to have a distinctive role in managing R-CDH. More high-powered series are needed to elucidate differences between R-CDH and left-sided CDH that may dictate alternate forms of management.

Development of an artificial placenta I: pumpless arterio-venous extracorporeal life support in a neonatal sheep model.

PURPOSE: Effective treatment of respiratory failure in premature infants remains an unsolved problem. The development of an artificial placenta, in the form of a pumpless arteriovenous extracorporeal life support (AV-ECLS) circuit that maintains fetal circulation, is an appealing alternative. METHODS: A near-term (140 d/term = 145 days) neonatal lamb model was used (n = 7). Fetuses were exposed by hysterotomy, and flow probes were placed on the ductus arteriosus, aorta, and carotid artery. Catheters were placed into the umbilical vessels, and pumpless AV-ECLS was initiated. Fetuses were submerged in a warm saline bath, and support was maintained for up to 4 hours. RESULTS: Mean initial device flow was 383 mL/min but steadily declined to 177 mL/min at 4 hours. Mean initial pO(2) was 24 mm Hg and 18 mm Hg at 4 hours. Initial mean pCO(2) was 60 mm Hg and declined to 42 mm Hg at 4 hours. Mean arterial pressure was initially 43 mm Hg and decreased to 34 mm Hg at 4 hours. Flow in the ductus arteriosus was maintained for 4 hours. Of 7 fetuses, 5 survived 4 hours of support. CONCLUSIONS: Pumpless AV-ECLS can support gas exchange and maintain fetal circulation in a neonatal lamb model for a 4-hour period. Prolonged support (>4 hours) is hampered by high cannula resistance and declining device flow.

Salvaging the severe congenital diaphragmatic hernia patient: is a silo the solution?

BACKGROUND: Infants with severe congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) have a high morbidity and mortality. We hypothesized that placement of an abdominal wall silo and staged abdominal wall closure may reduce problems associated with decreased abdominal domain in CDH. METHODS: We performed a retrospective review and identified 7 CDH patients requiring ECMO who had a silastic abdominal wall silo between 2003 and 2006. Variables analyzed included survival, ECMO duration, duration of silo, time to discharge, and long-term outcome. RESULTS: Predicted mean survival for the entire cohort using the published CDH Study Group equation was 47% (range, 9%-86%). All 7 patients (100%) survived. Extracorporeal membrane oxygenation duration averaged 15 days (range, 5-19 days). Four of the patients (58%) were repaired with a silo on ECMO, and 3 (42%) had their repair after ECMO. The abdominal wall defect was closed at a mean of 21 days (range, 4-41 days). Hospital stay after silo placement averaged 54 days (range, 20-170 days) with no infections or wound complications. CONCLUSIONS: Abdominal wall silo placement in infants with CDH requiring ECMO appears to be an effective strategy for decreased abdominal domain. Further studies are warranted to determine the efficacy of such a strategy for these high-risk CDH patients.