Upper Extremity Diaphyseal Osseous Gap Reconstruction with Free Vascularized Bone Flaps: A Scoping Review.

BACKGROUND: Reconstruction of upper extremity osseous diaphyseal defects often require complex reconstructions. In this study, we characterized and summarized the available literature on free vascularized bone flap (VBF) reconstruction for upper extremity diaphyseal defects. METHODS: A scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of VBF reconstruction of upper limb long bone defects. Articles with patient-level data were included. Descriptive statistics were performed using Python. RESULTS: Overall, 364 patients were included in this study. The most common indications for VBFs included atrophic non-union (125, 34.3%), post-oncologic resection (125, 34.3%), septic non-union (56, 15.4%), and trauma (36, 9.9%). Mean defect size was 8.53±5.14 cm. 67 (18.4%) cases had defects <6cm, and 166 cases (45.6%) had defects >6cm. The fibula was the most utilized VBF (272, 74.73%), followed by the medial femoral condyle flap (69, 18.96%). Overall, primary union rate was 87.1%. Subsequent flap fracture rate was 3.3%. There were only 2 (0.6%) reported VBF losses reported in the included cases, and donor site complications were similarly rare (17, 4.7%). CONCLUSIONS: VBF reconstruction is often utilized for post-oncologic defects and recalcitrant non-unions. The fibula is the most utilized VBF, but the medial femoral condyle flap is used frequently for smaller defects. VBF reconstruction demonstrates high union rates and low flap fracture rate across indications.

Perceptions of Surgical Drains Among Breast Reconstruction Patients and Health Care Staff: A Qualitative Survey Study.

BACKGROUND: Surgical drains are a key component for recovery in breast reconstruction procedures. However, they are often cumbersome and carry a risk for infection with prolonged use. Our aim was to develop a more thorough understanding of patient and health care provider perspectives on surgical drains, to inform future efforts in improving the breast reconstruction patient experience. METHODS: Twenty-nine breast reconstruction patients and eight plastic surgery providers were recruited to complete surveys focused on surgical drains. Likert scales ranging from 1-5 were developed to gauge how bothersome drains felt, as well as concern for infection. Ordinal variable and categorical multiple-choice analyses were applied as appropriate. RESULTS: Fifteen (51.7%) patients underwent implant-based breast reconstruction, and 14 (48.3%) patients underwent autologous breast reconstruction. The most common duration of drain placement was two weeks (N=13). The surgical site infection rate requiring antibiotics was 28% (N=8). On a scale of 1-5, both patients (median = 3) and providers (median = 2.5) viewed drains as bothersome. Patients were "frequently" concerned about infection risk (median = 3). Other high-frequency patient concerns included general pain and discomfort. CONCLUSIONS: Surgical drains are a common component of breast reconstruction procedures and are viewed as cumbersome by both patients and providers. Patients expressed concerns about drain site pain, discomfort, and tugging on clothing. Patients and providers both believed that drains could contribute to surgical site infection. Overall, this data provides insight to drive future improvements in the patient drain experience.

Comparison Between Intramedullary Nail and Percutaneous Pin Fixation in Proximal Phalanx Fractures.

BACKGROUND: Percutaneous pinning has been the predominant technique for fixation of proximal phalanx fractures, but stiffness is a reported complication. The introduction of intramedullary (IM) nail fixation of proximal phalanx fractures provides a stronger biomechanical fixation for amenable fracture patterns with the added benefit of not tethering the soft tissue. The goal of this study was to compare the surgical outcomes of IM nail and percutaneous pin fixation in isolated proximal phalanx fractures. METHODS: A retrospective review was performed at our institution between the years 2018 and 2022 for patients treated for proximal phalanx fractures. Patients that underwent fixation with IM nails or percutaneous fixation for isolated extraarticular proximal phalanx fractures were included. Patients were excluded if they had concomitant hand fractures, tendon injury, or intraarticular extension. RESULTS: A total of 50 patients were included in this study. Twenty-eight patients received percutaneous pin fixation, and 22 patients underwent IM nail or screw fixation. There was no significant difference in injury patterns or demographics between these two groups. Patients that underwent IM nail fixation had a significantly quicker return to active motion, shorter duration of orthosis treatment, and fewer occupational therapy visits. In addition, patients in the IM fixation group had significantly improved range of motion (ROM) at 6 weeks postoperatively. CONCLUSIONS: This study demonstrates that patients receiving percutaneous pin or IM nail fixation have equivocal union and complication rates. The IM nail fixation group was able to have quicker return to mobilization, fewer required occupational therapy visits, and improved early ROM.

Exploration of the Utility of the Generic ICHOM Standard Set Measures in Evaluating the Speech of Patients with Cleft Lip/Palate.

Background: The International Consortium of Health Outcome Measurements (ICHOM) standard set for cleft care appraisal recommends clinicians assess articulation with percentage consonants correct (PCC) and velopharyngeal function with velopharyngeal competency rating (VPC-R). This study explores the utility and limitations of these generic measures in detecting cleft speech sound disorders by comparing them with two cleft-specific speech-rating systems, cleft audit protocol of speech-augmented Americleft modification (CAPS-A-AM) and Pittsburgh weighted speech scale (PWSS). Methods: Consecutive children with repaired, nonsyndromic cleft lip/palate, aged 5 years or older (n = 27) underwent prospective speech evaluations conducted at a single academic institution. These evaluations were conducted, recorded, and evaluated by blinded speech-language pathologists experienced with all tools. Results: When comparing measures of articulation, PCC scores correlated better with scores for relevant subcomponents of CAPS-A-AM than PWSS. When comparing measures of velopharyngeal function, VPC-R scores correlated well with relevant components of both scales. Using a "screening test versus diagnostic test" analogy, VPC-R ratings were 87.5% sensitive and 73.7% specific for detecting velopharyngeal dysfunction according to subcomponents of CAPS-A-AM, and 70.6% sensitive and 100% specific according to subcomponents of PWSS. Conclusions: This exploratory study demonstrates that PCC and VPC-R perform moderately well in detecting articulatory and velopharyngeal dysfunction in patients with cleft lip/palate; however, these tools cannot describe nuances of cleft speech sound disorder. Thus, although PCC and VPC-R adequately track basic minimum outcomes, we encourage teams to consider extending the standard set by adopting a cleft-specific measurement system for further evaluation of the tools.

Using "Real-World Data" to Study Cleft Lip/Palate Care: An Exploration of Speech Outcomes from a Multi-Center US Learning Health Network.

OBJECTIVE: To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings. DESIGN: Cross-sectional analysis of prospectively collected data from 2019-2022. SETTING: Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol. PARTICIPANTS: 714 English-speaking children and adolescents with non-syndromic cleft lip/palate. INTERVENTION: Routine multidisciplinary care and systematic outcomes measurement by cleft teams. OUTCOME MEASURES: Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress. RESULTS: 12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes. CONCLUSIONS: This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of "real-world" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

Aesthetic Outcomes in Cleft Care: Exploring Patterns in Patient-Reported Outcomes Across Adolescence.

BACKGROUND: For patients with cleft lip/palate, adolescence is a time of maxillofacial growth and complex psychosocial stressors. The personal significance of facial differences may change, making patient-reported outcomes measures (PROMs) invaluable. In this study, we use several scales from CLEFT-Q™ and FACE-Q™ to explore how aesthetic outcomes differ by age and by sex among patients with unilateral cleft lip/palate. MATERIALS AND METHODS: This was a multi-center, cross-sectional study that prospectively collected CLEFT-Q™ and FACE-Q™ data across six cleft treatment centers during clinical appointments from 2019-2022. Subjects were aged 8-22y with unilateral cleft lip, alveolus, and palate who had not undergone tertiary operative care (maxillary advancement or septorhinoplasty) at the time of survey response. Data cross-sections were prepared by age (8-10y, 11-13y, 14y+), by sex, and by age and sex together. RESULTS: Older age groups reported poorer aesthetic outcomes and worse appearance-related distress compared to younger groups. Although male and female subjects reported similar aesthetic outcomes, female subjects reported more appearance-related distress. When considered simultaneously, age and sex appear to have an intersectional impact on perceived aesthetic outcome and appearance-related distress during adolescence. CONCLUSIONS: This exploratory project suggests that patients with cleft lip/palate may perceive worsening of facial aesthetic throughout the course of adolescence, the exact pattern of which may be dependent on sex. Future work will evaluate this hypothesis using longitudinal cohorts. It will be important to investigate psychosocial factors that may impact these outcomes, and also to quantify the impact of tertiary operative care on these outcomes.

Systematic Review and Critical Appraisal of the Evidence Base for Nasoalveolar Molding (NAM).

OBJECTIVE: To critically appraise the body of scientific literature supporting the risks and efficacy of nasoalveolar molding (NAM), specifically in contrast to alternative methods of presurgical infant orthopedics (PSIO) or to treatment without PSIO. MAIN OUTCOME MEASURES: Five outcome domains were considered: nasolabial aesthetics; dentoalveolar relationship; midfacial growth; cost and burden of care; and number of anesthetic events. DESIGN: MEDLINE, Embase, and Scopus were queried for articles from the first description of the Grayson-Santiago NAM technique (1993) through December 13, 2021. After the application of inclusionary and exclusionary criteria, selected articles were critically appraised using a systematic framework that included risk of bias assessment using the Cochrane RoB 2.0 and ROBINS-I tools. RESULTS: A total of 88 studies were included. Level-I and -II evidence showed on par or better approximation and alveolar alignment achieved by NAM compared to other PSIO. Level-II and -III evidence showed improved nasolabial aesthetics compared to other PSIOs. Level-II and -III evidence supported no harm to maxillofacial skeletal growth through age 12. Sparse level-III evidence supported a reduced number of labial or nasal revisions following NAM. Level-II and -III evidence showed NAM requiring upfront cost and frequent appointments but reducing caregiver psychosocial burden and reducing long-term costs compared to select alternatives. Many studies carried a high risk of bias. CONCLUSIONS: Current evidence supports the overall efficacy of NAM regarding short/mid-term outcomes, with a low risk of negative effects on midfacial growth or dental development. The high risk of bias discovered in many papers underscores the need for robust study design in future research.