Diagnosis of a Rare Flexor Tendon Entrapment Using 3D CT Imaging Techniques.

Flexor tendon entrapments as a result of fractures or dislocations in the upper extremity are rare. Diagnosis by clinical examination is not always possible, and imaging such as magnetic resonance imaging and ultrasound is often obtained. These modalities have the disadvantages of reduced sensitivity or increased cost and time, respectively. We present a unique case of a triquetral fracture and pisiform dislocation causing index finger flexor digitorum profundus (FDP-I) entrapment that was diagnosed preoperatively with computed tomography (CT) imaging with 3-dimensional (3D) volume rendering. A 30-year-old man presented in delayed fashion 4 weeks after a dune buggy accident. Among other injuries noted on examination, his index finger was held in flexion and unable to be passively extended. The CT source images showed dislocation and interposition of the FDP-I tendon within a fracture-dislocation of the triquetrum and pisiform. Postprocessed 3D volume renderings obtained from the CT source images confirmed this finding. The patient underwent operative intervention, where FDP-I entrapment between the triquetral fracture fragments and the dislocated pisiform was confirmed and released. Practitioners should be aware of this injury pattern and evolving advanced CT techniques which may be used to aid in soft-tissue diagnoses and obviate the need for additional advanced imaging.

Tissue Expander-Assisted Component Separation for Pediatric Abdominal Wall Reconstruction.

BACKGROUND: Tissue expander-assisted component separation can be used to increase the amount of skin, muscle, and fascial components available for repair of congenital abdominal wall defects via a staged approach without the need for flap reconstruction. We present the largest case series to date using a tissue expander-assisted component separation technique for treatment of congenital abdominal wall defects in a pediatric patient population. METHODS: A retrospective chart review of 9 patients with large congenital abdominal wall defects not initially amenable to primary repair between 2009 and 2020 was performed. Patients first underwent placement of tissue expanders, followed by removal once they had reached a sufficient expander volume. Component separation, with and without mesh placement, was performed to achieve abdominal wall closure. RESULTS: The average age of patients at primary repair was 3.2 years (SD ±1.7 years). Eight patients (88.8%) had congenital omphalocele, and 1 patient (11.1%) had gastroschisis; none were amenable to primary repair. The average size of the defects before closure was 87.6 cm2 (SD = 33.6 cm2). Eighteen tissue expanders were placed in 9 patients, 72.2% of which were placed in the plane between the external and internal oblique muscles. Patients were seen in clinic an average of 6.8 times (SD, ±3.3 visits) for volume expansion into the tissue expander, receiving an average of 32.0 mL in each per visit. An average of 4.3 months (SD, ±1.8 months) elapsed between placement and removal of the expanders. At the time of tissue expander removal and abdominal wall closure, the defects ranged from 30 to 132 cm2 (mean, 54 cm2). All defects were successfully repaired using a component separation and bilateral fasciocutaneous flap advancement. Two patients (18.2%) experienced infection of the surgical site and seroma, both of which required debridement. One patient (9.1%) experienced partial thickness skin necrosis that was managed nonsurgically. The overall complication rate was 36.4%. CONCLUSIONS: Omphalocele and gastroschisis can produce abdominal wall defects that are not amenable to primary repair. Staged reconstruction using tissue expander-assisted component separation is a safe and effective method of obtaining adequate local soft tissue to achieve primary closure.

Application of Antibiotic-Impregnated Polymethyl-Methacrylate Bone Cement for the Treatment of Infected Cranioplasties: Initial Experience.

BACKGROUND: Management of infected cranioplasty implants remains a surgical challenge. Surgical debridement, removal of the infected implant, and prolonged antibiotic therapy are part of the acute management. In addition, cranioplasty removal poses the risk of dural tear. Reconstruction of the cranial defect is usually delayed for several months to years, increasing the difficulty due to soft tissue contraction and scarring. OBJECTIVE: The aim of the study was to propose an alternative to delayed reconstruction in the face of infection with a dual purpose: treat the infection with a material which delivers antibiotic to the area (polymethyl-methacrylate antibiotic) and which functions as a temporary or permanent cranioplasty. METHODS: We reviewed the records of 3 consecutive patients who underwent single-stage polymethyl-methacrylate antibiotic salvage cranioplasty. RESULTS: All patients underwent debridement of infected tissue. Titanium mesh was placed over the bony defect. Polymethyl methacrylate impregnated with vancomycin and tobramycin was then spread over the plate and defect before closure. Patients also received extended treatment with systemic antimicrobials. Early outcomes have been encouraging for both cosmesis and treatment of infection. CONCLUSIONS: Benefits of this treatment strategy include immediate reconstruction rather than staged procedures and delivery of high concentrations of antibiotics directly to the affected area in addition to systemic antibiotics.

The Association of Liposomal Bupivacaine on Opioid Consumption in the Pediatric Alveolar Cleft Population.

Surgical infiltration of liposomal bupivacaine in the adult population has been shown to decrease perioperative use of opioids, but there have been few studies conducted in the pediatric surgical population. The authors' objective was to assess the effect of liposomal bupivacaine on opioid reduction in the pediatric alveolar cleft population. The authors hypothesized that the use of surgical site infiltration with liposomal bupivacaine would be associated with decreased post-operative opioid requirements following alveolar bone grafting.The authors performed a retrospective cohort study at a tertiary craniofacial center. Forty-four pediatric patients undergoing alveolar bone grafting from November 2016 to December 2018 by the 2 craniofacial surgeons at Rady Children's Hospital were included in the study. Surgical site infiltration with liposomal bupivacaine was performed and the amount of oral morphine equivalents administered within the first 24 hours was measured.Patients in the liposomal bupivacaine cohort required 12.0 mg OME less than those patients who received standard bupivacaine or 1% lidocaine. When controlling for age, sex, weight, laterality, and harvest technique, multivariable linear regression analysis demonstrated a difference of 15.7 mg OME in favor of the LB cohort (P = 0.0006).The authors' study revealed that intraoperative surgical site infiltration of liposomal bupivacaine was associated with decreased post-operative opioid requirements following alveolar bone grafting. It should be considered as an effective part of multimodal pain therapy in the pediatric surgical population.