Pediatric Mandible Reconstruction for Osteomyelitis During Largest Reported Mycobacterium Abscessus Outbreak.

In 2016, water lines at a children's dental clinic in Orange County, California were contaminated with Mycobacterium abscessus (MA), a non-tuberculosis rapidly-growing mycobacterium, leading to the largest MA outbreak ever reported. Mandatory reporting and active case finding directed by the Public Health Department was conducted in collaboration with community Pediatric Infectious Disease physicians for patients who underwent dental pulpotomies at the contaminated Dental Clinic from January 1 to September 6, 2016. Seventy-one cases (22 confirmed and 49 probable) were identified. One case that required extensive debridement and reconstruction of the mandible is presented in detail. CT maxillofacial demonstrated osteomyelitis extending from the right mandibular angle to the left ramus with multifocal periapical lucencies. CT chest and neck revealed numerous pulmonary nodules and bilateral cervical lymphadenopathy. Extraction of several involved teeth, bilateral selective neck dissection, and extensive mandibular debridement was performed, followed by mandibular stabilization with a custom pre-bent 2.0-mm locking plate. CT images 1-year post-operative showed clearance of infection and sufficient bony stability. Subsequent removal of hardware and bone grafting was performed and the patient is doing well. In the event of a future odontogenic mycobacterium outbreak, the experience at our institution can inform multidisciplinary treatment approaches. Prophylactic extraction of primary teeth that received pulpotomies with contaminated water should be performed. Early and thorough debridement of affected bone, including enucleation of secondary teeth, should be performed if necessary for early source control.

Resorbable Plates Prevent Regression in Pediatric Mandibular Distraction Osteogenesis.

BACKGROUND: Mandibular distraction osteogenesis is an important technique to correct the pediatric hypoplastic mandible. Regression of the mandible after distraction continues to be a challenge, with some studies reporting up to 22% to 56% decrease toward predistraction length in the first year. We hypothesize that a resorbable plate placed after removal of the distractor will provide additional stability to newly formed bone, allowing further time for consolidation and minimizing regression. METHODS: This is a retrospective review of neonatal and pediatric patients between 2010 and 2015 who had mandibular distraction osteogenesis performed by the senior author (D.J.). Five patients, including 1 control and 4 intervention subjects, who had preoperative, postdistraction, and follow-up imaging were evaluated. Mandibular distraction was performed via internal devices (KLS Martin, Jacksonville, Fla) and followed by a consolidation period of 6 to 8 weeks. At the second operation when the distractors were removed, the intervention group had a SonicWeld Resorbx (KLS Martin) resorbable plate placed across the bone regenerate. A digital imaging and communications in medicine viewer was used to create a 3-dimensional reconstruction of each of the computed tomography scans and measurements of the mandible were made in the lateral cephalometric view. We then determined distraction distance, regression distance and percent regression. RESULTS: The average mandible distraction distance was 8.2 mm for the control group, and 9.9 mm for the intervention group (range, 6.7-12 mm). The average distance that the mandible regressed after distraction (regression distance) was 2.7 mm for the control group, and 0.5 mm for the intervention group (range, 0.2-0.9 mm). The average percent regression was 32.9% for the control group, and 5.1% for the intervention group (range 1.8 to 7.5%). CONCLUSIONS: The results of this study suggest that resorbable plate placement after removal of distractors helps prevent regression in pediatric mandibular distraction osteogenesis. The improvement was readily apparent both radiographically and clinically.

Diagnostic pediatric computed tomographic scans of the head: actual dosage versus estimated risk.

BACKGROUND: Recent publications have implicated computed tomographic scans in the genesis of cancer and developmental delay. To determine whether the imaging protocols used in the authors' craniofacial practice could be harmful, they reviewed patient radiation exposure data for 77 patients. They then reviewed the literature concerning the documented effects of low linear energy transfer received during radiation and the application of the linear no-threshold hypothesis. METHODS: This is a retrospective single-institution analysis of the senior surgeon's (A.D.) patients who underwent computed tomographic scanning of the head and face. Patient data from the years 2001 through the first half of 2008 were reviewed and the authors evaluated those who had radiation dose reports for each computed tomographic examination. RESULTS: Newly diagnosed craniosynostosis patients underwent an average of 1.74 computed tomographic scans per year at an average dose of approximately 1.39 mSv. Syndromic patients had a higher total number of studies when compared with nonsyndromic patients (9.73 versus 4.11). In comparison with published data, the level of radiation received by the authors' patients for computed tomographic scans of the head was 100 to 1000 times less than those levels shown to increase carcinogenesis, and nearly 40 times less than that shown to purportedly affect development and cognition. CONCLUSIONS: The authors suggest that published experimental evidence does not support the linear no-threshold model at low linear energy transfer levels similar to the exposure of their patients undergoing computed tomographic scans of the head. In addition, no convincing epidemiologic data exist demonstrating an increase in cancer incidence for doses below 100 mSv.

Peripheral nerve injuries: an international survey of current treatments and future perspectives.

Peripheral nerve injuries are a serious health concern and leave many patients with lifelong disabilities. There is little information about incidences, current practice, outcomes, and type of research that may help delineate new strategies. A questionnaire was designed to determine characteristics of peripheral nerve injuries and the need for alternative strategies and sent to 889 plastic, hand, trauma, and orthopedic surgeons in 49 countries; 324 completed surveys were collected and analyzed (total response rate of 36.45%). The majority of institutions treat more than 3000 patients annually. Trauma was the leading cause of injury with the majority located on the upper extremity. In most cases, a primary repair was achieved, but 2.52% were unrepairable. The overall outcome was linked to their Sunderland classification (SCL). A grade 1 nerve injury (SCL-1) reached a maximum outcome after 7.15 months. SCL-2, -3, -4, and -5 needed 10.69, 14.08, 17.66, and 19.03 months, respectively. Tissue engineering was considered the most important research field, resulting in a visual analogue scale of 8.6. Despite marked advances in the treatment of peripheral nerve injuries, clinical outcomes still appear unsatisfactory. The importance of research in the field of tissue engineering should be emphasized as a pathway toward improving these outcomes.