The Risk of Medication-Related Osteonecrosis of the Jaw in Children: Guidance for Antiresorptive Use in Pediatric Patients.

BACKGROUND: Antiresorptive targeted cancer therapies, such as denosumab and bisphosphonates, are used in adults, but their application in pediatric cancer is more recent. Side effects such as osteonecrosis of the jaw (ONJ) observed in adults have curtailed use of these medications in the pediatric population. PURPOSE: This study assesses the frequency of ONJ, other side effects, and the indications for use of denosumab versus bisphosphonates in pediatric subjects. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study of pediatric subjects who underwent bisphosphonate or denosumab therapy at our institution from 2007-2023 was conducted. Subjects aged ≥ 18 years at therapy initiation were excluded. INDEPENDENT VARIABLE: The independent variable was antiresorptive therapy divided into 2 groups, treatment with intravenous bisphosphonates or denosumab. MAIN OUTCOME VARIABLE(S): Primary outcomes were development of bisphosphonate-related and denosumab-related ONJ. Secondary outcomes included additional side effects. COVARIATES: ONJ risk factors, subject demographics, indications for use, timing, duration, and cumulative dose of antiresorptive therapy were abstracted. ANALYSES: Univariate and bivariate statistics were computed to describe the sample and measure associations between antiresorptive therapy and outcomes. P values < .05 conferred statistical significance. RESULTS: The sample was composed of 178 subjects with a mean age of 11.7 ± 6.1 years. There were 14 (7.9%) and 164 (92.1%) subjects treated with denosumab and bisphosphonate therapies, respectively. There were 0 cases of ONJ across all subjects. The most common indication for treatment was adjuvant targeted therapy for aggressive tumors and malignancy (39.3%) followed by osteoporosis (14.6%). Subjects treated with denosumab had higher frequencies of hypercalcemia and severe bone pain than subjects treated with bisphosphonates, 28.6% versus 1.2% (P < .001) and 14.3% versus 0.00% (P < .001), respectively. CONCLUSION AND RELEVANCE: While invasive dental procedures are ideally performed before antiresorptive treatment, our data suggest that bisphosphonates may be used safely in the pediatric population with low concern for ONJ. Our data also demonstrated bisphosphonates may have a more tolerable side effect profile than denosumab. If the perceived benefits are similar, we recommend using bisphosphonates as first-line therapy in children while reserving denosumab for refractory cases. Future studies will help determine long-term side effects and differences in efficacies of these medications.

Does Side Matter? The Impact of Free Flap Harvest Laterality on Ambulatory Function in Lower Extremity Traumatic Reconstruction.

BACKGROUND: Free flaps are essential for limb salvage in patients with lower extremity (LE) trauma; however, significant donor-site morbidity could impact functional outcomes. This study compares postoperative ambulatory function between contralateral and ipsilateral free flap harvest in LE traumatic reconstruction. METHODS: A retrospective review was performed on patients who underwent LE reconstruction at a level 1 trauma center from 2009 to 2022. Flap characteristics, injury history, and ambulatory function were collected. Flap harvest laterality was determined in relation to the injured leg. The flaps were categorized as either fasciocutaneous or those that included a muscle component (muscle/myocutaneous). Chi-squared and Mann-Whitney tests were used for statistical analysis. RESULTS: Upon review, 173 LE free flaps were performed, of which 70 (65.4%) were harvested from the ipsilateral leg and 37 (34.6%) were from the contralateral leg. Among all LE free flaps, the limb salvage rate was 97.2%, and the flap survival rate was 94.4%. Full ambulation was achieved in 37 (52.9%) patients in the ipsilateral cohort and 18 (48.6%) in the contralateral cohort (p = 0.679). The average time to full ambulation did not vary between these cohorts (p = 0.071). However, upon subanalysis of the 61 muscle/myocutaneous flaps, the ipsilateral cohort had prolonged time to full ambulation (6.4 months, interquartile range [IQR]: 4.8-13.5) compared with the contralateral one (2.3 months, IQR: 2.3 [1.0-3.9]) p = 0.007. There was no significant difference in time to full ambulation between flap harvest laterality cohorts among the fasciocutaneous flaps (p = 0.733). CONCLUSION: Among free flaps harvested from the ipsilateral leg, fasciocutaneous flaps were associated with faster recovery to full ambulation relative to muscle/myocutaneous flaps. Since harvesting muscle or myocutaneous flaps from the ipsilateral leg may be associated with a slower recovery of ambulation, surgeons may consider harvesting from a donor site on the contralateral leg if reconstruction requires a muscle component.

The Forgotten Flap: The Pedicled Trapezius Flap's Utility in Pediatric Head and Neck Reconstruction-A Systematic Review.

BACKGROUND: When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted. RESULTS: A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (n = 11) and case series (n = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (n = 46, 73.0%) and chronic wounds secondary to H&N masses (n = 9, 14.3%). Defects were most commonly located in the neck (n = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm2 and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (n = 48, 71.6%) and based on the dorsal scapular artery (n = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (n = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years. CONCLUSION: This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.

The Impact of Intraoperative Vasopressor Use and Fluid Status on Flap Survival in Traumatic Lower Extremity Reconstruction.

BACKGROUND: Historically, the use of intraoperative vasopressors during free flap lower extremity (LE) reconstruction has been proposed to adversely affect flap survival due to concerns about compromising flap perfusion. This study aims to analyze the impact of intraoperative vasopressor use and fluid administration on postoperative outcomes in patients undergoing traumatic LE reconstruction. METHODS: Patients who underwent LE free flap reconstruction between 2015 and 2023 at a Level I Trauma Center were retrospectively reviewed. Statistical analysis was conducted to evaluate the association between vasopressor use and intraoperative fluids with partial/complete flap necrosis, as well as the differential effect of vasopressor use on flap outcomes based on varying fluid levels. RESULTS: A total of 105 LE flaps were performed over 8 years. Vasopressors were administered intraoperatively to 19 (18.0%) cases. Overall flap survival and limb salvage rates were 97.1 and 93.3%, respectively. Intraoperative vasopressor use decreased the overall risk of postoperative flap necrosis (OR 0.00005, 95% CI [9.11 × 10-9-0.285], p = 0.025), while a lower net fluid balance increased the risk of this outcome (OR 0.9985, 95% CI [0.9975-0.9996], p = 0.007). Further interaction analysis revealed that vasopressor use increased the risk of flap necrosis in settings with a higher net fluid balance (OR 1.0032, 95% CI [1.0008-1.0056], p-interaction =0.010). CONCLUSION: This study demonstrated that intraoperative vasopressor use and adequate fluid status may be beneficial in improving flap outcomes in LE reconstruction. Vasopressor use with adequate fluid management can optimize hemodynamic stability when necessary during traumatic LE microvascular reconstruction without concern for increased risk of flap ischemia.

Lessons Learned from a Single Institution's Eight Years of Experience with Early Cleft Lip Repair.

Background and Objectives: The traditional approach in managing wide cleft lip deformities involves presurgical nasoalveolar molding (NAM) therapy followed by surgical cleft lip repair between three and six months of age. This institution has implemented an early cleft lip repair (ECLR) protocol where infants undergo primary cleft lip repair between two and five weeks of age without NAM. This study aims to present this institution's ECLR repair protocol over the past eight years from 188 consecutive patients with unilateral or bilateral CL/P deformity. Materials and Methods: Retrospective review was conducted at Children's Hospital Los Angeles evaluating patients who underwent ECLR before three months of age and were classified as American Society of Anesthesiologists (ASA) class I or II from 2015-2022. Anthropometric analysis was performed, and pre- and postoperative photographs were evaluated to assess nasal and lip symmetry. Results: The average age at cleft lip repair after correcting for gestational age was 1.0 ± 0.5 months. Mean operative and anesthetic times were 120.3 ± 33.0 min and 189.4 ± 35.4, respectively. Only 2.1% (4/188) of patients had postoperative complications. Lip revision rates were 11.4% (20/175) and 15.4% (2/13) for unilateral and bilateral repairs, respectively, most of which were minor in severity (16/22, 72.7%). Postoperative anthropometric measurements demonstrated significant improvements in nasal and lip symmetry (p < 0.001). Conclusions: This analysis demonstrates the safety and efficacy of ECLR in correcting all unilateral cleft lip and nasal deformities of patients who were ASA classes I or II. At this institution, ECLR has minimized the need for NAM, which is now reserved for patients with bilateral cleft lip, late presentation, or comorbidities that preclude them from early repair. ECLR serves as a valuable option for patients with a wide range of cleft severity while reducing the burden of care.

A comparison of negative pressure wound therapy modalities, VAC versus non-commercial NPWT alternatives: A systematic review of RCTs/CCTs.

BACKGROUND: Negative pressure wound therapy (NPWT) has been described as an effective treatment for wounds of various etiologies, however it is expensive. Various authors have investigated low-cost alternatives to commercial NPWT devices. A systematic review summarizing their findings is needed for clinicians operating in resource-limited locations and for those interested in potential cost savings. METHODS: A systematic review was performed evaluating articles from Cochrane, PubMed and EMBASE. The studies included randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared commercially available Vacuum-Assisted Closure (VAC) devices with non-commercial NPWT modalities in human subjects. RESULTS: Seven hundred and ninety-six articles were retrieved, of which six met inclusion criteria. All six studies were RCTs and had in total 409 participants with wounds of various etiologies, including acute, chronic, and traumatic wounds. All studies compared VAC to a non-commercial NPWT device. Five studies were found to have low risk of bias, and one study had high risk of bias. There were three types of non-commercial NPWT devices used: wall suction applied to a sealed gauze dressing (GSUC), AquaVac, and Redon drains. The following outcomes were assessed: granulation tissue formation, effect on wound size area, skin graft take, pain/time associated with dressing changes and cost. In trials that compared GSUC vs VAC, there was no significant difference between the two groups for the following outcomes: granulation tissue formation, effect on wound size and skin graft take. GSUC dressings were significantly less painful and less time-consuming than VAC dressings. In the trial that compared AquaVac vs VAC, there was no significant difference between the two groups for the following outcomes: granulation tissue formation, effect on wound size, and the time or pain associated with dressing changes. In the trial that compared Redon drains vs VAC, there was significantly more granulation tissue formed in the VAC group. All non-commercial NPWT devices were found to be less costly than VAC. CONCLUSION: The data from the trials evaluated in this review indicate that GSUC and AquaVac are two non-commercial NPWT devices that are non-inferior to VAC for various outcomes while also being less costly. GSUC was less painful and less time-consuming than VAC. Of the non-commercial NPWT devices evaluated in this review, GSUC had the most evidence to support its future use. Prospective, multi-institutional RCTs with a large sample size are needed to confirm the findings presented here.

A Systematic Review of Simulation in Burn Care: Education, Assessment, and Management.

Assessment and management of burns require nuanced, timely interventions in high-stake settings, creating challenges for trainees. Simulation-based education has become increasingly popular in surgical and nonsurgical subspecialties to supplement training without compromising patient safety. This study aimed to systematically review the literature on existing burn management-related simulations. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing burn-specific surgical and nonsurgical simulation models were included. The model type, study description, simulated skills, assessment methods, fidelity, cost, and outcomes were collected. Of 3,472 articles, 31 met inclusion criteria. The majority of simulations were high-fidelity (n=17, 54.8%). Most were immersive (n=17, 54.8%) and used synthetic benchtop models (n=13, 41.9%), whereas none were augmented/virtual reality. Simulations of acute and early surgical intervention techniques (n=16, 51.6%) and burn wound assessments (n=15, 48.4%) were the most common, whereas burn reconstruction was the least common (n=3, 9.7%). Technical skills were taught more often (n=29, 93.5%) than non-technical skills (n=15, 48.4%). Subjective assessments (n=18, 58.1%) were used more often than objective assessments (n=23, 74.2%). Of the studies that reported costs, 91.7% (n=11) reported low costs. This review identified the need to expand burn simulator options, especially for burn reconstruction, and highlighted the paucity of animal, cadavers, and augmented/virtual reality models. Developing validated, accessible burn simulations to supplement training may improve education, patient safety, and outcomes.