Improving speech outcomes after failed palate repair: evaluating the safety and efficacy of conversion Furlow palatoplasty.

BACKGROUND: Velopharyngeal insufficiency occurs in a nontrivial number of cases following cleft palate repair. We hypothesize that a conversion Furlow palatoplasty allows for long-term correction of VPI resulting from a failed primary palate repair, obviating the need for pharyngoplasty and its attendant comorbidities. METHODS: A retrospective review of patients undergoing a conversion Furlow palatoplasty between 2003 and 2010 was performed. Patients were grouped according to the type of preceding palatal repair. Velopharyngeal insufficiency was assessed using Pittsburgh Weighted Speech Scale (PWSS). Scores were recorded and compared preoperatively and postoperatively at 3 sequential visits. RESULTS: Sixty-two patients met inclusion criteria and were grouped by preceding repair (straight-line repair (n = 37), straight-line repair with subsequent oronasal fistula (n = 14), or pharyngeal flap (n = 11). Median PWSS scores at individual visits were as follows: preoperative = 11, first postoperative = 3 (mean, 114.0 ± 6.7 days), second postoperative = 1 (mean, 529.0 ± 29.1 days), and most recent postoperative = 3 (mean, 1368.6 ± 76.9 days). There was a significant difference between preoperative and postoperative PWSS scores in the entire cohort (P < 0.001) with overall improvement, and post hoc analysis showed improvement between each postoperative visit (P < 0.05) with the exception of the second to the most recent visit. There were no differences between postoperative PWSS scores in the operative subgroupings (P > 0.05). Eight patients failed to improve and showed no differences in PWSS scores over time (P > 0.05). Patients with a PWSS score of 7 or greater (n = 8) at the first postoperative visit (0-6 months) displayed improvement at the most recent visit (P< 0.05). CONCLUSIONS: Conversion Furlow palatoplasty is an effective means for salvaging speech. Future studies should elucidate which factors predict the success of this technique following failed palate repair.

Efficacy of passive helmet therapy for deformational plagiocephaly: report of 1050 cases.

OBJECT: There has been a tremendous increase in the incidence of deformational plagiocephaly in children throughout the world. Therapeutic options include observation, active counterpositioning, external orthotics, and surgery. The current treatment in the US is highly debated, but it typically includes external orthotic helmets in patients with moderate to severe plagiocephaly presenting between 4 and 10 months of age or in children with significant comorbidities limiting passive (no-pressure) therapy. The present study was designed to evaluate 3 key issues: 1) the accuracy of the Argenta classification in defining a progressive degree of severity, 2) identification of an upper age limit when treatment is no longer effective, and 3) the effectiveness of an off-the-shelf prefabricated helmet in correcting deformational plagiocephaly. METHODS: An institutional review board-approved retrospective study was conducted of all patients at the authors' clinic in whom deformational plagiocephaly was assessed using the Argenta classification system over a 6-year period; the patients underwent helmet therapy, and a minimum of 3 clinic visits were recorded. Inclusion criteria consisted of an Argenta Type II-V plagiocephalic deformity. Patients' conditions were categorized both by severity of the deformity and by patients' age at presentation. Statistical analysis was conducted using survival analysis. RESULTS: There were 1050 patients included in the study. Patients with Type III, IV, and V plagiocephaly required progressively longer for deformity correction to be achieved than patients with Type II plagiocephaly (53%, 75%, and 81% longer, respectively [p < 0.0001]). This finding verified that the Argenta stratification indicated a progressive severity of deformity. No statistically significant difference in the time to correction was noted among the different age categories, which suggests that the previously held upper time limit for correction may be inaccurate. An overall correction rate to Type I plagiocephaly of 81.6% was achieved irrespective of severity and degree of the original deformity. This suggests that an inexpensive off-the-shelf molding helmet is highly effective and that expensive custom-fitted orthoses may not be necessary. The patients in the older age group (> 12 months) did not have a statistically significant longer interval to correction than the patients in the youngest age group (< 3 months). The mean length of follow-up was 6.3 months. CONCLUSIONS: Patients treated with passive helmet therapy in the older age group (> 12 months) had an improvement in skull shape within the same treatment interval as the patients in the younger age group (< 3 months). This study supports the use of passive helmet therapy for improvement in deformational plagiocephaly in infants from birth to 18 months of age and verifies the stratification of degree of deformity used in the Argenta classification system.

Changes in Nerve Conduction Studies After Distal Radius Fracture Fixation Using a Volar Approach and Locked Plate.

Purpose: To determine whether there are changes in nerve conduction studies (NCS) of the median nerve after distal radius fracture (DRF) and to determine how operative fixation through a volar approach with a locking plate contributes to nerve conduction changes. We hypothesized that a considerable percentage of patients would have electrodiagnostic evidence of median neuropathy at the wrist after fracture, but fixation with a volar locked plate would not worsen the electrodiagnostic findings. Methods: This was a prospective cohort study of 14 neurologically asymptomatic patients who underwent surgical treatment of an isolated DRF using a volar plate. All patients underwent surgery within 2 weeks of injury. On the day of surgery and at the 6-week follow-up, patients were clinically examined, Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire was completed, and patients underwent NCS using a handheld device with the unaffected limb, which was used as a comparison. Preoperative and postoperative nerve function were compared with the unaffected limb as a baseline. Results: Patients without symptoms after DRF had a 28% incidence of prolonged latencies compared with reference values for the device used. Distal sensory latencies of the median nerve were 3.64 ± 0.32 ms in the unaffected arm, 3.76 ± 0.70 ms before surgery, and 3.81 ± 0.52 ms after surgery. Distal motor latencies of the median nerve were 3.91 ± 0.59, 3.60 ± 0.68, and 3.88 ± 0.36 ms in respective arms and time points. Quick-Disabilities of the Arm, Shoulder, and Hand scores improved from 77 before surgery to 46 at 6 weeks. Conclusions: Asymptomatic patients may satisfy nerve conduction criteria for median neuropathy at the wrist after DRF; however, open reduction and treatment with a volar locked plate has no significant effect on NCS findings. Type of study/level of evidence: Prognostic II.

A Novel Surgical Technique for Resuspension of Digital Pulp Tissue after Degloving Injuries.

Adherence of pulp tissue to the underlying distal phalanx is required for fundamental actions including grip, proprioception, and fine motor skills. Disruption of the fibrous septa causes sliding between the distal phalanx and overlying soft tissues, hindering basic hand function. The authors present a novel surgical technique in which the fibrous pulp septa are resuspended to the distal phalanx with bone anchors and sclerosing agents after a closed degloving injury.

Carpal Tunnel Syndrome in the Setting of Mucopolysaccharidosis II (Hunter Syndrome).

BACKGROUND: Carpal tunnel syndrome (CTS) is a rare finding in children, but heavily represented in pediatric patients with mucopolysaccharidoses. Diagnosis is a challenge due to lack of the stereotypical symptomatic complaints and relies on examination and objective nerve conduction studies. METHODS: We present a case of delayed presentation of CTS in a 12-year-old boy with Hunter syndrome, followed by a review of the literature. RESULTS: Patient Z.D. presented with minimal reported CTS symptoms but advanced median nerve damage on electromyography. He underwent bilateral carpal tunnel release with median nerve neurolysis and flexor tenosynovectomies. Intraoperative examination demonstrated the presence of a "waist sign" of the median nerve and moderate flexor tenosynovial hypertrophy bilaterally. Parents reported mild subjective improvement of dexterity and fine motor skills postoperatively. CONCLUSION: To optimize functional outcome, routine screening for CTS and intervention at an early age are emphasized in the mucopolysaccharidoses population.

Unusual Volar Pulp Location of Glomus Tumor.

Glomus tumors are benign, painful growths originating from glomus bodies and comprise just 1% of tumors arising in the hand, with fewer than 10% in the volar pulp of digits. Hallmark symptoms of glomus tumors include hypersensitivity to cold, heightened pinprick sensitivity, and paroxysmal pain. We report a 72-year-old, right-hand dominant man who presented with pain in the left middle finger, localized to the tip. The fingertip was incredibly sensitive to touch, and his pain increased at night. He reported no recollection of trauma. Palpation of the finger revealed no mass, although it did indicate a focal point of pain within the distal pulp of the digit. Magnetic resonance imaging of the left hand revealed a round 7.0 × 4.0 × 6.0-mm soft tissue lesion along the volar ulnar aspect of the distal third digit. An incision was made in the mid-axial plane, circumscribing and removing the mass bluntly. It was a tan-yellow, soft tissue nodule of 0.8-cm in diameter without stalk or adherences to joints. Pathology revealed the mass was a glomus tumor. Symptoms improved on removal, and he healed without complication. Glomus tumors in the volar digital pulp can be difficult to diagnose. However, the presence of localized pain in the fingertip was reason to consider glomus tumor and proceed with treatment. Complete surgical removal of a glomus tumor is necessary to resolve symptoms and prevent recurrence.

Vacuum-assisted closure for the treatment of complex breast wounds.

Complex breast wounds are a constant problem for surgeons. Wound vacuum-assisted closure therapy (VAC) has been shown to be effective for a variety of complex wounds. Our goal was to evaluate our experience with the (VAC) device in the treatment of open breast wounds. We retrospectively identified 18 patients with complex breast wounds treated with the VAC. We analyzed the data regarding the nature and management of these wounds using the VAC device. Fifteen of 18 patients were treated effectively using the VAC. Two patients required muscle flap coverage. One patient had the VAC dressing discontinued secondary to a denial by an insurance company for VAC in the home setting. VAC therapy is an effective treatment for complex wounds. Specifically, our experience shows it to be effective in the treatment of complex breast wounds. Utilization of VAC therapy should be considered for the management of these challenging wounds.

Obstetrical brachial plexus palsy: Can excision of upper trunk neuroma and nerve grafting improve function in babies with adequate elbow flexion at nine months of age?

Accepted indications for exploration in obstetrical brachial plexus palsy (OBPP) vary by center. Most agree that full elbow flexion against gravity at nine months of age implies high chance of spontaneous recovery and thus excludes a baby from surgical intervention. However, there are certain movements of the shoulder and forearm that may not be used frequently by the infant, but are extremely important functionally as they grow. These movements are difficult to assess in a baby and may lead to some clinicians to recommend conservative treatment, when this cohort of infants may in fact benefit substantially from surgery. A retrospective review was conducted on all infants managed surgically at the Brachial Plexus Center of a major children's hospital from 2009 to 2014. Further analysis identified five patients who had near-normal AMS scores for elbow flexion but who had weakness of shoulder abduction, flexion, external rotation, and/or forearm supination. In contrast to standard conservative management, this cohort underwent exploration, C5-6 neuroma excision, and sural nerve grafting. Data analysis was performed on this group to look for overall improvement in function. During an average follow-up period of 29 months, all patients made substantial gains in motor function of the shoulder and forearm, without loss of elbow flexion or extension, or worsening of overall outcome. In select infants with brachial plexus injuries but near-normal AMS scores for elbow flexion, surgical intervention may be indicated to achieve the best functional outcome.

A review of eight unusual pediatric skin and soft-tissue lesions: Diagnosis, workup, and treatment.

The spectrum of clinical presentations in pediatric skin and soft-tissue lesions often makes diagnosis challenging. Delays in diagnosis and subsequent treatment can be life threatening, and they can subject patients to more complicated reconstruction. This retrospective case series reviews the presentation, management, and current literature on eight pediatric skin and soft-tissue lesions. For rare lesions and those with unclear pathology, a multidisciplinary approach is strongly advocated for optimal management.