Bioabsorbable Temporizing Matrix (BTM): Not Just for Burns.

A skin substitute developed in Australia 2 decades ago for use in acute burns was recently introduced into the United States for the treatment of open wounds. This product has been shown to be very efficacious for coverage of debrided burn wounds. It consists of an inorganic synthetic woven layer that induces cellular ingrowth and deposition of interstitial tissue. It is covered by an attached silicone layer that seals the wound. The product is placed with the woven side directly on the wound. It is fixed in place and optimally covered by a negative pressure dressing for the first 5-10 days. Due to its synthetic composition, it is highly resistant to infection and can stay on the wound for as long as needed. The authors have used this matrix in a wide variety of complex reconstructions in 27 patients, consisting of 10 females and 17 males. Eleven had traumatic wounds of various etiologies (deep burns, crush injuries, Morell-Lavallee lesion, hand injuries, multiple trauma, open fractures, compartment syndromes and soft tissue avulsions). The following wounds were also treated with BTM: pressure ulcers, axillary hidradenitis, scalp wounds, severe facial acne keloidalis, Fournier's gangrene, a diabetic foot ulcer, a chronic venous ulcer, a cutaneous pyoderma gangrenosum, a radiation ulcer with exposed Achilles tendon, a disfiguring scar from an old Dupytrens excision and a non-healing chemotherapy extravasation ulcer. Hand and leg wounds with exposed tendon achieved coverage without tethering. The scalp wounds developed a neodermis and were skin-grafted. A pyoderma gangrenosum patient with excessive slough and uncontrolled bleeding was temporarily immunosuppressed, aggressively debrided and covered with the matrix. Her bleeding resolved. She developed a neodermis, and had reduced symptoms. The Fournier's patient had immediate skin-grafting of his penis and testicles, but the remaining extensive perineal and upper thigh wounds were treated with the matrix and healed without additional skin grafting. A hand patient with a forearm fasciotomy wound was covered with the matrix. As the swelling resolved the size of the defect decreased to the point that the wound was delaminated. The adjacent skin was elevated and used to cover the open area, achieving full closure. There were no complications attributed to the use of the matrix. Several patients healed secondarily with the silicone sheeting gradually peeling off. Seven patients have received or are awaiting skin grafts to be placed over the neodermis. Although this is an early review of the use of this synthetic matrix in the US, it comes with a positive legacy from Australia. The findings thus far indicate that there is a wide range of applications for this product well beyond burn care. Its safety record, resistance to infection and ease of use facilitate surgery.

Evaluation in a porcine wound model and long-term clinical assessment of an autologous heterogeneous skin construct used to close full-thickness wounds.

Acute and chronic wounds involving deeper layers of the skin are often not adequately healed by dressings alone and require therapies such as skin grafting, skin substitutes, or growth factors. Here we report the development of an autologous heterogeneous skin construct (AHSC) that aids wound closure. AHSC is manufactured from a piece of healthy full-thickness skin. The manufacturing process creates multicellular segments, which contain endogenous skin cell populations present within hair follicles. These segments are physically optimized for engraftment within the wound bed. The ability of AHSC to facilitate closure of full thickness wounds of the skin was evaluated in a swine model and clinically in 4 patients with wounds of different etiologies. Transcriptional analysis demonstrated high concordance of gene expression between AHSC and native tissues for extracellular matrix and stem cell gene expression panels. Swine wounds demonstrated complete wound epithelialization and mature stable skin by 4 months, with hair follicle development in AHSC-treated wounds evident by 15 weeks. Biomechanical, histomorphological, and compositional analysis of the resultant swine and human skin wound biopsies demonstrated the presence of epidermal and dermal architecture with follicular and glandular structures that are similar to native skin. These data suggest that treatment with AHSC can facilitate wound closure.

American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline: Eyelid Surgery for Upper Visual Field Improvement.

BACKGROUND: A group of experts from different disciplines was convened to develop guidelines for the management of upper visual field impairments related to eyelid ptosis and dermatochalasis. The goal was to provide evidence-based recommendations to improve patient care. METHODS: A multidisciplinary group of experts representing their specialty organizations was selected. A systematic literature review was performed including topics regarding documentation of the underlying cause for visual field impairment, selection of an appropriate surgical repair, assessment of the type of anesthesia, the use of adjunctive brow procedures, and follow-up assessments. The Grading of Recommendations, Assessment, Development, and Evaluation methodology process was used to evaluate the relevant studies. Clinical practice recommendations were developed using BRIDGE-Wiz (Building Recommendations In a Developers' Guideline Editor) software. RESULTS: Each topic area was assessed. A clinical recommendation was made, and the relevant literature was discussed. CONCLUSIONS: The review of the literature revealed varied complication rates and diverse treatment modalities for the correction of upper visual field deficit. Strong recommendations could not be made in most topic areas because of a paucity of methodologically sound studies in the literature. More rigorously designed studies are needed to measure outcomes of interest, with fewer sources of potential error or bias. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Management of Pediatric Nasoorbitoethmoid Complex Fractures at a Level 1 Trauma Center.

PURPOSE: A universally accepted treatment algorithm for rare pediatric nasoorbitoethmoid (NOE) fractures has yet to be established. In this study, the authors examine how severity of pediatric NOE fractures interplays with patient characteristics, management choices, and complications from injury and surgical intervention at our institution. METHODS: A retrospective chart review was performed for all cases of pediatric NOE fracture at a level 1 trauma center (University Hospital in Newark, New Jersey) between 2002 and 2014. RESULTS: Fifteen of 1922 patients met our inclusion criteria. Ten (66.7%) demonstrated Markowitz type I injuries, 2 (13.3%) had type II NOEs, and 3 (20%) sustained type III fractures. Five (33.3%) of our patients were only monitored. Six (40.0%) were treated with plate fixation. One patient (6.7%) required enucleation alone, while 1 (6.7%) warranted enucleation with medial canthoplasty and plate fixation. Transnasal canthopexy was performed for 1 patient (6.7%). Zero patients managed without surgery had complications at 1-year follow-up. Surgical intervention was associated with complications in 4 of 15 patients. Both nonoperative treatment and plate fixation were associated with a higher rate of complications from initial injury or subsequent therapy when than other mentioned forms of treatment (P = .004). CONCLUSION: Nonoperative management for nondisplaced fractures is associated with zero complications at 1-year follow-up in our data; plate fixation and watchful waiting yield significantly fewer postoperative complications and injury sequelae than surgical intervention for medial canthal tendon and globe injuries.

Periorbital and Globe Injuries in Pediatric Orbital Fractures: A Retrospective Review of 116 Patients at a Level 1 Trauma Center.

STUDY DESIGN: Retrospective chart review of pediatric and globe injuries associated with orbital fractures. OBJECTIVE: Our study seeks to examine these injuries and their association with orbital fractures at our trauma center to gain a better understanding of how to approach pediatric patients with orbital fractures. METHODS: A retrospective review of all facial fractures in pediatric patients at an urban level 1 trauma center was performed for the years 2002 to 2014. Patient demographics were collected, as well as orbital fracture location, mechanism of injury, concomitant injuries, ophthalmologic documentation, imaging, and perioperative records. RESULTS: One hundred sixteen pediatric patients over a 12-year period sustained an orbital fracture. The orbital floor was the most commonly fractured orbital bone in our series (60%). Thirty-four (30%) of the pediatric patients with orbital fractures had documented periorbital and/or globe injuries at the time of presentation. The most common periorbital injury was entrapment related to orbital floor fractures. Significant eyelid lacerations were present in seven patients, with five of these patients had canalicular injuries and two had canthal malposition. Five pediatric patients presented with traumatic optic neuropathy. Two patients had ruptured globes requiring enucleation. CONCLUSIONS: Periorbital soft tissue and globe injuries associated with orbital fractures occurs in a substantial number of pediatric patients. There are no guidelines for treatment of these type of injuries in the pediatric population. Further research should be performed to better understand the appropriate management of periorbital injuries in conjunction with surgical management of the orbital fractures.

Pediatric Palate Fractures: An Assessment of Patterns and Management at a Level 1 Trauma Center.

STUDY DESIGN: Literature discussing palate fractures in the pediatric population is limited. We performed a retrospective review of pediatric palatal fractures at our institution to better understand the impact of this fracture pattern in the pediatric patient. OBJECTIVES: The goal of our study is to analyze our institutional experience with pediatric palate fractures, focusing on epidemiology, concomitant injuries, and fracture management. METHODS: Records were collected for all palatal fractures in pediatric patients diagnosed between 2000 and 2016 at an urban Level I trauma center. Patient imaging was reviewed. Demographic characteristics and inpatient clinical data were recorded. RESULTS: Nine pediatric patients were diagnosed with fracture of the bony palate. Average age was twelve with male predominance (66%). Pedestrian struck injuries (33%) and motor vehicle accidents (33%) were the most common etiologies. Five patients sustained skull fractures. Three patients were found to have intracranial hemorrhage, two required emergent bolt placement. Two patients sustained cervical spine injury. One patient had severe facial hemorrhage requiring embolization. According to the Hendrickson classification, there were three type I fractures, two type II fractures, one type III fracture, one type IV fracture, and one type V fracture. Lefort I and/or alveolar fracture was present in every patient. Four patients underwent surgical treatment with open reduction and restoration of facial height with maxillomandibular fixation. Three patients underwent concomitant mandible fracture repair. CONCLUSIONS: Pediatric palatal fractures are rare and are usually accompanied by devastating concomitant injuries. Surgical repair of the palate in the pediatric patient is often necessary to restore facial height.

A prospective, randomized, controlled, crossover study comparing three multilayered foam dressings for the management of chronic wounds.

Aim: Compare foam dressings - Mepilex Border Flex (MxBF), Allevyn Life (AL) and Optifoam Gentle EX (OGEX) - in treatment of chronic wounds. Materials & methods: Prospective, randomized, controlled trial (crossover design). Subjects received one dressing for 2 weeks, then comparator dressing for following 2 weeks. Wound/periwound characteristics evaluated weekly at dressing change. Primary end point: dressing durability (incidence of exudate strikethrough). Results: Higher incidence of intact dressings (no strikethrough) at Day 7 (Week 1) with MxBF (6/17; 35.3%) compared with AL (1/18; 5.6%), and with MxBF (7/16; 43.8%) compared with OGEX (2/16; 12.5%; p < 0.05). No significant differences between groups regarding wound size reduction. Conclusion: MxBF had statistically greater durability than AL/OGEX during first critical week of treatment.

Facial Fractures and Mixed Dentition - What Are the Implications of Dentition Status in Pediatric Facial Fracture Management?

INTRODUCTION: The stage of maturation of the pediatric facial skeleton at the time of injury has a significant impact on both facial fracture patterns and management strategies. For instance, the relative prominence of the pediatric cranium during the early years of life affords protection to the structures of the midface, whereas delayed aeration of the frontal sinuses may predispose younger patients to frontal bone fractures. The dentition status of a pediatric patient may have similar implications in the setting of facial fracture. In this study, the authors examine the effect of dentition status on facial fracture patterns and management strategies at an urban, level 1 trauma center. METHODS: A retrospective chart review was performed for all cases of facial fracture occurring in the pediatric patient population at a level 1 trauma center (University Hospital in Newark, NJ) between 2002 and 2014. A database including patient demographics, facial fracture, and concomitant injury patterns, and operative management data was constructed and analyzed. RESULTS: A total of 72 patients with mixed dentition met inclusion criteria for our study and were compared against patients with primary (n = 35) and permanent (n = 349) dentition. The mean age at presentation was 9.2 years, with a male predominance of 68%. The most common fracture etiology was pedestrian struck accident (n = 23), fall (n = 21), motor vehicle collision (n = 12), and assault (n = 9). The most frequently identified facial fractures were that of the orbit (n = 31), mandible (n = 21), nasal bone (n = 19), and frontal sinus (n = 14). Additionally, 8 Le Fort and 4 nasoorbitoethmoid fractures were identified. Twenty-one patients (29%) required operative management for 1 or more facial fractures. Operative intervention was required in 38% of mandibular fractures, with 6 patients requiring only maxillomandibular fixation and 2 requiring open reduction and internal fixation with titanium plating. Nine cases of orbital fracture (29%) were managed operatively - 4 with absorbable plates, 3 with Medpor implants, and 8 with titanium plating. Management of all nasal fractures requiring operative intervention was accomplished through closed reduction. Concomitant injuries included traumatic brain injury (TBI) (n = 35), skull fracture (n = 24), intracranial hemorrhage (ICH) (n = 20), and long bone fracture (n = 12). Seventeen patients required admission to the intensive care unit. Patients with mixed dentition were significantly more likely to sustain frontal sinus and Le Fort fractures (P < 0.01), as well as skull fracture, ICH, and TBI (P < 0.01) as compared to those with permanent dentition. CONCLUSIONS: The dentition status of a pediatric patient may have significant implications in both patterns of injury and operative management strategies in the setting of acute facial trauma. Our study finds that Le Fort and frontal sinus fractures were significantly more common in patients with mixed dentition. Severe concomitant injuries such as ICH and TBI were also significantly more likely in this cohort. A patient's dentition status may also play a role in the decision for ridged fixation of mandibular and orbital fractures, as well as the method of maxillomandibular fixation in maxillary and mandibular alveolar fracture.

A Single Center Review of Pediatric Nasal Bone Fractures - An Analysis of Concomitant Injuries, Management, and Outcomes.

Background: Pediatric nasal bone fractures presenting as isolated fractures or with concomitant facial injuries are rare and not well documented. Analysis of treatment at an urban, level-one trauma center provides insight into their management. Methods: Data were collected for pediatric nasal bone fractures diagnosed between January 2000 and December 2014. Patients were divided into groups based on presence or absence of isolated nasal bone fractures. Groups were compared using Chi-squared analysis, and a Bonferroni correction was used for a more conservative alpha (a = .004). Results: Assault was the most common etiology presenting in 46 of 122 pediatric nasal bone fractures. There was no significant difference in surgical versus non-surgical management of isolated and non-isolated nasal bone fractures (P = 0.98). Treatment for both was predominantly watchful waiting in 91% to 95% of the cases followed by closed reduction in 3.2% to 3.3%. In the patients with isolated fractures, 11.5% sustained intracranial hemorrhage, compared to 35.6% of multifracture cases (P = .002); 15.0% of isolated fractures sustained a traumatic brain injury, compared to 55.9% of multifracture cases (P = .000003). No significant difference in fatality existed between groups (P = 0.53). Conclusions: Multi-facial fracture cases were more likely to present with traumatic brain injuries and be admitted to the intensive care unit than isolated nasal bone fractures. Rates of surgical and non-surgical management were not significantly different between the 2 groups. Watchful waiting of pediatric nasal bone fractures was the management approach selected 92% to 95% of the time regardless of the presence or absence of concomitant facial fractures.

A Single Center Review of Pediatric Nasal Bone Fractures - An Analysis of Concomitant Injuries, Management, and Outcomes.

Background: Pediatric nasal bone fractures presenting as isolated fractures or with concomitant facial injuries are rare and not well documented. Analysis of treatment at an urban, level-one trauma center provides insight into their management. Methods: Data were collected for pediatric nasal bone fractures diagnosed between January 2000 and December 2014. Patients were divided into groups based on presence or absence of isolated nasal bone fractures. Groups were compared using Chi-squared analysis, and a Bonferroni correction was used for a more conservative alpha (a = .004). Results: Assault was the most common etiology presenting in 46 of 122 pediatric nasal bone fractures. There was no significant difference in surgical versus non-surgical management of isolated and non-isolated nasal bone fractures (P = 0.98). Treatment for both was predominantly watchful waiting in 91% to 95% of the cases followed by closed reduction in 3.2% to 3.3%. In the patients with isolated fractures, 11.5% sustained intracranial hemorrhage, compared to 35.6% of multifracture cases (P = .002); 15.0% of isolated fractures sustained a traumatic brain injury, compared to 55.9% of multifracture cases (P = .000003). No significant difference in fatality existed between groups (P = 0.53). Conclusions: Multi-facial fracture cases were more likely to present with traumatic brain injuries and be admitted to the intensive care unit than isolated nasal bone fractures. Rates of surgical and non-surgical management were not significantly different between the 2 groups. Watchful waiting of pediatric nasal bone fractures was the management approach selected 92% to 95% of the time regardless of the presence or absence of concomitant facial fractures.

Rigid External Distractors in Midface Fractures: A Review of Relevant and Related Literature.

INTRODUCTION: Literature discussing the use of rigid external distraction devices in midfacial trauma is limited. Rigid external distraction devices have been described for use in craniofacial surgery, allowing for distraction and stabilization of bony segments. In complex facial trauma, bony fragments are often comminuted and unstable, making traditional approaches with internal fixation difficult. Moreover, these approaches require subperiosteal dissection, limiting blood supply that is important for bone healing. OBJECTIVE: The goal of this study was to evaluate the role of rigid external distraction devices for the treatment of complex facial trauma. METHODS: We performed a literature review of rigid external distraction devices, as relevant both for facial trauma and for other craniofacial indications, to better elucidate their use and efficacy in complex facial fractures. RESULTS: The review revealed only 2 articles explicitly describing rigid external distraction devices for facial trauma, while 6 other articles describing its use for other craniofacial cases. An important benefit associated with the use of rigid external distraction devices is their ability to provide controlled traction of bony segments while also allowing for movement as needed for fracture reduction. Various articles describe performing internal fixation following rigid external distraction device usage, while others emphasize that internal fixation is not necessarily indicated if the rigid external distraction device is left intact long enough to ensure bony healing. One potential setback described is unfamiliarity with using the rigid external distraction device, which can preclude its use by many surgeons. In addition, the literature review did not provide any uniform guidelines or recommendations about how long rigid external distraction devices should remain intact. CONCLUSION: Based on relevant literature, rigid external distraction devices have been shown to be useful in the stabilization and treatment of complex facial fractures. Further studies should be conducted to better elucidate the specific indications for rigid external distraction devices in complex facial trauma.

Autologous Homologous Skin Constructs Allow Safe Closure of Wounds: A Retrospective, Noncontrolled, Multicentered Case Series.

An autologous homologous skin construct (AHSC) has been developed for the repair and replacement of skin. It is created from a small, full-thickness harvest of healthy skin, which contains endogenous regenerative populations involved in native skin repair. A multicenter retrospective review of 15 wounds in 15 patients treated with AHSC was performed to evaluate the hypothesis that a single application could result in wound closure in a variety of wound types and that the resulting tissue would resemble native skin. Patients and wounds were selected and managed per provider's discretion with no predefined inclusion, exclusion, or follow-up criteria. Dressings were changed weekly. Graft take and wound closure were documented during follow-up visits and imaged with a digital camera. Wound etiologies included 5 acute and chronic burn, 4 acute traumatic, and 6 chronic wounds. All wounds were closed with a single application of AHSC manufactured from a single tissue harvest. Median wound, harvest, and defect-to-harvest size ratio were 120 cm2 (range, 27-4800 cm2), 14 cm2 (range, 3-20 cm2), and 11:1 (range, 2:1-343:1), respectively. No adverse reactions with the full-thickness harvest site or the AHSC treatment site were reported. Average follow-up was 4 ± 3 months. An AHSC-treated area was biopsied, and a micrograph of the area was developed using immunofluorescent confocal microscopy, which demonstrated mature, full-thickness skin with nascent hair follicles and glands. This early clinical experience with ASHC suggests that it can close different wound types; however, additional studies are needed to verify this statement.

Motor Vehicle Collision Injuries: An Analysis of Facial Fractures in the Urban Pediatric Population.

PURPOSE: Motor vehicle collisions (MVC) are a leading cause of unintentional death and injury in the US pediatric population. Compliance with prevention measures such as seatbelts and child safety seats varies considerably with patient demographics. In this study, the authors examine facial fracture secondary to MVC in an urban pediatric population. METHODS: A retrospective chart review was performed of all facial fractures as a result of MVC in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. RESULTS: Seventy-five patients met inclusion criteria for the authors' study. Mean age was 14 years old. Common fracture sites included orbital, mandible, nasal bone, and frontal sinus. Patients were more likely to incur fracture of the zygoma, orbit, nasal bone, frontal sinus, and nasoorbitoethmoid (NOE) if involved in an MVC compared to all other etiologies. Common concomitant injuries included traumatic brain injury, intracranial hemorrhage, and skull and long bone fractures. Open reduction and internal fixation with titanium plates was the most common surgical procedure indicated. CONCLUSION: Motor vehicle collisions related injury has significant health implications in the urban pediatric population. Orbital, zygoma, and nasal facial fractures and TBI are injuries commonly associated with MVC. The facial fractures are likely due to lack of proper utilization of safety equipment and airbags. Development of effective prevention techniques relies heavily on analysis of injury patterns and management strategies.

Mentorship Through Research: A Novel Approach to Increasing Resident and Medical Student Research Competency Through an Institutional Database.

BACKGROUND: We describe a novel research database development project to increase resident and medical student scholarly ability and mentorship skills. We collected data on 3147 facial fractures treated at our institution over a 12-year period. This data was used to publish novel research on multiple types of facial fractures and outcomes. METHODS: We learned about key database aspects that led to its high level of research quality and output volume through over 6 years of database development and expanded research output. A retrospective review was completed to compile the total research produced during this time period. RESULTS: Research resulted in 20 manuscripts, 17 podium presentations, and 11 posters. 16 medical students, 5 residents and 3 faculty members were authors on at least one project. The average number of published manuscripts was 5.17 overall and 2.9, 7.0, and 14.0 for medical students, residents, and faculty, respectively. Four residents matched into fellowship, 7 medical students matched into residency, and one faculty member was promoted academically. CONCLUSIONS: A database focused on a common and under-researched pathology can result in a high volume of novel research output. Additional program benefits include increased scholarly and mentorship ability in engaged residents and medical students.

Assessment of Panfacial Fractures in the Pediatric Population.

PURPOSE: Management of panfacial fractures is critical and often difficult in adults; however, there is little to no literature regarding these fractures in the pediatric population. In this study, we present our experience to provide insight and further investigation regarding prevention and management strategies within the pediatric population. PATIENTS AND METHODS: We performed a retrospective chart review of all panfacial fractures in the pediatric population between 2002 and 2014 treated at an urban, level 1 trauma center (University Hospital, Newark, NJ). Data including patient demographic characteristics, mechanisms of injury, locations of fractures, concomitant injuries, and surgical management strategies were collected. RESULTS: We identified 82 patients aged 18 years or younger who had sustained a panfacial fracture. The mean age at the time of injury was 12.9 years, with a male predominance of 64.9%. A total of 335 fractures were identified on radiologic imaging. The most common etiologies were motor vehicle accidents and pedestrians being struck. Orbital, frontal sinus, nasal, and zygoma fractures were the most common fractures. The mean score on the Glasgow Coma Scale on arrival was 12.0. A total of 29 patients were intubated on arrival-or before arrival-at the trauma bay. A surgical airway was required in 9 patients. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Surgical repair was required in 38 patients. The cephalic-to-caudal approach was used most, followed by caudal to cephalic, medial to lateral, and lateral to medial. Within a year of the initial surgical procedure, 4 patients underwent reoperations for complications. Four patients died. CONCLUSIONS: Pediatric panfacial fractures are rare occurrences; however, the impact of these injuries can be devastating, with concomitant life-threatening injuries and complications. Given the lack of literature, as well as the preventable nature of these injuries, we hope this study can address primary prevention strategies and provide insight toward the management and characteristics of these fractures.

Latest Advances in Wound Debridement Techniques.

The surgical surgical debridement of wounds has evolved over the past 250 years. At that time, the amputation of extremities was recognized as a life-saving procedure to treat major wounds suffered in combat. This continued until after World War I. As the survival of patients with diabetes and other chronic conditions improved, and as advanced therapies were developed to meet the needs of an increasing number of patients with chronic wounds, debridement became a focal point of surgical wound care. It is now well-established that debridement enhances wound-healing and improves the efficacy of advanced therapies and surgical closure. Up until the last two decades, sharp excision with "cold steel" was the only option for debridement. In the early 2000's, a high-power waterjet was introduced, and provided a more precise debridement of wound surfaces. As our understanding of biofilms increased, so came the realization that biofilms are stratified within the wound, with anaerobic species preferentially developing deeper within the wound. The latest surgical instrument for wound debridement, the direct contact low frequency ultrasound device (DCLFU), has recently been introduced. A vacuum sheath was added to the active tip to contain spray dispersion. The device is capable of removing all of the wound tissue including biofilm down to a healthy base. This allows for optimal preparation of the wound prior to deployment of an advanced therapy, graft, or flap. This instrumentation is designed specifically for use in the operating room. However, the manufacturer has recently introduced a less powerful, but still effective, version for use in the outpatient clinic. These advances in surgical debridement technology have paved the way for more effective subsequent interventions for treating chronic wounds.

Human-derived Acellular Dermal Matrix Grafts for Treatment of Diabetic Foot Ulcers: A Systematic Review and Meta-analysis.

BACKGROUND: Treating diabetic foot ulcers (DFUs) requires thorough understanding of available surgical tools. OBJECTIVE: This meta-analysis compares human-derived acellular dermal matrices (H-ADMs) with standard of care (SOC) to evaluate the number of healed ulcers at 12 and 16 weeks and number of days to complete healing. As a secondary outcome, the efficacy of 3 H-ADM subtypes are studied. METHODS: Two researchers searched PubMed, EMBASE, and The Cochrane Central Register of Controlled Trials for relevant titles from inception through July 2018. Inclusion criteria indicated articles be randomized controlled trials investigating the effects on neuropathic, nonischemic DFUs. RESULTS: Data from 312 DFUs in total were included in the meta-analysis. The results show H-ADMs are more effective in healing patients within a 12-week (3.14; range, 2.04-4.83) and 16-week period (2.35; range, 1.25-4.43) in comparison with SOC. Further, the mean time to complete healing was shorter in the H-ADM group (-2.31 days; range, -2.67 to -1.95 days) in comparison with SOC. Within the subgroups, 2 H-ADMs were associated with a higher likelihood of complete healing within 12 weeks when compared with SOC. The third H-ADM had a point estimate, which suggested superiority over SOC. CONCLUSIONS: This study shows H-ADMs are associated with a higher likelihood of complete healing and fewer days to complete healing within a 12-week and 16-week periods when compared with SOC. Also, the commercial products performed similarly.

Pediatric Pedestrian Facial Fracture Patterns and Management Following Motor Vehicle Collisions.

PURPOSE: Pedestrian trauma due to motor vehicle crashes can be especially destructive to the pediatric population as the facial skeleton is immature and developing. Almost half of crashes resulting in pedestrian death involved alcohol consumption, and children are often victims of irresponsible driving. The objective of this study was to examine the prevalence of facial fractures in this patient population in order to analyze management strategies that optimize functional recovery. METHODS: A retrospective chart review was performed for all facial fractures resulting from motor vehicle collisions with pedestrians in the pediatric population at a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. RESULTS: During the time period examined, 55 patients were identified as 18 years of age or younger and having sustained a facial fracture as the result of being struck by a motor vehicle. The mean age was 11.3 (range 1-18) years, with a male predominance of 69.0%. There were a total of 125 fractures identified on radiologic imaging via CT or X-ray. The most common fractures were those of the orbit (20.0%), mandible (19.2%), and nasal bone (10.4%). The mean Glasgow Coma Scale on arrival was 12.1 (range 4-15). Fifteen patients were intubated on, or prior to, arrival to the trauma bay. The most common concomitant injuries were intracranial hemorrhage, long bone fractures, and cervical spine fractures. The mean operative time was 216.9 (range 63-515) minutes. Surgery was required in 36 patients, with most undergoing open reduction and internal fixation with titanium plates and screws. Two patients required resorbable plates, and one required Medpor implants. The mean hospital length of stay was 9.9 (range 1-59) days. Two patients expired. CONCLUSIONS: There is currently a dearth of literature regarding the management and patterns of injury for pediatric pedestrian injuries due to motor vehicle collisions. The impact of these injuries can be devastating with concomitant life-threatening complications, and may influence the future development of the facial skeleton after healing of the bone and soft tissue. The authors hope this study can provide insight and further investigation regarding prevention and management.

Sports-Related Pediatric Facial Trauma: Analysis of Facial Fracture Pattern and Concomitant Injuries.

Objective Sports-related injuries, such as facial fractures, are potentially debilitating and may lead to long-term functional and aesthetic deficits in a pediatric patient. In this study, we analyze sports-related facial fractures in the urban pediatric population in an effort to characterize patterns of injury and improve management strategies and outcomes. Methods Retrospective chart review was performed for all facial fractures resulting from sports injuries in the pediatric population at a level-1 trauma center (University Hospital, Newark, NJ). Results Seventeen pediatric patients were identified as having sustained a fracture of the facial skeleton due to sports injury. Mean age was 13.9 years old. A total of 29 fractures were identified. Most common fracture sites included the orbit ( n = 12), mandible ( n = 5), nasal bone ( n = 5), and zygomaticomaxillary complex ( n = 3). The most common concomitant injuries included skull fracture ( n = 3), intracranial hemorrhage ( n = 4), and traumatic brain injury ( n = 4). One patient was intubated upon arrival to the emergency department. Hospital admission was required in 13 patients, 4 of which were admitted to an intensive care setting. Nine patients required operative intervention. Mean length of hospital stay was 2.4 days. No patients were expired. Conclusions Sports-related facial fractures are potentially debilitating injuries in the pediatric population. Analysis of fracture pattern and concomitant injuries is imperative to develop effective management strategies and prevention techniques.