Orbital Osteomyelitis in the Pediatric Patient.

ABSTRACT: Orbital osteomyelitis in the pediatric patient is a rare clinical entity with limited reports in the literature. Outcomes for orbital osteomyelitis can be potentially fatal, and effective diagnosis and treatment often requires an extensive differential and multidisciplinary team approach. As such, the authors systematically evaluated a pooled analysis of patients in published studies to better understand the clinical trends of this condition. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines, the authors queried the PubMed, Cochrane Library, and ISI Web of Science databases. A total of 23 patients (47.8% males) participated in 10 studies between 1977 and 2017. Average age of included patients was 7.3 ±â€Š5.3 years old with follow-up of 8.7 ±â€Š9.8 months. Over half of the patients present with fistula (65.2%) and/or fever (43.5%). Sequestrum formation was common (52.2%) but only seen in chronic osteomyelitis patients. The most frequently infected orbital bone was the frontal bone (n = 10, 43.5%). Nearly all patients were cultured (82.6%) and received imaging, such as computerized tomography (43.5%) or X-ray (47.8%). Streptococcus pyogenes was the most common organism isolated (21.7%), while trauma was the most common source of infection (26.1%). Most patients were treated successfully with combined surgical debridement and antibiotics (73.9%). Significant differences between acute and chronic orbital osteomyelitis patients include clinical presentation, use of magnetic resonance imaging, methicillin-resistant Staphylococcus aureus infection, and procedure only treatments. The studies reviewed here provide a comprehensive overview of the clinical presentation, infection sources, diagnostic modalities, common organisms, and treatment options involved in pediatric orbital osteomyelitis.

Etiology and Survival of Secondary Revascularizations after Hand and Digit Replantations.

Introduction Hand and digit replantations can be complicated by vascular insufficiency necessitating revision of the original replantation. To date, few studies have evaluated outcomes in secondary revascularizations following replantation. Therefore, the objective of this study was to evaluate the incidence, etiology, and survival rates following secondary revascularization after hand and digit replantations. Materials and Methods A literature search was performed on NCBI for studies documenting secondary revascularization procedures following hand and digit replant. Studies were evaluated for the etiology of vascular failure, frequency of secondary revascularization, and survival rates following intervention. Statistical analysis was conducted across the pooled dataset. Results A total of 16 studies including 1,192 amputations were analyzed. We found that 16.9% (201/1,192) of replants were complicated by vascular compromise. The frequency of vascular compromise was not statistically different between arterial and venous etiologies. The survival rate following secondary revascularization was 55.6%, with no significant difference between the arterial and venous groups. Secondary arterial revascularization was often treated with arterial revision (nine of nine studies) and/or with vein grafting (two of nine studies). Secondary revascularization for venous insufficiency resulted in different survival rates for nonsurgical modalities (58%) versus vein revision (37.5%) versus vein grafting (100%). Conclusion Survival rates following secondary revascularization are lower; however, they may be improved using vein grafts following venous insufficiency. These data can be used to better understand the etiology of replant failure and guide decision-making.

Characteristics of Secondary Procedures following Digit and Hand Replantation.

Introduction Secondary procedures following digit and hand replants are often necessary to optimize functional outcomes. To date, the incidence and characteristics of secondary procedures have yet to be fully defined. Materials and Methods A literature search was performed using the NCBI (National Center for Biotechnology Information) database for studies evaluating secondary procedures following digit and hand replantation/revascularization. Studies were evaluated for frequency and type of secondary procedure following replantation. Descriptive statistical analysis was conducted across the pooled dataset. Results Nineteen studies representing 1,485 replants were included in our analysis. A total of 1,124 secondary procedures were performed on the 1,485 replants. Secondary procedures most commonly addressed tendons (27.1%), bone/joints (16.1%), soft tissue coverage (15.4%), nerve (5.4%), and scar contractures (4.5%). A total of 12.7% of replants resulted in re-amputation (16.7% of secondary procedures). The details of secondary procedures are further described in the article. Conclusion Secondary procedures are often necessary following hand and digit replants. Patients should be informed of the possible need for subsequent surgery, including delayed amputation, to improve hand function. These data improve our understanding of replant outcomes and can help patients better comprehend the decision to undergo replantation.

Clinical Utility of Postoperative Computed Tomography Imaging in Orbital Floor Fracture Management.

BACKGROUND: Surgical repair of orbital floor fractures aims to improve visual function and appearance. Postoperative care often involves computed tomography (CT) imaging in addition to physical examination. It has yet to be investigated whether postoperative CT imaging influences treatment of orbital floor fractures. METHODS: A retrospective chart review was conducted for all patients who underwent orbital floor fracture repair at University of California, Irvine, from 2008 to 2017. Demographics, injury characteristics, and presurgical and postsurgical management were retrospectively extracted for 217 cases. Patients who experienced a change of care following postoperative CT (n = 6) were compared with the entire patient cohort. RESULTS: Postoperative CT imaging influenced orbital floor fracture management in 6 patients (7.2% of patients with imaging). The positive predictive value of a postoperative CT scan was 10.3%, compared with 17.6% for a physical examination. An estimated $2013.76 was spent to obtain a postoperative CT scan that revealed 1 additional patient who needed reoperation (number needed to treat = 14). A multivariate regression model demonstrated no association between postoperative CT scans and change in management (P = 0.995). CONCLUSIONS: In this patient cohort, postoperative CT imaging and its associated costs did not significantly benefit management of orbital floor fracture repair. Careful clinical physical examination should be emphasized over postoperative CT imaging to reliably determine the necessity for reoperation in orbital floor fracture management.

Traumatic macular retinoschisis in infants and children.

PURPOSE: To provide detailed description of pediatric traumatic retinoschisis. METHODS: The medical records of children with either abusive head trauma and traumatic macular retinoschisis seen at a single center from 1993 to 2006 were reviewed retrospectively. Clinical details were extracted from the record and photographic documentation. Evaluation regarding abuse excluded ophthalmology findings to avoid circular reasoning. RESULTS: Of 134 patients with suspected abusive head trauma, 31 had retinoschisis. Mean age was 9 months. Of the 31, 22 (71%) offered a history of injury, and 9 (29%) were found unresponsive without history of injury; 6 were reportedly shaken. All patients had seizures, vomiting, and/or altered responsiveness. All had subdural hemorrhage, with cerebral edema in 17 (55%). In 10 (32%), there were findings of blunt force head injuries; in 4 of these there was no impact history. Retinal hemorrhages were present in all cases. Agreement between sidedness of retinoschisis and subdural hemorrhage was poor. Eleven patients had retinal folds, 3 of which had a hemorrhagic edge to the schisis. Nine patients had extracranial manifestations of abuse. Multidisciplinary team adjudications were as follows: of the 31 cases, 18 were suspicious for abuse, 11 were indeterminate, and 2 were possibly accounted for by accidental severe crush injury. Three children died, and 11 suffered neurological sequelae. CONCLUSIONS: Traumatic retinoschisis in children is highly associated with subdural hemorrhage, neurologic symptoms, and poor outcomes. Even with a conservative approach to opinion formulation, traumatic retinoschisis was associated with likely abuse.

One stage placement of permanent implant compared to two stage tissue expander reconstruction.

With the advent of the skin sparing mastectomy, immediate breast reconstruction with placement of the definitive prosthesis at the time of mastectomy is possible. The question remains: does single-stage prosthetic reconstruction result in greater numbers of complications or rates of re-operation, compared to two-stage tissue expander reconstruction? A retrospective cohort study of a single centre?s experience with these techniques was carried out. From 2004 to 2012, 54 cases of immediate breast reconstruction with implant were identified, and 108 cases of immediate breast reconstruction using a tissue expander were identified. Gathered preoperative data included tumour, prior exposure to radiation, preoperative chemotherapy, smoking, and comorbidities. Complication rates, as well as the rate of secondary operations, were examined. There were no significant increased risks in the rate of post-operative complications (p = .910, odds ratio = 0.9) nor in the rate of re-operation (p = 0.421, odds ratio = 1.4) associated with the insertion of a definitive prosthesis at the time of skin sparing mastectomy. However, previously radiated breasts experienced a 100% rate of wound complications in our subset of 9 breasts that underwent one stage breast reconstruction with immediate final prosthesis placement. Our study suggests that patients with early stage disease can undergo single stage breast reconstruction without increased risk of complications nor need for secondary operations. While the mean time to completion of the reconstructive process is shortened by 5 months with the single stage technique, implant based breast reconstruction requires careful counseling and patient selection in radiated patients.