Clinical Features and Management of Skull Base Fractures in the Pediatric Population: A Systematic Review.

Pediatric basilar skull fractures (BSFs) are a rare type of traumatic head injury that can cause debilitating complications without prompt treatment. Here, we sought to review the literature and characterize the clinical features, management, and outcomes of pediatric BSFs. We identified 21 relevant studies, excluding reviews, meta-analyses, and non-English articles. The incidence of pediatric BSFs ranged from 0.0001% to 7.3%, with falls from multi-level heights and traffic accidents being the primary causes (9/21). The median presentation age ranged from 3.2 to 12.8 years, and the mean age of patients across all studies was 8.68 years. Up to 55% of pediatric BSFs presented with intracranial hematoma/hemorrhage, along with pneumocephalus and edema. Cranial nerve palsies were a common complication (9/21), with the facial nerve injured most frequently (7/21). While delayed cranial nerve palsy was reported in a few studies (4/21), most resolved within three months post-admission. Other complications included CSF leaks (10/21) and meningitis (4/21). Management included IV fluids, antiemetics, and surgery (8/21) to treat the fracture directly, address a CSF leak, or achieve cranial nerve compression. Despite their rarity, pediatric skull base fractures are associated with clinical complications, including CSF leaks and cranial nerve palsies. Given that some of these complications may be delayed, patient education is critical.

Exosome-Laden Scaffolds for Treatment of Post-Traumatic Cartilage Injury and Osteoarthritis of the Knee: A Systematic Review.

Mesenchymal stem cell (MSC)-based exosomes have garnered attention as a viable therapeutic for post-traumatic cartilage injury and osteoarthritis of the knee; however, efforts for application have been limited due to issues with variable dosing and rapid clearance in vivo. Scaffolds laden with MSC-based exosomes have recently been investigated as a solution to these issues. Here, we review in vivo studies and highlight key strengths and potential clinical uses of exosome-scaffold therapeutics for treatment of post-traumatic cartilage injury and osteoarthritis. In vivo animal studies were gathered using keywords related to the topic, revealing 466 studies after removal of duplicate papers. Inclusion and exclusion criteria were applied for abstract screening and full-text review. Thirteen relevant studies were identified for analysis and extraction. Three predominant scaffold subtypes were identified: hydrogels, acellular extracellular matrices, and hyaluronic acid. Each scaffold-exosome design showcased unique properties with relation to gross findings, tissue histology, biomechanics, and gene expression. All designs demonstrated a reduction in inflammation and induction of tissue regeneration. The results of our review show that current exosome-scaffold therapeutics demonstrate the capability to halt and even reverse the course of post-traumatic cartilage injury and osteoarthritis. While this treatment modality shows incredible promise, future research should aim to characterize long-term biocompatibility and optimize scaffold designs for human treatment.

Performance Assessment of the American College of Surgeons Risk Calculator in Metastatic Spinal Tumor Surgery.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to assess the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator performance in patients undergoing surgery for metastatic spine disease. SUMMARY OF BACKGROUND DATA: Patients with spinal metastases may require surgical intervention for cord compression or mechanical instability. The ACS-NSQIP calculator was developed to assist surgeons with estimating 30-day postoperative complications based on patient-specific risk factors and has been validated within several surgical patient populations. MATERIALS AND METHODS: We included 148 consecutive patients at our institution who underwent surgery for metastatic spine disease between 2012 and 2022. Our outcomes were 30-day mortality, 30-day major complications, and length of hospital stay (LOS). Predicted risk, determined by the calculator, was compared with observed outcomes using receiver operating characteristic curves with area under the curve (AUC) and Wilcoxon signed-rank tests. Analyses were repeated using individual corpectomy and laminectomy Current Procedural Terminology (CPT) codes to determine procedure-specific accuracy. RESULTS: Based on the ACS-NSQIP calculator, there was good discrimination between observed and predicted 30-day mortality incidence overall (AUC=0.749), as well as in corpectomy cases (AUC=0.745) and laminectomy cases (AUC=0.788). Poor 30-day major complication discrimination was seen in all procedural cohorts, including overall (AUC=0.570), corpectomy (AUC=0.555), and laminectomy (AUC=0.623). The overall median observed LOS was similar to predicted LOS (9 vs. 8.5 d, P =0.125). Observed and predicted LOS were also similar in corpectomy cases (8 vs. 9 d; P =0.937) but not in laminectomy cases (10 vs. 7 d, P =0.012). CONCLUSIONS: The ACS-NSQIP risk calculator was found to accurately predict 30-day postoperative mortality but not 30-day major complications. The calculator was also accurate in predicting LOS following corpectomy but not laminectomy. While this tool may be utilized to predict risk short-term mortality in this population, its clinical value for other outcomes is limited.

Five-Strand Hamstring Grafts are Biomechanically Comparable to Four-Strand Grafts and Offer Greater Diameter for Anterior Cruciate Ligament Reconstruction.

Purpose: The purpose of this study was to compare the biomechanics of 4-strand and 5-strand hamstring constructs for anterior cruciate ligament grafts. Methods: Thirty-six human cadaveric hamstring grafts were tested in 3 different conditions: (1) graft femoral fixation complex, (2) graft femoral and tibial fixation (GFTF) complex using a human model, and (3) GFTF complex using a porcine model. Grafts were tested on a tensile testing machine. Four-stranded grafts served as the control group, and 5-stranded grafts served as the experimental group. Cyclic elongation, ultimate load to failure, stiffness, and diameter of the grafts were analyzed. Results: Average 4-strand graft diameter was 7.96 mm compared to 9.32 mm for the 5-strand graft (P = .00017). Average stiffness of grafts ≥8 mm was 105.04 N/mm compared to 85.05 N/mm for grafts <8 mm (P = .04988). There was a positive correlation between graft diameter and stiffness (13.4 N/mm per every 1 mm increase in diameter, r 2 value of 13.1%, and F-significance of 0.02778). There were no significant differences in terms of ultimate load to failure, cyclic elongation, or stiffness between the experimental groups. Conclusion: Five-strand hamstring grafts offer greater diameter and are biomechanically comparable to 4-strand equivalents at time 0. Grafts >8 mm offer significantly greater stiffness compared to grafts sized <8 mm. There is a weak positive correlation between graft diameter and stiffness. Clinical Relevance: A potential drawback to hamstring grafts is their variability in size. Five-strand hamstring grafts provide increased diameter in comparison to 4-strand equivalents and might be used when quadrupled graft diameter is <8 mm.