Facial sensation has significant functional importance. Loss of sensation in the lower lip can cause significant morbidity, including the inability to detect dislodged food, drooling, and injury. The value of reinnervating lower lip sensation lies in mitigating these complications and enhancing functional recovery and social interaction. Cross-facial nerve grafting techniques can be used to restore facial sensation. We describe our technique and outcomes of 2 pediatric patients who underwent mental nerve sensory restoration with sural nerve cross-facial nerve grafting. The intact contralateral mental nerve was used as the donor nerve using an end-to-side neurorrhaphy via intraoral incisions. Both patients had restoration of lower lip sensation on Semmes-Weinstein monofilament testing. Donor site changes were imperceptible to the patients.

For paediatric patients with visually noticeably hand differences, disparities between how a patient, parent, or treating surgeon might view the appearance of their hand can lead to discrepancies of satisfaction. Hand appearance after surgery is an integral success, yet little data exists on how to quantify hand appearance. A systematic scoping review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using the Ovid MEDLINE, PubMed, and EMBASE databases looking specifically for separate measurements relating to the appearance outcomes after operative interventions for congenital hand differences. A total of 5014 studies were identified by the literature search. 67 met inclusion criteria and underwent data extraction. Methods of measuring appearance outcome fell into one of five categories: visual analogue scales, categorical scales, binary scales, patient-reported outcome measures (PROMs), and anthropometric scales. Eighteen of the 67 studies used the appearance measurement as part of a composite score which assessed multiple functional domains, such as the Tada or ALUURA systems. The most common assessor were the patients themselves, followed by patient proxies (usually a parent), and hand surgeons. The aesthetic appearance and satisfaction after surgery for a congenital hand difference is judged by numerous different assessment tools, most of which are unvalidated. Of the tools that do exist, many are utilized for a single diagnosis and are not appropriate for more global assessment of congenital hand differences in general. Future promising tools include variations of PROMs, which may give a better idea of a patient’s personal satisfaction after surgery, but their widespread use with children remains to be adopted. Level of Evidence: Not ratable

BACKGROUND:Extravasation is the leakage of intravenous drugs, chemicals, or fluids into the extravascular compartment and is common in paediatric patients. These injuries can cause ulceration with tissue loss. This study investigates whether a washout procedure can reduce the incidence of partial- or full-thickness skin loss following extravasation. METHODS:All extravasation injuries referred to the Plastic and Maxillofacial Department at the Royal Children's Hospital, Melbourne, from June 2018 to June 2023 were prospectively identified and reviewed. Data collected included patient demographics, extravasated fluid potency, injury grade, anatomical site, washout timing, and outcomes at 24 and 48 h. Logistic regression was used to identify predictors of skin loss. RESULTS:A total of 216 extravasation injuries were analysed; 61.1% were male, and 41.7% were under 1 year old. Washout was performed in 50.5% of cases, and 16.7% developed skin loss. Multivariate analysis identified lower limb site (OR = 7.46; p = 0.008), grade 3 injury (OR = 193.10; p < 0.001), and grade 4 injury (OR = 441.30; p < 0.001) as strong predictors of skin loss. Absence of washout significantly increased the risk (OR = 7.51; p = 0.018), particularly in grade 3 and 4 injuries (OR = 15.48; p = 0.003). Fluid potency and age were not independent predictors after adjusting for confounders. CONCLUSION:Washout is effective for reducing skin loss in paediatric extravasation injuries, particularly in grades 3 and 4. Lower limb cannulation carries a significantly higher risk of skin loss. Injury grade should guide urgent washout intervention.

Congenital dorsal curvature of the distal phalanx has been previously described as 'reverse Kirner' or 'ski-jump' deformity. This report describes bilateral occurrence in the thumbs. A 13-year-old male presented with difficulty caring for his thumbnails and in picking up small objects. Examination showed dorsal curvature of the distal phalanges of both thumbs, with greater curvature of the right side. Radiographs showed wedge-shaped epiphyses and dorsal curvature without coronal plane deviation of the distal phalanges. There was objective and subjective decrease in function associated with lateral pinch and tripod grasp. The reported aetiopathogenesis for Kirner deformity cannot explain the observed dorsal curvature. The bilateral nature makes a secondary physeal cause unlikely and suggests an embryologic basis. Due to the noticeable deficits in function, operative intervention may be warranted. Level of Evidence: Level V (Therapeutic).

Summary: Improvements in the management of pediatric sarcoma, including imaging, neo- and adjuvant therapy, and surgical technique, have enhanced long-term survival. Pediatric patients diagnosed with a femoral osteosarcoma undergoing oncologic resection who are ineligible for limb-preservation reconstruction or rotationplasty are offered an above-knee amputation (AKA). Limb amputation in the skeletally immature patient poses particular problems specific to endosteal bone overgrowth and spiking. Approximately half of these patients undergo revision of their amputation site. Furthermore, a high AKA often requires a hip-based prosthesis, which can be uncomfortable, leading to poorer outcomes and higher energy expenditures. The authors have completed 4 “spare parts” microvascular free tibial transfers for pediatric patients diagnosed with femoral osteosarcoma who were treated with an AKA. Two of these patients are ambulatory with their prosthesis and have not required long-term revision of their amputation site. One patient demonstrated radiographic evidence of bony union 4 months postoperatively, but subsequently died of chemotherapy-resistant metastases. The fourth patient is in the process of prosthetic fitting and rehabilitation. This is a novel technique, and the authors present the first series describing both proximal and distal free microvascular tibial bone transfers as a reconstructive option for pediatric patients with femoral osteosarcomas. This reliable flap, which has possible variations in vascular anatomy, offers multiple benefits, including prevention of bony spiking, AKA stump augmentation, and facilitation of appropriate prosthetic fitting, improving functional outcomes and leading to decreased energy expenditure. The soft-tissue coverage must be well-planned.

BJU InternationalEarly View Case of the Month Case of the month from the University of Melbourne, Melbourne, Australia: treatment of iatrogenic erectile dysfunction with somatic-to-autonomic sural nerve grafting David C. Dangerfield, Corresponding Author David C. Dangerfield [email protected] orcid.org/0000-0002-0503-4344 Complete Urology Care, Brighton, Vic., Australia Correspondence: David C. Dangerfield, Complete Urology Care, Suite 7 243 New St, Brighton, VIC 3186, Australia. e-mail: [email protected]Search for more papers by this authorChristopher J. Coombs, Christopher J. Coombs Department of Surgery, The University of Melbourne, Parkville, Vic., Australia Department of Paediatrics, The University of Melbourne, Parkville, Vic., Australia Southern Plastic Surgery, Brighton, Vic., AustraliaSearch for more papers by this author David C. Dangerfield, Corresponding Author David C. Dangerfield [email protected] orcid.org/0000-0002-0503-4344 Complete Urology Care, Brighton, Vic., Australia Correspondence: David C. Dangerfield, Complete Urology Care, Suite 7 243 New St, Brighton, VIC 3186, Australia. e-mail: [email protected]Search for more papers by this authorChristopher J. Coombs, Christopher J. Coombs Department of Surgery, The University of Melbourne, Parkville, Vic., Australia Department of Paediatrics, The University of Melbourne, Parkville, Vic., Australia Southern Plastic Surgery, Brighton, Vic., AustraliaSearch for more papers by this author First published: 10 May 2023 https://doi.org/10.1111/bju.16034Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL References 1Souza Trindade JC, Viterbo F, Petean TA, Favaro WJ, Trindade-Filho JCS. Long-term follow-up of treatment of erectile dysfunction after radical prostatectomy using nerve grafts and end-to-side somatic-autonomic neurorraphy: A new technique. BJU Int 2017; 119: 948– 54 2Reece JC, Dangerfield DC, Coombs CJ. End-to-side somatic-to-autonomic nerve grafting to restore erectile function and improve quality of life after radical prostatectomy. Eur Urol 2019; 76: 189– 96 3Lawrentschuk N. Funding of all issues related to prostate cancer treatment should be a priority and have equal access – A key to survivorship. BJU Int 2022; 130: 4 4Motlagh RS, Abufaraj A, Yang L et al. Penile rehabilitation strategy after nerve sparing radical prostatectomy: A systematic review and network meta-analysis of randomized trials. J Urol 2021; 205: 1018– 30 5Dovey ZS, Tewari AK. Somatic to autonomic nerve grafting for the treatment of erectile dysfunction: It seems to work, but how? Eur Urol 2019; 76: 197– 9 6Tal R, Valenzuela R, Aviv N et al. Persistent erectile dysfunction following radical prostatectomy: The association between nerve-sparing status and the prevalence and chronology of venous leak. J Sex Med 2009; 6: 2813– 9 Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

Children with a congenital upper limb difference (CoULD) are a diverse group who often require multidisciplinary care and long‐term support for functional and social impacts. The Australian Hand Difference Register (AHDR) provides a national database of children born with a CoULD and aims to facilitate research and improve health care for affected children. Using data from the first 3 years of its operation, we analysed the demographic and clinical features of participating families, including type of CoULDs and the frequency of pre‐natal and syndromic diagnoses.

BACKGROUND:Dermatofibrosarcoma protuberans (DFSP) is a rare fibrohistiocytic tumor of dermal origin. Six percent of all cases present in children, with a childhood incidence of 1 per million.METHODS:This is a retrospective review of all cases of pediatric DFSP managed at a single institution over a 23-year period.RESULTS:Seventeen patients (10 male; mean age, 9.9 years) were managed during the study period. The median follow-up was 29 months. All patients had surgical excision. Three patients required further excision to achieve uninvolved final margins. There were no recurrences observed.CONCLUSIONS:Pediatric DFSP should be managed by a soft tissue tumor multidisciplinary team, with experienced pathologists and reconstructive surgeons. Where R0 resections are obtained, patients can experience recurrence-free survival.

ANZ Journal of SurgeryVolume 92, Issue 1-2 p. 13-16 PERSPECTIVES Designing a better incision for proximal tibial osteosarcoma resection and reconstruction: a reminder of the skin's vascular anatomy William Alexander MBBS, FRACS (Plast), William Alexander MBBS, FRACS (Plast) orcid.org/0000-0001-5304-6844 Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Parkville, Victoria, Australia Contribution: Conceptualization, Writing - original draft, Writing - review & editingSearch for more papers by this authorDavid McCombe MBBS, FRACS (Plast), David McCombe MBBS, FRACS (Plast) Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Parkville, Victoria, Australia Murdoch Children's Research Institute, Parkville, Victoria, Australia Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia Contribution: Conceptualization, Writing - review & editingSearch for more papers by this authorChristopher Coombs MBBS, FRACS (Plast), Christopher Coombs MBBS, FRACS (Plast) Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Parkville, Victoria, Australia Murdoch Children's Research Institute, Parkville, Victoria, Australia Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia Contribution: Conceptualization, Supervision, Writing - review & editingSearch for more papers by this author William Alexander MBBS, FRACS (Plast), William Alexander MBBS, FRACS (Plast) orcid.org/0000-0001-5304-6844 Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Parkville, Victoria, Australia Contribution: Conceptualization, Writing - original draft, Writing - review & editingSearch for more papers by this authorDavid McCombe MBBS, FRACS (Plast), David McCombe MBBS, FRACS (Plast) Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Parkville, Victoria, Australia Murdoch Children's Research Institute, Parkville, Victoria, Australia Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia Contribution: Conceptualization, Writing - review & editingSearch for more papers by this authorChristopher Coombs MBBS, FRACS (Plast), Christopher Coombs MBBS, FRACS (Plast) Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Parkville, Victoria, Australia Murdoch Children's Research Institute, Parkville, Victoria, Australia Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia Contribution: Conceptualization, Supervision, Writing - review & editingSearch for more papers by this author First published: 24 February 2022 https://doi.org/10.1111/ans.17222Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume92, Issue1-2January/February 2022Pages 13-16 RelatedInformation

BACKGROUND:The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumors. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and the local bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique-an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening.METHODS:We retrospectively included 10 patients (mean age 10 y) with an osteosarcoma of the distal femur, who were treated according to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome.RESULTS:The mean defect size after tumor resection was 14.5 cm, the mean length of the harvested fibula graft 22 cm, resulting in a mean (acute) shortening of 4.7 cm (in 8 patients). Consolidation was achieved in all cases, 4 patients required supplementary bone grafting. Hypertrophy at the graft-host junctions was observed in 78% of the evaluable junctions. In total 11 intramedullary lengthening procedures in 9 patients had been performed at the last follow up. The mean Muskuloskeletal Society Rating Scale (MSTS) score of the evaluable 9 patients was 85% (57% to 100%) with good or excellent results in 7 patients.CONCLUSIONS:A-frame vascularised fibula reconstructions showed encouraging results with respect to defect reconstruction, length as well as function and should therefore be considered a valuable option for reconstruction of the distal femur after osteosarcoma resection. The surgical implementation is demanding though, which is emphasized by the considerable high number of complications requiring surgical intervention, even though most were not serious.LEVEL OF EVIDENCE:Level IV-case series.

Although the primary aim of pollicization is to augment function, aesthetic improvement is an important secondary aim. Satisfaction with hand appearance in children with index pollicization for thumb hypoplasia was evaluated in 18 patients at an average of 7.5 years after surgery. Patients and their parents rated the appearance of their operated hand using a 10-point visual analogue scale (VAS). Four independent surgeons and 16 non-surgeon observers also rated the hands after reviewing standardized photographs of each child. The median patient-reported and parent-reported scores were 9 for both groups (IQR: 7-10) with a trend for children 12 years and older, to report lower satisfaction with appearance. The non-surgeon group assessments varied more for a given hand than the surgeons' assessments, though when scores were averaged within these groups for each hand, there was a high degree of correlation between the two groups. Surprisingly, the patient's own assessment showed a trend towards negative correlation when compared with the average rating of the non-surgeon assessors, suggesting that patients' own assessment of their hand's appearance is more affected by subjective factors than the objective physical outcome.

This qualitative study explored the psychosocial concerns of children born with congenital hand and upper limb differences (CHULDs) from the point of view of these children and their parents. Qualitative, in-depth, semi-structured interviews were conducted face-to-face with eight parent–child dyads. Open format questions allowed spontaneous emergence of relevant themes, followed by guided questioning. Thematic analysis of audio-recorded and transcribed interviews found that children as young as 5 years old had unique and meaningful opinions about their CHULD, of which parents were sometimes unaware. Children reported that unsolicited questions from peers caused significant stress, and this increased around the time of surgery. All children used planned responses to peers as an effective coping mechanism. Children also identified positive aspects of their difference, including an increased sense of determination and an appreciation for being unique. Strategies that may improve psychosocial outcomes for children with CHULDs are discussed. Level of evidence: IV

INTRODUCTION:Proximal tibial sarcoma resections result in a reconstructive challenge, necessitating joint and extensor mechanism reconstruction. The gait and functional outcomes for children reconstructed with a combination of megaprosthesis and pedicled fibular flap for extensor mechanism reconstruction, are presented.METHODS:Four patients, aged 11-18 years old, were available for comprehensive analysis. The proximal tibial osteosarcoma was resected, and the reconstructive technique involved a megaprosthesis for the knee joint, used in combination with a pedicled fibula flap as a biologic structure for reinsertion of the knee extensor mechanism. Outcomes were measured with three-dimensional gait analysis and patient questionnaires.RESULTS:Minor postoperative wound issues occurred in some patients, requiring debridement with skin grafting. One patient fractured their transferred fibula, requiring fixation. The follow up period ranged from 1.7 to 24 years postoperatively. The longevity and quality of reconstructions were strong, measured by both objective and patient-reported outcomes. All patients reported independent walking >500 m in the Functional Mobility Scale and rated their walking as a nine or 10 (out of 10) on the Functional Assessment Questionnaire. Knee society scoring revealed overall satisfaction rate of 75-80%. No patients required gait aids. The gait profile analysis revealed effective gait patterns, with patterns deviating 5.4-7° from "typical gait." Deviations >6.5° are considered abnormal.CONCLUSION:The long-term results of combining a megaprosthesis with a pedicled fibula flap for extensor reinsertion, revealed a high level of independent function. The patients performed well, without the need for aids, and gait study evidence of minimal gait deviations.

Abstract The management of complex exomphalos major is difficult, and traditional techniques fail to address the visceroabdominal disproportion in the most severe cases. Intra-abdominal tissue expansion is a novel technique and has been used in a small number of patients to safely increase the intra-abdominal volume and allow the reduction of viscera and subsequent closure of the abdominal domain. We review 7 published reports of this technique and add a case report describing our refinement of the technique. We propose that the use of multiple expanders placed in the intra-abdominal preperitoneal space, when expanded slowly, can allow safe reduction of viscera and immediate direct closure of the musculofascial layer of the abdomen.

Displaced subcapital phalangeal fractures of the middle or proximal phalanges occur primarily in children. The degree and direction of displacement, patient age and time since injury influence treatment decisions and patient outcomes. Delayed presentation with malunion and reduced joint motion is common. This paper presents a case series of displaced subcapital phalangeal fracture early malunions managed conservatively. Near complete remodelling of dorsal angular deformity was seen in all patients. Conservative management of phalangeal subcapital fracture malunions is a viable alternative to the complex procedure of corrective osteotomy.

Background: Radical prostatectomy (RP) is recommended for the treatment of men with clinically localised prostate cancer. However, RP is associated with a high incidence of erectile dysfunction (ED), which can impact the quality of life (QoL) significantly. Objective: To evaluate the effectiveness of end-to-side nerve grafting surgery to restore erectile function and improve sexual QoL in men with ED after RP. Design, setting, and participants: A retrospective review of a single-centre experience of nerve grafting in men with ED following RP was performed. Seventeen men had surgery between March 2015 and October 2017 in Melbourne, Australia, which fulfilled study inclusion and exclusion criteria. Intervention: Microsurgical bilateral end-to-side nerve grafts from a selective fascicular neurotomy of the femoral nerve to the penile corpora cavernosa. Outcome measurements and statistical analysis: Results were serially measured utilising the International Index of Erectile Function (IIEF-5) and the sexual domain of Expanded Prostate Cancer Index Composite (EPIC-26). The proportion and 95% confidence interval (CI) of men recovering sexual function following nerve grafting were determined. Results and limitations: All patients had ED following their RP. Median age at nerve grafting was 64 yr (interquartile range [IQR] 60-66 yr). Median time between nerve- and non-nervesparing RP, and nerve grafting was 2.4 (IQR 2.1-3.1) and 2.2 (IQR 1.7-5.1) yr, respectively. Median follow-up was 18 (IQR 15-24) mo. At 12 mo after nerve grafting, 71% (95% CI 44-90%) of patients had erectile function recovery sufficient for satisfactory sexual intercourse, and 94% (95% CI 71-99%) and 82% (95% CI 57-96%) had clinically significant improvements in sexual function and reduced bother, respectively. There were two minor wound infections. Limitations include the retrospective study design. Conclusions: End-to-side nerve grafting restored erectile function in 71% of men with ED following RP, supporting previous findings. Of the men, 94% had clinically relevant improvements in sexual QoL. We recommend multicentre implementation of post-RP nerve grafting into clinical practice with appropriate data collection to confirm its efficacy and feasibility. Patient summary: We provide confirmatory evidence that end-to-side nerve grafting surgery restored erectile function and improved sexual quality of life in, respectively, 71% and 94% of men with erectile dysfunction following radical prostatectomy. (C) 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.

The case of a seven-year-old boy with a Ewing’s sarcoma of the humerus diaphysis extending into the epiphysis proximally. He underwent chemotherapy followed by 12 cm resection of the proximal humerus with preservation of rotator cuff. Reconstruction was performed using a 15 cm vascularized fibula epiphyseal transfer raised using a postero-lateral approach based on the peroneal artery and its venae commitans. The common peroneal nerve was protected proximally and all motor branches were preserved. The pedicle length was 7cm. When isolated on the peroneal artery, bleeding was seen at the level of the epiphysis and periosteum of the fibula head.