Molecular identification of EhCRT gene Calreticulin isolated from children infected with Entamoeba histolytica.

Objective: To detect the gene of entamoeba histolytica by polymerase chain reaction and investigate the expression of immunogene entamoeba histolytica calreticulin in stool samples of infected patients. METHODS: The case control study was conducted at Central Teaching Hospital of Paediatrics and Al Mahmoudia General Hospital, Iraq, from December 30, 2020, to September 1, 2021, and comprised diarrhoeal faecal samples collected from 86 children with age ranging from ˂1 year to 13 years who were suspected of having been infected with entamoeba histolytica. Microscopically positive samples were then subjected to conventional and real-time polymerase chain reaction for the detection of entamoeba histolytica HM1:IMSS strain using Phage shock protein (Psp) gene sequences and detection of entamoeba histolytica calreticulin expression. RESULTS: Of the 86 patients, 71(82.6%) were found to be infected with entamoeba histolytica; 39(54.93%) boys and 32(45.07%) girls. The remaining 15(17.4%) patients were taken as non-amoebic controls; 8(53.3%) boys and 7(46.7%) girls. There were 36(50.70%) cases and 8(53.33%) controls aged 1-4 years. Among the Entamoeba histolytica gene was detected in 44(62%) of the cases using conventional polymerase chain reaction, and immunogene entamoeba histolytica calreticulin was expressed in 36(50.7%) using real-time polymerase chain reaction. Data was analysed using SPSS 24. CONCLUSIONS: Polymerase chain reaction was found to be a useful tool for diagnosing entamoeba histolytica infection in children.

An Innovative Plate Concept for Rotational Guided Growth: A Porcine Pilot Study.

Background Rotational deformities in children are currently treated with an osteotomy, acute de-rotation, and surgical fixation. Meanwhile, guided growth is now the gold standard in pediatric coronal deformity correction. This study aimed to evaluate the feasibility of a novel implant intended for rotational guided growth (RotOs Plate) in a large porcine animal model. Methodology A submuscular plate was inserted on the medial and lateral aspect of the distal femoral physis of the left femur in 6 pigs. Each plate was anchored with a screw in the metaphysis and epiphysis respectively. The plates were expected to rotate the femur externally. The right femur acted as a control in a paired design. The animals were housed for 12 weeks after surgery. MRI scanning of both femora was performed before euthanasia after 12 weeks. Rotation was determined as the difference in the femoral version on MRI between the operated and non-operated femur after 12 weeks. Results External rotation in all operated femurs was observed. The mean difference in the femoral version on MRI between operated and non-operated femurs was 12.5° (range 9°-16°). No significant changes in axial growth were detected. Conclusions This study shows encouraging results regarding rotational guided growth, which may replace current invasive surgical treatment options for malrotation in children. However, further studies addressing potential secondary deformities are paramount and should be carried out.

Correction of rotational deformities in long bones using guided growth: a scoping review.

Purpose: The objective of this scoping review was to describe the extent and type of evidence of using guided growth to correct rotational deformities of long bones in children. Methods: This scoping review was conducted in accordance with the JBI methodology for scoping reviews. All published and unpublished studies investigating surgical methods using guided growth to perform gradual rotation of long bones were included. Results: Fourteen studies were included: one review, three clinical studies, and ten preclinical studies. In the three clinical studies, three different surgical methods were used on 21 children. Some degree of rotation was achieved in all but two children. Adverse effects reported included limb length discrepancy (LLD), knee stiffness and rebound of rotation after removal of tethers. Of the ten preclinical studies, two were ex vivo and eight were in vivo. Rotation was achieved in all preclinical studies. Adverse effects reported included implant extrusions, LLD, articular deformities, joint stiffness and rebound of rotation after removal of tethers. Two of the studies reported on histological changes. Conclusions: All studies conclude that guided growth is a potential treatment for rotational deformities of long bones. There is great variation in animal models and surgical methods used and in reported adverse effects. More research is needed to shed light on the best surgical guided growth method, its effectiveness as well as the involved risks and complications. Based on current evidence the procedure is still to be considered experimental. Level of evidence: 4.

Morphology of the knee after guided growth using tension-band devices: a retrospective multicenter study of 222 limbs and 285 implants.

BACKGROUND AND PURPOSE: Temporary hemiepiphysiodesis by tension-band devices is commonly applied to correct angular limb deformities in children. We aimed to evaluate knee joint morphology after guided growth using these devices. PATIENTS AND METHODS: In a retrospective multicenter study we analyzed standardized anteroposterior long-leg radiographs of 222 limbs (285 implants) of patients treated by temporary hemiepiphysiodesis with either eight-Plates or FlexTacks for coronal angular deformities of the knee joint between 2013 and 2019. Femoral floor angle (FFA), femoral notch-intercondylar distance (FNID), and tibial roof angle (TRA) were measured pre- and postoperatively to assess the central knee joint morphology. Statistical exploratory analyses were performed using linear mixed models, t-tests, Wilcoxon signed-rank test, and Mann-Whitney U test. RESULTS: 217 FlexTacks (femur 106, tibia 111) in 104 children and 68 eight-Plates (femur 61, tibia 7) in 35 children were identified. Median time period under growth guidance was 11 months (range 4-42). No statistically significant change in the FFA was detected (eight-Plate: P = 0.2; FlexTack: P = 0.3). A statistically significant difference of the FNID was found in the eight-Plate group (P = 0.02), but not in the FlexTack group (P = 0.3). While TRA increased in both groups, a statistical significance was observed only in the FlexTack group (P < 0.01). CONCLUSION: We found minor but clinically irrelevant changes in knee morphology after the treatment.

Radiographic reference values of the central knee anatomy in 8-16-year-old children.

BACKGROUND AND PURPOSE: For correction of leg-length discrepancy or angular deformity of the lower limb in skeletally immature patients temporary or permanent (hemi-)epiphysiodesis can be employed. These are reliable treatments with few complications. Recently, radiographic analysis of treatment-related alterations of the central knee anatomy gained interest among pediatric orthopedic surgeons. To date the comparison and adequate interpretation of potential changes of the central knee anatomy is limited due to the lack of defined standardized radiographic references. We aimed to establish new reference values of the central knee anatomy. PATIENTS AND METHODS: A retrospective analysis of calibrated longstanding anteroposterior radiographs of 254 skeletally immature patients with a chronological age ranging from 8 to 16 years was conducted. The following radiographic parameters were assessed: (1) femoral floor angle, (2) tibial roof angle, (3) width at femoral physis, and (4) femoral notch-intercondylar distance. RESULTS: All observed radiographic parameters were normally distributed with a mean age of 12.4 years (standard deviation [SD] 2, 95% confidence interval [CI] 12.2-12.6). Mean femoral floor angle was 142° (SD 6, CI 141.8-142.9), mean tibial roof angle was 144° (SD 5, CI 143.7-144.1), mean width at femoral physis was 73 mm (SD 6, CI 72.8-73.9), and mean femoral notch-intercondylar distance was 8 mm (SD 1, CI 7.5-7.7). The estimated intraclass correlation coefficient values were excellent for all measurements. CONCLUSION: This study provides new radiographic reference values of the central knee anatomy for children between 8 and 16 years and we suggest considering values within the range of 2 SD as the physiological range.

Controlled rotation of long bones by guided growth: A proof of concept study of a novel plate in cadavers.

Our novel plate design has been developed for controlled rotation of long bones by guided growth. The objective of this proof-of-concept study was to evaluate the precision of the rotation in the femur. Twelve cadaverous femora of six adults (right = 6, left = 6) underwent an osteotomy at the level of the physeal scar. The plates were inserted on each side of the distal femur. Growth was simulated by axial distraction of the bone segments. The femur was stabilized using a unilateral external fixator. Femoral torsion was assessed with computed tomography (CT) and with an electric goniometer before and after distraction. The obtained rotation was compared to the predicted rotation based on the dimension of the plate and the bone. All femora were rotated as intended. The mean obtained rotation was 26.3° (95% confidence interval [CI]: 23.5-29.0) and the mean predicted rotation was 28.2° (95% CI: 26.9-29.5) (p > 0.82). The mean axial distraction was 19.5 mm (95% CI: 17.7-21.3). The predicted rotation of the femora was similar to the obtained values on CT and by goniometer. The obtained rotation occurred as a result of an axial distraction of approximately 2 cm. This suggests a potential for controlled rotation of the femur based on the circumference of the bone and plate dimensions that occurs simultaneously with axial distraction. Clinical significance: These findings suggest a possible clinical application in the treatment of maltorsion in children by guided growth, where theplate design guides the bone into torsional axial growth correcting the deformity.

Resection of Tarsal Coalition in 27 Children with 2 Years Follow-Up - Patient-Reported Outcomes Using the Validated Oxford Ankle Foot Questionnaire.

Background: Patient Reported Outcome Measures (PROM) after resection of tarsal coalitions are sparse. This cross-sectional study evaluates the outcome after resection of tarsal coalitions in children using the validated Oxford Foot and Ankle Questionnaire (OxAFQ). Methods: Tarsal coalition patients between 5-16 years of age from Aarhus University Hospital (Denmark) and The Royal London Hospital (United Kingdom) were included. The patients were identified using patient and theatre register. All patients and proxies filled in the PROM: OxAFQ-C and OxAFQ-proxy respectively. The scores were calculated within each domain and reported as means (95% confidence intervals). Talocalcaneal coalitions were compared to calcaneonavicular coalition with regard to OxAFQ score and re-operation rate. Results: 27 patients and their proxies returned 54 questionnaires in total regarding 36 feet. Mean time from surgery to filling of the questionnaire was 25 (21-30) months. The relative mean OxAFQ score was higher in the School and Play and Emotional domain than the Physical domain, p = 0.007. The OxAFQ scores and re-operation rates were similar for both coalitions, p=0.63. Conclusion: The OxAFQ PROM showed more encouraging results in playing or emotional health status than the physical health status. The outcome for both types of coalitions is similar.Level of Evidence: IV.

Does Retrograde Femoral Nailing through a Normal Physis Impair Growth? An Experimental Porcine Model.

MATERIALS AND METHODS: The study was carried out using an experimental porcine model. Eleven juvenile female porcines were randomized for insertion of a retrograde femoral nail in one limb. The other limb acted as a control. The animals were housed for 8 weeks before the nail was removed and housed for 8 additional weeks, that is, 16 weeks in total. Growth was assessed by interphyseal distance on 3D magnetic resonance imaging (MRI) after 16 weeks and the operated limb was compared to the non-operated limb. Histomorphometric analysis of the physeal canal was performed. RESULTS: No difference in longitudinal growth was observed when comparing the operated femur to the non-operated femur using MRI after 16 weeks. No osseous tissue crossing the physis was observed on MRI or histology. The empty canal in the physis after nail removal was filled with fibrous tissue 16 weeks after primary surgery. CONCLUSION: Growth was not impaired and no bone bridges were seen on MRI or histology 16 weeks after insertion and later removal of the retrograde femoral nail. CLINICAL SIGNIFICANCE: The insertion of a retrograde intramedullary femoral nail centrally through the physis and later removal might be safe, however, long-term follow-up is needed. AIM AND OBJECTIVE: The insertion of an intramedullary nail may be beneficial in certain cases of leg length discrepancy (LLD) in children. However, it is unknown if the physeal injury due to the surgery may cause bone bridge formation and thereby growth arrest after removal. This study aimed to assess longitudinal interphyseal growth 16 weeks after insertion and later removal of a retrograde femoral nail passing through the physis. Moreover, to analyse the tissue forming in the empty physeal canal after removal of the nail. HOW TO CITE THIS ARTICLE: Abood AA, Rahbek O, Olesen ML, et al. Does Retrograde Femoral Nailing through a Normal Physis Impair Growth? An Experimental Porcine Model. Strategies Trauma Limb Reconstr 2021;16(1):8-13.

Removal of broken PRECICE Stryde intramedullary lengthening nails.

This paper describes two different techniques for removal of broken Precice Stryde intramedullary bone lengthening nails, which unlike trauma nails are solid containing mechanical components. Consequently, surgeons face unique challenges when these implants brake within medullary canal. Here, we present our surgical approach for removal of three broken implants. In one patient (46kg) both Ø10mm femoral Stryde implants (max. weight allowance 68kg) broke through the proximal locking screw hole preoperatively on the right side and intraoperatively on the left side (413 and 504 days after index surgery respectively). The third Ø11.5 femoral nail broke through the area containing the magnet (55kg patient, 325 days after index surgery). LEVEL OF EVIDENCE: IV.

Comparison of histomorphometric and radiographic effects of growth guidance with tension-band devices (eight-Plate and FlexTack) in a pig model.

Background and purpose - Temporary hemiepiphysiodesis for growth modulation in skeletally immature patients is a long-known technique. Recently the use of tension-band devices has become popular. This study compares 2 tension-band implants (eight-Plate and FlexTack) regarding their effects on the growth plate.Animals and methods - 12 pigs in 2 equally sized groups (A and B) were investigated. The right proximal medial tibia was treated with either eight-Plate or FlexTack. The left tibia of the same pig was treated with the opposite implant. After 9 weeks all implants were removed. Animals in group B were then hosted for another 5 weeks. Histomorphometric analysis of the growth plate was carried out after 9 and 14 weeks, respectively. Radiographs were taken at implantation, removal, and after 14 weeks.Results - Both tension-band devices achieved a statistically significant and clinically relevant growth inhibition, whereas the effect appeared to be more distinct after the use of FlexTack. Implant-related complications or physeal damage was not observed. After implant removal, rebound phenomenon was radiologically observed in all cases. The growth plates treated with eight-Plate showed a paradox reversal of the zonal distributions, with an increase of the proliferative zones at the previously arrested medial aspect of the physis and a decrease laterally.Interpretation - Both eight-Plate and FlexTack proved to be appropriate devices for growth-guiding treatment. The radiographic evaluation showed a change in angular axes after treatment with each implant, while the correction appeared to be faster with FlexTack. The paradox cartilaginous reaction observed after removal of the eight-Plate might be a histopathological correlate for rebound phenomenon.

Autologous cartilage and fibrin sealant may be superior to conventional fat grafting in preventing physeal bone bridge formation - a pilot study in porcines.

PURPOSE: The article compares physeal recovery after insertion of autologous cartilage and a conventional fat graft in a standardized porcine physeal gap model. Presence of a bone bridge was the primary outcome. METHODS: Ten porcines in two groups of five were included in a paired design. A standardized physeal gap in the distal femur was made in all animals. One group (n = 5) was randomized for deposition of autologous cartilage and a Tisseel® or Tisseel® alone. The autologous cartilage was harvested from the femoral articular surface. The other group was randomized for fat grafting or no grafts at all. All animals were housed for 14 weeks. Magnetic resonance imaging (MRI) was performed at 14 weeks prior to euthanasia. The physis was harvested for histology. RESULTS: MRI - Three bone bridges were seen in the fat grafted gaps. All empty gaps formed a bone bridge. No gaps filled with autologous cartilage and Tisseel® resulted in bone bridges. One gap filled with Tisseel® only caused a bone bridge. Histology - The cartilage grafted gaps recovered with physeal-like cartilaginous tissue in histological analysis. CONCLUSIONS: Fat grafts seems ineffective in preventing bone bridges. The use of autologous cartilage may be superior to the current treatment. However, donor site complications were not investigated. The study serves as a proof of concept study and requires further investigation. LEVEL OF EVIDENCE: III.

[Diagnosis of complete transphyseal separation of the distal humerus].

Transphyseal separation of the distal humerus is a rare injury. Trauma, battered child syndrome and birth-related injuries are amongst the most common causes of the injury. This case report illustrates the importance of applying proper imaging and analysis to detect the injury. However, the diagnosis can be missed on conventional radiographs due to the cartilaginous elbow in infants. Instead, magnetic resonance imaging, artrography or ultra-sound can be applied to detect the injury. In this case, the infant was treated non-operatively with good clinical outcome.

Comparison of Temporary Epiphysiodesis With RigidTacks™ and Blount-Staples in a Porcine Animal Model Using Magnetic Resonance Imaging.

RigidTack™ is a newly developed implant for total temporary epiphyseodesis. The implant combines the technical advantages of the traditionally used rigid Blount-staples and the newer flexible eight-plates™. Thus, the implant is rigid like the Blount-staples, which may be a biomechanical advantage in temporary epiphyseodesis, and has an easy and guided implantation technique like the eight-plate™. As in eight-plates™, supposedly only two RigidTacks™ are sufficient for temporary epiphyseodesis compared to six Blount-staples in traditional treatment. The goal of this study was to compare Blount-staples and RigidTacks™ in regard to the total potential of growth arrest, the occurrence of postoperative implant-associated complications, secondary angular deformities, and central joint deformations. Twelve pigs were allocated in two groups (n = 6) for treatment of the proximal tibia. Total temporary epiphysiodesis was performed with either four Blount-staples or two RigidTacks™. Magnetic resonance imaging (MRI)-scans were performed before and 14 weeks after surgery, and the amount and distribution of growth arrest were evaluated by measuring the interphyseal distance in nine defined zones. Total temporary epiphysiodesis with two RigidTacks™ resulted in a similar amount of growth arrest as that of four Blount-staples. No significant coronal or sagittal angular deformities or joint deformities were observed in either group; however, one secondary loosening of a Blount-staple occurred. The study concluded that Blount-staples and RigidTacks™ are adequate implants for total temporary epiphysiodesis. Whether or not the precise implant-placement through the guided implantation technique of RigidTacks™ and a reduced number of implants indeed lead to a reduction of secondary angular deformities has to be investigated in further clinical trials. © 2019 The Authors. Journal of Orthopaedic Research® published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 38:946-953, 2020.

The Joint Angle Tool for Intraoperative Assessment of Coronal Alignment of the Lower Limb.

AIM: Presentation of the joint angle tool (JAT), a low-cost goniometer for intraoperative assessment of the lower limb alignment. BACKGROUND: Intraoperative assessment of coronal alignment is important when performing corrective osteotomies around the knee and ankle, limb lengthening, and trauma surgery. JAT provides surgeons with information about the anatomic and mechanical axes intraoperatively based on true anteroposterior radiographs. TECHNIQUE: JAT consists of pre-printed joint orientation angles of the anatomic and mechanical axis including normal variations on a plastic sheet. It is placed on the screen of the image intensifier after obtaining a true anteroposterior image. The pre-printed joint orientation angles can assist the surgeons intraoperatively in achieving the pre-planned axis correction. Here, its feasibility is demonstrated in four cases. CONCLUSION AND CLINICAL SIGNIFICANCE: JAT is a modified goniometer that allows intraoperative assessment of the mechanical and anatomic axis. JAT is applicable throughout the entire surgical procedure irrespective of the method of internal fixation and may provide additional reassurance of correct alignment. JAT consists of a plastic sheet with printed joint orientation angles and their normal variation. JAT is freely available from profeedback.dk/JAT/JAT.pdf for use and modification according to the Creative Commons license (CC BY-SA 4.0) if this paper is attributed. HOW TO CITE THIS ARTICLE: Abood AA-H, Petruskevicius J, Vogt B, et al. The Joint Angle Tool for Intraoperative Assessment of Coronal Alignment of the Lower Limb. Strategies Trauma Limb Reconstr 2020;15(3):169-173.

[Femur shaft fractures in infants should be considered despite no known trauma].

Femur shaft fractures in infants are rare and associated with abuse or fall from heights. The fracture is often easy to recognize on X-ray, however, the determination of the indication can be difficult. It is important to pay attention to pain signals from the extremity and the objective findings, such as a swollen and tight thigh. Early recognition of the fracture is of importance to the prognosis and to detection of possible violence resulting in battered child syndrome. Exploration for injuries of the extremities is of utmost necessity in these cases, despite the absence of trauma in the anamnesis.

Postural seated balance in children can be assessed with good reliability.

BACKGROUND: Seated postural stability can be measured using Tekscan, CONFORMat. Standing postural stability has gained great clinical and, research value by use of different force platforms with mostly good reliability. No reliability testing or biologic variation assessment has been documented regarding seated balance. This study determines the reliability of the parameters of seated balance in healthy children using the Tekscan CONFORMat equipment. METHODS: Sixty-six healthy children completed six measurements of seating position the first three with the child seated in a relaxed normal back position and the next three with the child seated in a complete up-right back position. The SAM software calculated five default parameters of balance (area, distance, variability, antero-posterior (AP) excursion and left-right excursion). RESULTS: Reliability parameters were assessed by one-way analysis of variance intra-class correlation (ICC) proving excellent reliability for relaxed and up-right back position with respect to distance (0.75/0.84) and good reliability with respect to variability (0.61/0.62) and area (0.61/0.60). AP excursion (0.41/0.59) and left-right excursion (0.54/0.24) showed fair to poor reliability. CONCLUSION: In conclusion, two of the five default parameters of balance used in the Tekscan CONFORMat system are direction-independent parameters and have been found reproducible for measuring seated balance in children. This study can be used as reference for comparisons of seated balance in children with affected seated postural control and for evaluating a clinical treatment effect.

[Monteggia fractures in children can be overlooked]. / Monteggiafrakturer hos børn kan overses.

Monteggia fractures in children are rare fractures presenting with anterior radial head dislocation and ulnar bowing in typical cases. In adulthood, pain, instability, deformity, loss of power and range of motion in the elbow joint are experienced. Early treatment is crucial, since the prognosis is depending on the time delay from injury to treatment. Full forearm X-rays including the elbow joint in two perpendicular projections are highly recommended in order to achieve an exact diagnosis without delay.

Thermal epiphysiodesis performed with radio frequency in a porcine model.

BACKGROUND AND PURPOSE: Current techniques for epiphysiodesis involve opening of cortical windows; use of staples, screws, and tension devices; and fusion with curettes or drills. Complications may have serious consequences. There is a need for a more reliable, precise, and less traumatic procedure that overcomes the known complications from existing techniques. We analyzed a new epiphysiodesis technique using radio-frequency ablation (RFA) in a porcine model. METHODS: Six 35-kg and two 25-kg immature pigs were used. 1 hind leg of each animal was randomly selected and the proximal tibia growth plate was ablated laterally and medially. The contralateral leg was used as a control. MR images were obtained immediately after the ablation and 12 weeks later for 6 animals, and 24 weeks later for the other 2 animals. CT was done for the 2 animals that were followed for 24 weeks for proof of bone bridges. RESULTS: Both tibias were equal in length initially. At the 12-week follow-up, there was an average leg length discrepancy of 3.9 mm (95% CI: 3.0-4.8), and at 24 weeks the difference was 8.4 mm and 7.5 mm. No damage to the adjacent tissue was found. Bone bridges and physeal closure were found after 24 weeks. The pigs showed no discomfort after the intervention. INTERPRETATION: We found RFA to be feasible for epiphysiodesis in a pig model. The method is minimally invasive and recovery may be quick compared to conventional methods. We recommend that the method should be tested in larger-scale safety studies before clinical application.