Neurocognitive sequelae of scaphocephaly.

OBJECTIVE: Early cranioplasty for scaphocephaly has become routine in most countries. In addition to normalizing the shape of the skull, it has been found to decrease intracranial hypertension. Whether corrective surgery benefits the child's cognitive outcome has been poorly documented. DESIGN: Eighteen children whose sagittal suture showed premature fusion at birth or soon thereafter were operated on at age 1 week to 7 months. All patients healed without complications and were followed-up at regular intervals. At the age of 7.8 to 16.3 years they were examined to clarify their neurocognitive development and to compare the results with their age- and gender-matched healthy controls. RESULTS: Originally scaphocephalic children, although operated on, had mild deficiencies in auditory short-term memory and language development when examined with the general comprehension, similarities, and digit span subscales of the Wechsler Intelligence Scale for Children-Revised. In all other respects their developmental outcome was equal to that of the controls. CONCLUSIONS: Despite relative early correction of the skull shape, originally scaphocephalic children's neurocognitive performances do not reach the same level in all of the neurocognitive domains as their matched controls at school age. Early operation (

Macrophages in trauma-induced myositis ossificans.

The basic cellular mechanisms of different forms of myositis ossificans are poorly known. In the current experiment the nature of the early (24-168 h) inflammatory cell reaction preceding trauma-induced myositis ossificans was studied. New bone formation was induced in the vastus intermedius region of the rabbit quadriceps muscle by means of immobilization and daily passive mobilization. Before the start of treatment, a cell harvesting device (viscose cellulose sponge in a silastic tube) was implanted in the region of interest. The opposite intermedius muscle and a standardized surgical skin wound served as the control sites. The results showed a significantly prolonged invasion of macrophages into the ossifying intermedius muscle as compared with the control intermedius muscle. It is hypothesized that microinjury and subsequent muscle necrosis cause the invasion of macrophages, and these cells respond to the conditions of the traumatized muscle under passive mobilization by releasing osteogenic growth factors.

Is cellulose sponge degradable or stable as implantation material? An in vivo subcutaneous study in the rat.

The long-term behaviour of cellulose sponge implants, 10 x 10 x 5 mm in size, and tissue reactions in and around them were examined in the subcutaneous tissue of the rat from 1 to 60 weeks after implantation. The cellulose sponge used was filled up with connective tissue 4 to 8 weeks after implantation. Histologically, moderate foreign body tissue reaction inside the implant, the appearance of cracks and fissures, spotty colouration, and softening of the pore walls were observed up to 16 weeks after implantation. Later, the foreign body reaction inside the sponge became milder, the spotty colouration disappeared and micropores enlarged in the viscose cellulose matrix. Histomorphometrically, the cross-sectional area of the implants and the size of the pore wall fragments decreased, and the number of pore wall fragments increased significantly. The cellulose sponge used can be regarded as a slowly degradable implantation material. However, the time needed for the total disappearance of the cellulose sponge from subcutaneous tissue is longer than the 60 weeks.

Disinfection of surgical wounds without inhibition of normal wound healing.

The goal of disinfection of surgical wounds is to destroy as large a number as possible of the microbes that have made their way into the surgical wounds during the time of surgery, without disturbing the normal wound-healing process. It is not a substitute for preoperative disinfection of the skin or aseptic technique, but makes it possible to further decrease the rate of infection in slightly or moderately contaminated wounds. This was shown with a series of 294 pediatric surgical patients, 283 of whom had undergone appendectomy. A 5% povidone-iodine solution, especially in combination with excipients, was too strong, whereas a 1% povidone-iodine solution without excipients applied to the surgical wound was safe from the standpoint of wound healing, and decresed the number of wound infections in those patients with appendicitis in whom neither peritonitis nor periappendicular abscess had yet developed.

Treatment results of osteogenic sarcoma. An evaluation of 36 patients treated during 30-year period in south-western Finland.

Histological re-evaluation revealed 36 osteogenic sarcoma (OS) patients for analysis in South-Western Finland treated between 1958 and 1987. In 21 cases (58%) the tumour was located in the knee region. The mean age at diagnosis was 28 years (range: 5-62 years) and the follow-up time of the patients was at least 5 years or until death. In 29 patients without metastases at the time of diagnosis, the extent of the primary tumour was T2 in 37% and T3 in 63% of the patients. There were no differences regarding the extent of the primary tumour, delay of the diagnosis, mean age of the patients, or duration of the symptoms while comparing the three decades of the study. Before the 1970s the treatment consisted of surgery with or without radiotherapy in most cases. Since the 1970s the combination of surgical treatment (amputation or wide excision) and adjuvant chemotherapy was the most common treatment modality. Since the late 1970s limb-salvage surgery has been applied in selected cases, and it seems to be justified. None of the patients treated before 1970 survived for 5 years. The 5- and 10-year survival of all 36 patients was 44.4% and 33.6%, respectively. In non-metastatic patients both the 5- and 10-year disease-free survival was 46.7%. A certain group exhibiting a good prognosis was found; the 10-year survival of the 10 patients with OS in extremities, treated with combined chemotherapy and surgery, was 70%. The median survival time was significantly longer for the patients with an intracompartmental tumour extent of T2 (112 months) compared with an extracompartmental extent of T3 (23 months), and for the patients with the primary tumour in the knee region (112 months) compared with other locations (18 months). The long-term survival of the OS patients has improved concomitantly with the multimodality of the treatment.

Wound healing in children as assessed by the CELLSTIC method.

Assessment of the quality and speed of wound healing in man has been rather difficult until the present time. By the use of CEELSTIC, a tissue-sensitive test drain composed of a standardized piece of viscose cellulose sponge inside a thin Silastic tube, cells existing between wound edges can be analyzed by histologic, cytologic, and enzyme histochemical means. The 166 pediatric surgical patients studied showed that wound healing is an age-dependent process reflected by the increased time needed for cellular transformation and maximal activation of hexokinase and isocitrate dehydrogenase with increasing age.

Bicycle and moped spoke injuries in children. Analysis of 103 consecutive cases.

The series consists of 60 boys and 43 girls, aged from 1 to 14 years, mean 4.95 years, whose right (42) or left (61) foot was caught between the bicycle (97) or moped (6) spokes. The skin was involved with ankle sprain, with fracture or without other injuries in 97 children; lateral aspect of the ankle and foot in 65 and heel in 21 patients. The X-rays revealed 10 tibial fractures, 4 fractures of the tibia and fibula, one fracture of the medial malleolus, one of the lateral malleolus and one bimalleolar fracture. Hence an X-ray of the leg should always be taken. Twenty-six patients were treated on the ward, 77 as outpatients. The mean total time of healing in the group as a whole was 25 days and 44 days in patients having a fracture. Heel avulsion injuries caused by the spokes need special attention. The vitality of the crushed and dirty, caudally or medially based skin flap is minimal and very often yields a marginal or total necrosis if primary suture is done.

Effect of haematocrit on wound healing in children.

The effects of mild or moderate normovolaemic anaemia on wound healing (WH) continue to be debatable. The results of animal experiments and clinical experience are somewhat controversial. In this study, sixty-six boys, aged from 5 to 15, mean 10.1 years, were routinely operated on for a unilateral inguinal hernia, after which their WH was studied by the Cellstic device. Based on differential count of wound cells and their mutual transformed cell to cell ratios it was found that the optimum level of haematocrit (Hct) for WH was 37-39% with haemoglobin (Hb) values of 12.0-12.4 g/100 ml. Hct values under and over these limits began to retard WH significantly (p less than 0.02) without any visual signs of delay in WH. Both values are below the age adjusted means but just above the lower limits of normal. It is thus allowed, for the majority of healthy children with normal blood values, a mild decrease of Hct during the operation without any harmful effect on WH.

Significance of histopathological findings in Dupuytren's contracture.

Clinical and histopathological data were compared in a series of 59 patients with Dupuytren's contracture (DC) from the years 1946-1971 in order to clarify whether histopathological findings were in accordance with the clinical development of the disease. All well known histopathological features were inspected. The most valuable prognostic sign seemed to be the appearance of several active nodules, indicating rather rapid development of DC, with a high frequency of postoperative recurrence in these patients. Lack of active nodules did not exclude this possibility but made it less likely. Other occasional findings typical of DC such as the number of mitoses, microhaemorrhages, perivascular lymphocytic infiltrations and hypertrophied corpuscles of Vater-Paccini seemed to be of minor prognostic value. Mucopolysaccharides from DC tissue showed metachromasia with toluidine blue did not stain with HID-AB (high iron diamine-alcian blue) as HID positive in specimens preserved embedded in paraffin blocks for several years.

Regeneration of subcutaneous connective tissue in children. A histological study with application of the CELLSTIC device.

Cellular patterns of healing subcutaneous connective tissue were studied histologically in 22 pediatric surgical patients using the CELLSTIC device. This wound drain, specially developed for this purpose, consists of a standardized, viscose cellulose sponge inside a thin silicone rubber tube. When left between the wound edges, wound exudate flows through the drain, allowing its cells to attach themselves to the sponge surface. The sponge serves as a framework within which the cells may migrate, divide and transform. During the first 12 h the cellular pattern in the sponge resembles that of peripheral blood, whereafter the number of polymorphonuclear leukocytes, almost exclusively neutrophils, gradually increases. Later on, monocytes, macrophages and lymphocytes invade. Fibroblasts were usually seen at the end of the third day postoperatively, but in some cases the first fibroblasts appeared even earlier. CELLSTIC neither disturbs normal wound healing nor increases the rate of wound infections. CELLSTIC, as a cell culture in situ, provides a practical way to study human connective tissue regeneration under both physiological and pathological conditions.

Signs of capillary formation in the early phase of wound healing in children.

Small silicone rubber tubes containing a standard size viscose cellulose sponge (Cellstic) were implanted in wounds of 23 children at the end of routine surgery. The Cellstics were drawn out of the wounds 1-4 days after implantation. Single cells and cell aggregates, called cell aggregation centers (CAC), were washed out of the Cellstic sponges by the retrograde injection technique, centrifuged, studied histologically and histochemically for cytochrome oxidase activity. Small leukocytic CACs and solitary cells, also including some macrophages and a few endothelial cells, were observed on the first postoperative day. On the second postoperative day and thereafter 2-4 endothelial cells were attached to each other surrounding a lumen. These capillary segment-looking formations (CSF) resembled capillary segments and they were seen both inside and outside the (now larger) CACs. Outside the CACs solitary endothelial cells occasionally exhibited ring-like formations. High cytochrome oxidase activity was observed especially in many CSFs but the solitary and the ring-shaped endothelial cells, in- and outside the CACs, also showed intense oxidative metabolism.

Local hyperalimentation of open wounds.

After débridement of necrotized and devitalized tissue in deep burns and large traumatic soft tissue defects, the raw surfaces were covered with separate sheets of viscose cellulose sponge (VCS), each moistened by continuous slow infusion of one of the following solutions: (a) 0-9 per cent NaCl; (b) 10 per cent glucose; (c) Rheomacrodex (dextrane hydrolysate in 0-9 per cent NaCl); (d) 7 per cent Levamin (a mixture of essential amino acids and glycin in 5 per cent sorbitol; (e) a combination of two solutions containing amino acids (Le-7402 A) and glucose, electrolytes and vitamins (Le-7402 B). The cellulose sponges were removed or changed 3-7 days later. Macroscopically, histologically and enzyme histochemically, the most active granulation tissue formation was found under the VCS moistened with amino acid solutions, especially when accompanied by glucose and vitamin supplementation. The results strongly suggest that local cellular hyperalimentation of open raw wound surfaces is possible, permitting a new kind of nutritional support in these patients.