Elbow flexion reconstruction with nerve transfer or grafting in patients with brachial plexus injuries: A systematic review and comparison study.

INTRODUCTION: Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury. METHODS: PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed. RESULTS: In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022). CONCLUSIONS: Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery. LEVEL OF EVIDENCE: Level II.

Assessment of biodistribution using mesenchymal stromal cells: Algorithm for study design and challenges in detection methodologies.

BACKGROUND AIMS: Biodistribution of candidate cell-based therapeutics is a critical safety concern that must be addressed in the preclinical development program. We aimed to design a decision tree based on a series of studies included in actual dossiers approved by competent regulatory authorities, noting that the design, execution and interpretation of pharmacokinetics studies using this type of therapy is not straightforward and presents a challenge for both developers and regulators. METHODS: Eight studies were evaluated for the definition of a decision tree, in which mesenchymal stromal cells (MSCs) were administered to mouse, rat and sheep models using diverse routes (local or systemic), cell labeling (chemical or genetic) and detection methodologies (polymerase chain reaction [PCR], immunohistochemistry [IHC], fluorescence bioimaging, and magnetic resonance imaging [MRI]). Moreover, labeling and detection methodologies were compared in terms of cost, throughput, speed, sensitivity and specificity. RESULTS: A decision tree was defined based on the model chosen: (i) small immunodeficient animals receiving heterologous MSC products for assessing biodistribution and other safety aspects and (ii) large animals receiving homologous labeled products; this contributed to gathering data not only on biodistribution but also on pharmacodynamics. PCR emerged as the most convenient technique despite the loss of spatial information on cell distribution that can be further assessed by IHC. DISCUSSION: This work contributes to the standardization in the design of biodistribution studies by improving methods for accurate assessment of safety. The evaluation of different animal models and screening of target organs through a combination of techniques is a cost-effective and timely strategy.

Femoral head bone viability after free vascularized fibular grafting for osteonecrosis: SPECT/CT study.

PURPOSE: To evaluate femoral head bone viability following free vascularized fibular grafting (FVFG) for osteonecrosis using SPECT/CT imaging. METHODS: Ten hips (9 patients) with osteonecrosis of the femoral head (ONFH) undergoing FVFG were prospectively enrolled. Four cases showed ARCO stage II, while six showed ARCO stage III. The mean age at surgery was 15.7 years (range, 13-22 years). Hip Harris Score (HHS) was measured pre- and post-operative. Bone scintigraphy with SPECT/CT was performed at 2 weeks and 6 months following surgery. RESULTS: Mean follow-up was 4.0 years (range, 2-5.9 years). Mean HHS increased from 37.2 to 92.3. SPECT/CT findings revealed a progressive increase of femoral head uptake in all cases, suggesting subchondral graft bone viability. No progressive deformation of the femoral head was evidenced in radiographic evaluation at final follow-up. CONCLUSIONS: This study demonstrates FVFG's capacity for revitalizing femoral head subchondral bone grafting in patients with ONFH, surgically treated following Urbaniak's technique. © 2015 Wiley Periodicals, Inc. Microsurgery 36:573-577, 2016.

The role of muscle imbalance in the pathogenesis of shoulder contracture after neonatal brachial plexus palsy: a study in a rat model.

BACKGROUND: An internal rotation contracture of the shoulder is common after neonatal brachial plexus injuries due to subscapularis shortening and atrophy. It has been explained by 2 theories: muscle denervation and muscle imbalance between the internal and external rotators of the shoulder. The goal of this study was to test the hypothesis that muscle imbalance alone could cause subscapularis changes and shoulder contracture. MATERIALS AND METHODS: We performed selective neurectomy of the suprascapular nerve in 15 newborn rats to denervate only the supraspinatus and the infraspinatus muscles, leaving the subscapularis muscle intact. After 4 weeks, passive shoulder external rotation was measured and a 7.2-T magnetic resonance imaging scan of the shoulders was used to determine changes in the infraspinatus and subscapularis muscles. The subscapularis muscle was weighed to determine the degree of mass loss. An additional group of 10 newborn rats was evaluated to determine the sectional muscle fiber size and muscle area of fibrosis by use of images from type I collagen immunostaining. RESULTS: There was a significant decrease in passive shoulder external rotation, with a mean loss of 66°; in the thickness of the denervated infraspinatus, with a mean loss of 40%; and in the thickness and weight of the non-denervated subscapularis, with mean losses of 28% and 25%, respectively. No differences were found in subscapularis muscle fiber size and area of fibrosis between shoulders after suprascapular nerve injury. CONCLUSIONS: Our study supports the theory that shoulder muscle imbalance is a cause of shoulder contracture in patients with neonatal brachial plexus palsy.

How to avoid genu recurvatum in leg-length discrepancy treated with tension-band plates. A volumetric magnetic resonance analysis.

Aims and objectives: Genu recurvatum deformity after treatment of leg-length discrepancy (LLD) with tension-band plating is a recognized, but poorly described phenomenon in medical literature. The aim of this study was to evaluate clinical and radiological features of patients treated with tension-band plating for LLD assessing the development of a recurvatum deformity and its relationship to plate and screw disposition in a transversal plane, thus attempting to establish optimal plate positioning. Materials and methods: Retrospective study of children with LLD treated with tension-band plating. Primary endpoints were clinical and radiological knee recurvatum and anterior and posterior physeal areas measured drawing a line spanning from the lateral to the medial tension-band plates in the transverse plane using volumetric magnetic resonance imaging (vMRI). These findings were compared between patients with and without knee recurvatum. Results: Twelve children (mean age 11.7 years) were included. Average follow-up was 2.6 years (1.5-5.0). Tension-band plating led to a significant reduction in LLD (mean, 15 mm). Six patients (50 %) developed clinical genu recurvatum (mean, 22°). According to vMRI, patients with genu recurvatum had a larger posterior to anterior physeal area ratio in both distal femur (1.6 versus 0.9, p < 0.05) and proximal tibial physes (2.2 versus 1.0, p < 0.05). Conclusion: The optimal position of the tension-band plates in distal femoral and proximal tibial physes should be in a point where a posterior to anterior physeal areas ratio is around 1.0, so as to achieve an even distribution of the physeal areas in the multidimensional physeal transverse plane. This point anatomically corresponds in the sagittal X-ray view to an imaginary line located just anterior to the posterior diaphyseal cortical bone on a true lateral radiograph for both femur and tibia.

Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP and SECOT.

Infection of a native joint, commonly referred to as septic arthritis, is a medical emergency because of the risk of joint destruction and subsequent sequelae. Its diagnosis requires a high level of suspicion. These guidelines for the diagnosis and treatment of septic arthritis in children and adults are intended for use by any physician caring for patients with suspected or confirmed septic arthritis. They have been developed by a multidisciplinary panel with representatives from the Bone and Joint Infections Study Group (GEIO) belonging to the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Paediatric Infections (SEIP) and the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT), and two rheumatologists. The recommendations are based on evidence derived from a systematic literature review and, failing that, on the opinion of the experts who prepared these guidelines. A detailed description of the background, methods, summary of evidence, the rationale supporting each recommendation, and gaps in knowledge can be found online in the complete document.

Single-Access Fetal Endoscopy (SAFE) for myelomeningocele in sheep model I: amniotic carbon dioxide gas approach.

BACKGROUND: This study aimed to assess the feasibility of single-access fetal endoscopy (SAFE) for the management of myelomeningocele (MMC) using intrauterine carbon dioxide as a distension medium in a sheep model. METHODS: This prospective experimental case-control study investigated 12 lamb fetuses that had a myelomeningocele-like defect surgically created on the 75th day of gestation. Four fetuses remained untreated (control group), and eight fetuses had MMC repair using two fetoscopic approaches with carbon dioxide used to distend the amniotic cavity. A collagen patch was placed over the defect and secured with surgical sealant. Four animals had a two-port fetoscopic procedure, and four animals had SAFE. Clinical and pathologic studies were performed after delivery. RESULTS: This study confirmed the validity of the animal MMC model. None of the control animals was able to stand or walk, and all had a significant defect in the lumbar area with continuous leakage of cerebrospinal fluid, ventriculomegaly, and a Chiari-II malformation. All the treated animals, independently of the number of ports used in the repair, were able to walk and had a closed defect with resolution of the Chiari malformation. CONCLUSIONS: The SAFE patch and glue coverage of surgically created fetal MMC is feasible and effective in restoring gross neurologic function in the fetal lamb model.

Evaluation of bone viability.

Bone scintigraphy is an excellent tool to assess bone viability. The functional information provided is crucial in several clinical settings, like the detection of avascular necrosis, septic embolism, frostbite lesions and osteonecrosis, and to evaluate the results of surgical treatment in cases of avascular necrosis. Mechanisms to obtain molecular images, as well as different kind of techniques, are detailed. Comparative and multimodality imaging to focus on any clinical problem and a review of the clinical indications reflect the multidisciplinary approach with close collaboration between orthopaedists, radiologists and nuclear medicine physicians. Finally, an effort has been made to list the most important points of imaging of bone viability in children.

Lateralized overgrowth as a guiding sign of abdominal neoplasms for pediatric orthopedic surgeons.

OBJECTIVES: This study aims to increase the awareness of the association between lateralized overgrowth (LO) and abdominal tumor among the pediatric orthopedic community and to evaluate its incidence in our center. PATIENTS AND METHODS: Between January 1997 and December 2021, a total of 166 patients with Wilms tumors and hepatoblastomas were retrospectively analyzed. Data including age, sex, initial clinical signs (hematuria, abdominal mass with or without general discomfort), type of asymmetric regional body overgrowth (isolated or in relation with any syndrome), and tumor stage at diagnosis were recorded. In addition, age at which asymmetric regional body overgrowth was described and age at the time of tumor diagnosis were noted. RESULTS: Of a total of 166 patients, 133 were diagnosed with Wilms tumors (nephroblastomas) and 33 were diagnosed with hepatoblastomas. In 94% of the cases, the initial clinical signs were an abdominal mass and/or hematuria. Overall, five (3%) patients presented with LO. Four patients with Wilms tumor presented it at the initial clinical examinations. In three of these cases (2.3%), we found it isolated and, in the remaining patient (0.75%), it was associated with Beckwith-Wiedemann spectrum. Only one patient affected from hepatoblastoma (3%) presented with an isolated LO at the time of tumor diagnosis. CONCLUSION: Our study results show an incidence of LO in relation to intra-abdominal tumors of 3%. The latest updates recommend genetic testing to identify subgroups with a higher risk for tumor development that are more likely to benefit from tumor protocol surveillance.

Vascularized fibular periosteal graft: a new technique to enhance bone union in children.

BACKGROUND: The periosteum in children has strong osteogenic power and is quite thick, facilitating procurement. However, it has been rarely used as a vascularized flap to enhance bone union in this age range. The purpose of this study is to assess the effectiveness of a new vascularized periosteal flap harvested from the fibula for the enhancement of bone union in the pediatric age. METHODS: Thirteen vascularized fibular periosteal grafts were used in 12 children, mean age 12.6 years. Indications included the prevention of bone allograft-host junction nonunion and treatment of recalcitrant bone nonunion. In 9 instances, the periosteal flap was harvested as a free flap and in 4 as a pedicled flap. Serial radiographs and computed tomography scans were used to evaluate the progression of callus formation and bone healing. RESULTS: All flaps were successful in promoting bone healing and achieving bone union in a mean time of 2.8 months for metaphyseal junctions and 7.1 months for diaphyseal ones, except for 1 case, which initially failed due to a pedicle torsion. It was then resolved with a second vascularized fibular periosteal grafts, with complete union after 5 months. CONCLUSIONS: Transfer of a vascularized fibular periosteal flap, either pedicled or as a free flap, is an effective treatment to enhance bone union in children in biologically unfavorable scenarios. The properties of periosteal tissue in the pediatric age are unique and its use in bone union enhancement permits new reconstructive strategies in children different from those described in adults. LEVEL OF EVIDENCE: IV.

Poland syndrome: a new classification system based on a retrospective analysis of 74 cases.

LEVEL OF EVIDENCE: III.

Seymour fracture: Better do not underestimate it.

OBJECTIVES: This study aims to analyze the functional results, management, and complications of acute Seymour fracture treatment and to generalize the understanding of Seymour fractures, as well as awareness about its controversial treatment and critical sequelae. PATIENTS AND METHODS: Between January 1994 and December 2019, a total of 29 patients (20 males, 9 females; mean age: 7.9±3.9 years; range, 1 to 15 years) who presented within the first 24 h of injury and were diagnosed with Seymour fractures and treated in the emergency setting were retrospectively analyzed. Clinical and radiological data were collected from medical records at the time of diagnosis and during follow-up, within a week after the treatment and in the visits required until fracture healing, and no sequelae were observed. In the event of complications, a minimum of one year of follow-up was carried out. Radiographs were taken of the anteroposterior and lateral views during each visit. RESULTS: The mean follow-up was 10.8±8.6 (range, 2 to 36) months. Surgical treatment in the operating room was performed in 24 (82.7%) patients using a single longitudinal Kirschner wire (K-wire) fixation through the distal phalanx and the distal interphalangeal joint in 21 patients. Non-operative treatment based on closed reduction and splinting was performed in five (17.3%) patients. There was no statistically significant difference in the final passive range of motion and physeal growth arrest in relation to the use or non-use of K-wires. The use of antibiotics in any of the three possible administrations (intravenous antibiotic regimen, intravenous and later oral antibiotic at-home or oral antibiotics), in relation to the non-use of antibiotics seemed to be a protective factor against infections (odds ratio=0.04; 95% confidence interval: 0.006-0.2; p=0.001). CONCLUSION: The identification of Seymour fractures is crucial for applying the correct treatment and reducing the risk of complications, such as osteomyelitis and physeal alterations. Based on our study results, we can suggest that the use of an antibiotic regimen causes a lower risk of infections in acute Seymour fractures. The prompt identification of these fractures with a standardized protocol covering irrigation, debridement, reduction, fixation, and prophylactic antibiotics is needed to avoid complications.

How the COVID-19 pandemic is affecting paediatric orthopaedics practice: a preliminary report.

PURPOSE: Since the state of alarm was decreed in Spain on 14 March 2020, the coronavirus disease 2019 (COVID-19) pandemic has had an extraordinary impact in paediatric hospitals. This study shows the effect of the pandemic on our practice in paediatric orthopaedics in a referral third level paediatric hospital. METHODS: We performed a single-centre retrospective review of the official census from a third level paediatric hospital from 14 March to 14 April for the years 2018, 2019 and 2020. RESULTS: The patients seen in our clinic during this period in 2020 decreased in by 82% (p < 0.001) compared with 2018 and 2019, however, the number of telemedicine consultations increased by 90.21% (p < 0.001). The total number of patients attending the clinic (including onsite and virtual) was reduced by 54.25% (p < 0.001). The total surgeries performed plummeted by 81% in this period in 2020 (p < 0.001) due to a reduction in elective cases of 94.6% (p < 0.001). No significant decrease was found in the number of urgent surgical cases per day in 2020 (p = 0.34). Finally, the number of orthopaedic patients admitted to our emergency department dropped by 78.6% during the state of alarm (p < 0.001). CONCLUSION: According to our results, the pandemic has significantly affected our daily practice by decreasing elective surgeries and onsite clinics, but other activities have increased. As we have implemented telemedicine and new technologies to adapt to this setback, we should take advantage of the situation to change our practice in the future to better allocate our health resources and to anticipate outbreaks.Published without peer review. LEVEL OF EVIDENCE: IV.

Fetal surgery of extremity amniotic bands: an experimental model of in utero limb salvage in fetal lamb.

BACKGROUND: Extremity amniotic band (EAB) syndrome can cause an intrauterine amputation as a result of a mechanical effect with progressive strangulation. The aim of the study is to assess the use of fetal surgery of EABs with risk of amputation in the ovine fetus. METHODS: Right limbs of fifteen 60-day-gestational age fetal sheep were ligated with silk suture at the infracondylar level. Left limbs were used for paired comparison. Fetuses were randomized into 3 groups: an early-repair group (n = 5), a late-repair group (n = 5), and a nonrepaired group (n = 5). The limbs of the 2 repaired groups underwent fetal release. The limbs obtained from at-term fetuses were analyzed morphologically, functionally, and radiologically. Statistical analysis with paired test was used to compare data. RESULTS: Nonrepaired limbs showed amputation or quasi amputation; the repaired ones did not. However, those late-repaired had significantly reduced passive ankle range of motion, shorter limb length, and mild residual changes. CONCLUSIONS: Intrauterine release of potentially severe EABs prevents limb amputation and leads to morphofunctional recovery. Early release shows better results. CLINICAL RELEVANCE: : Intrauterine amputations caused by EABs in the human fetus might be avoidable by fetal surgery.

Fetoscopic release of extremity amniotic bands with risk of amputation.

With the advent of less-invasive fetal surgery techniques, nonlethal disorders are considered amenable to intrauterine treatment. Extremity amniotic band syndrome fulfils the criteria of intrauterine disorders conformable with fetal treatment: capability of prenatal diagnosis and severity. We report 2 cases of extremity amniotic bands with risk of limb amputation released fetoscopically with YAG laser.

Isolation, characterization, and differentiation of multipotent neural progenitor cells from human cerebrospinal fluid in fetal cystic myelomeningocele.

Despite benefits of prenatal in utero repair of myelomeningocele, a severe type of spina bifida aperta, many of these patients will still suffer mild to severe impairment. One potential source of stem cells for new regenerative medicine-based therapeutic approaches for spinal cord injury repair is neural progenitor cells (NPCs) in cerebrospinal fluid (CSF). To this aim, we extracted CSF from the cyst surrounding the exposed neural placode during the surgical repair of myelomeningocele in 6 fetuses (20 to 26weeks of gestation). In primary cultured CSF-derived cells, neurogenic properties were confirmed by in vitro differentiation into various neural lineage cell types, and NPC markers expression (TBR2, CD15, SOX2) were detected by immunofluorescence and RT-PCR analysis. Differentiation into three neural lineages was corroborated by arbitrary differentiation (depletion of growths factors) or explicit differentiation as neuronal, astrocyte, or oligodendrocyte cell types using specific induction mediums. Differentiated cells showed the specific expression of neural differentiation markers (ßIII-tubulin, GFAP, CNPase, oligo-O1). In myelomeningocele patients, CSF-derived cells could become a potential source of NPCs with neurogenic capacity. Our findings support the development of innovative stem-cell-based therapeutics by autologous transplantation of CSF-derived NPCs in damaged spinal cords, such as myelomeningocele, thus promoting neural tissue regeneration in fetuses.

An ultrasound-guided technique for axillary brachial plexus nerve block in rabbits.

Regional anesthesia techniques, such as nerve blocks, are routinely used in humans and can contribute to multimodal approaches to pain management in research animals. Ultrasound guidance is an emerging aspect of regional anesthesia that has the potential to optimize local delivery and distribution of anesthetic agents, thereby reducing the amounts of these agents that must be administered. The authors developed an ultrasound-guided technique for effective block of the axillary brachial plexus in rabbits. They used this technique to carry out nerve block in 14 rabbits. The procedure was accomplished in a relatively short amount of time and achieved successful nerve block in all rabbits with no adverse effects. Sonographic visualization of the distribution of the local anesthetic ropivacaine led to administration of smaller anesthetic doses in eight of the rabbits without affecting the duration of nerve block. The authors conclude that their technique is feasible and safe and provides effective analgesia of the thoracic limb in rabbits. They recommend that this technique be integrated into multimodal approaches to pain management in rabbits undergoing thoracic limb surgery.

Severe Sprengel deformity associated with Klippel-Feil syndrome and a complex vascular abnormality that determined the corrective surgery technique.

Sprengel deformity (SD), a congenital condition characterized by elevation of the scapula, is a cause of functional and aesthetic defects that can be improved by surgical correction. Many cases of SD are associated with Klippel-Feil syndrome (KFS), in which there may be abnormalities of the supra-aortic vessels. We present the case of an 11-year-old girl with severe SD and KFS. The left vertebral artery arose from the subclavian artery in a very high cervical location, which made surgical descent of the scapula unfeasible. The patient was treated using a Mears procedure, with osteotomy of the scapula and tenotomy of the long head of the triceps. The appearance and range of motion of the shoulders improved considerably, and there were no vascular complications. A morphologic vascular assessment is essential in children with SD and concomitant KFS to avoid potentially serious iatrogenic vascular injury when performing a scapular-descending surgical technique.

The role of subscapularis muscle denervation in the pathogenesis of shoulder internal rotation contracture after neonatal brachial plexus palsy: a study in a rat model.

We assessed the role of subscapularis muscle denervation in the development of shoulder internal rotation contracture in neonatal brachial plexus injury. Seventeen newborn rats underwent selective denervation of the subscapular muscle. The rats were evaluated at weekly intervals to measure passive shoulder external rotation. After 4 weeks, the animals were euthanized. The subscapularis thickness was measured using 7.2T MRI axial images. The subscapularis muscle was then studied grossly, and its mass was registered. The fiber area and the area of fibrosis were measured using collagen-I inmunostained muscle sections. Significant progressive decrease in passive shoulder external rotation was noted with a mean loss of 58° at four weeks. A significant decrease in thickness and mass of the subscapularis muscles in the involved shoulders was also found with a mean loss of 69%. Subscapularis muscle fiber size decreased significantly, while the area of fibrosis remained unchanged. Our study shows that subscapularis denervation, per se, could explain shoulder contracture after neonatal brachial plexus injury, though its relevance compared to other pathogenic factors needs further investigation.

Reduction in neural injury with earlier delivery in a mouse model of congenital myelomeningocele: laboratory investigation.

OBJECT: The authors undertook this study to assess the effect of preterm delivery with respect to neural protection in a congenital myelomeningocele (MMC) mouse model. METHODS: After confirmation of pregnancy in 15 female mice, a congenital MMC model was produced by administration of retinoic acid on the 7th day of gestation. The pregnant mice underwent cesarean sections on Days 15 (n = 5, Group E15), 17 (n = 5, Group E17), and 19 (n = 5, Group E19). Histological analyses were conducted on the lumbar defect and on the craniocervical junction in all fetuses with MMC. RESULTS: Fetuses in Group E19 showed the most significant injury to neural tissue of the spinal cord at the MMC area followed by those in Group E17, with Group E15 being the least affected. All groups exhibited a degree of Chiari malformation; Group E19 was the most affected, followed by Group E17, and Group E15 was the least affected. CONCLUSIONS: Development of both Chiari malformation and exposed spinal cord injury are progressive during gestation. Preterm delivery in this mouse model of congenital MMC may minimize the degree of injury to the spinal cord neural tissue and the degree of Chiari malformation.