Congenital pseudarthrosis of the tibia in children: should we defer surgery until 3 years old?

Currently, the timing of surgery for congenital pseudarthrosis of the tibia (CPT) remains controversial. The aim of this study was to investigate the results of treatment of pseudarthrosis of the tibia in children younger than 3 years of age. A retrospective study was carried out to explore the relationship between postoperative complications and the age of surgery in children with CPT. The analysis was carried out on 42 patients with Crawford type IV CPT treated with a combined surgical technique between 2008 and 2012. Patients were divided into two groups according to their age: group A (<3 years) and group B (>3 years). The incidence rates of refracture, ankle valgus, tibial valgus, and limb-length discrepancy of the two groups were evaluated. Primary bone union was achieved in 28 out of 29 (97%) patients in group A and 12 out of 13 (92%) patients in group B (P>0.05). In group A, six (21%) patients developed a refracture; 14 (48%) patients had ankle valgus with a mean degree of 11° (range: 5°-25°); 11 (38%) patients had tibial valgus with a mean tibial valgus deformity of 8.6° (range: 5°-20°); and 12 (41%) patients had limb-length discrepancy with a mean limb length of 2.9 cm (range: 0.5-4 cm). In group B, five (38%) patients developed refracture; seven (54%) patients had ankle valgus with a mean degree of 14° (range: 5°-30°); seven (54%) patients had tibial valgus with a mean tibial valgus deformity of 10.7° (range: 5°-20°); and 10 (77%) patients had limb-length discrepancy with a mean limb length of 2.8 cm (range: 1.5-3 cm). Groups A and B were significantly different in limb-length discrepancy (P=0.033). This study suggests that there is no need to defer surgery for pseudarthrosis of the tibia until the child is older than 3 years of age.

IL-33 improves wound healing through enhanced M2 macrophage polarization in diabetic mice.

IL-33 is a newly discovered member of the IL-1 family and has been identified as a potent inducer of Th2 type immunity. Emerging evidence imply that IL-33 may also act as an alarm to alert the immune system when released by epithelial barrier tissues during trauma or infection. In this study, we further investigate the potential efficacy of IL-33 on dermal wound healing in streptozotocin-induced diabetic mice. A full-thickness skin wound was generated on the back of diabetic mice and treated with IL-33 or vehicle topically. Our data showed that IL-33 delivery contributed to diabetic wound closure with wounds gaping narrower and exhibiting elevated re-epithelialization. IL-33 promoted the new extracellular matrix (ECM) deposition and angiogenesis formation, which indicates an important role of IL-33 on matrix synthesis and neovascularization. Meanwhile, IL-33 accelerated the development of M2 macrophages in wound sites in vivo, and amplified IL-13-induced polarization of bone marrow-derived macrophages toward a M2 phenotype in vitro. Furthermore, IL-33-amplified M2 macrophages augmented the proliferation of fibroblasts and ECM deposition. All together, these results strongly suggest manipulation of IL-33-mediated signal might be a potential therapeutic approach for diabetic skin wounds.

Combination of intramedullary rod, wrapping bone grafting and Ilizarov's fixator for the treatment of Crawford type IV congenital pseudarthrosis of the tibia: mid-term follow up of 56 cases.

BACKGROUND: The purpose of this study was to investigate the initial union rate, refracture rate and residual deformities of congenital pseudarthrosis of the tibia (CPT), using combined surgery including pseudarthrosis resection, intramedullary rodding, autogenous iliac bone grafting and Ilizarov's fixator, with a mean 5.2 years follow-up. METHODS: We retrospectively reviewed the records and diagrams of patients with Crawford type IV congenital pseudarthrosis of the tibia between February 2007 and March 2010. Patients managed by pseudarthrosis resection, intramedullary rod of the tibia, wrapping autogenous iliac bone grafting and Ilizarov's fixator were enrolled. We evaluated the bone union rate, tibial alignment, limb length discrepancy (LLD), valgus deformity of the ankle and the frequencies of refracture during period of follow-up. RESULTS: There were 56 cases enrolled in the study, with a mean follow-up 5.2 years (range, 3 to 6.7 years). The mean age of the patients at surgery was 3.5 years (range, 1.5 to 12.4 years). Fifty (89.2 %) of the 56 patients had primary bone union at site of pseudarthrosis, while 5 obtained union after second surgery and 1 failed. The average time spent to obtain pseudarthrosis initial union was 4.5 months (range, 3.0 to 10.0 months) and mean duration of Ilizarov treatment was 4.7 months (range, 3.2 to 10.4 months). Eleven (19.6 %) patients had proximal tibial valgus with a mean angle of 9.5° (range, 5 to 24°), while 10 (17.9 %) patients had ankle valgus deformities with a mean of 12.3° (range, 6 to 21°). Sixteen (28.6 %) patients had an average 2.2 cm LLD (range, 1.5-4.2 cm). Of the 50 cases who obtained initial bone union of pseudarthrosis, 13 (26.0 %) had refracture which need cast immobilization or secondary surgery. CONCLUSIONS: This combined surgery obtained initial union rate of 89.2 % at primary surgery while the refracture rate is 26.0 %. However, residual deformities such as proximal tibial valgus, LLD and ankle valgus were also existed which should be pay more attention to and dealt with. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov under the name "The Effect of Combined Surgery in Management of Congenital Pseudarthrosis of Tibia" ( NCT02640040 ), which was released on August 31, 2015.

Effect of distraction osteogenesis in patient with tibial shortening after initial union of Congenital Pseudarthrosis of the Tibia (CPT): a preliminary study.

BACKGROUND: The purpose of our retrospective study was to evaluate the preliminary result of distraction osteogenesis in patient with tibial shortening after initial union of Congenital Pseudarthrosis of the Tibia (CPT). METHODS: All the CPT cases with tibial shortening after initial union managed by proximal tibial lengthening using Ilizarov technique were identified. All the patient charts and radiograms were reviewed. RESULTS: Between March 2007 and January 2012, 11 CPT cases were included with an average follow-up of 41 months (range, 34-51 months). The mean age at surgery was 8.5 years (range, 3.9-14.5y). The average length of discrepancy was 5.6 cm (range, 2.0-8.2 cm). Eight (8) cases had radiological findings of proximal tibial dysplasia, while the other 3 cases had not. The average distraction length gained was 5.3 cm (range, 3.5-8.0 cm) with a mean elongation rate of 21.4% (range, 15-30%). The Healing Index (HI) was 63.1 d/cm (range, 47-77 d/cm). In the 8 patients with proximal tibial dysplasia, 5 cases had lateral callus, 3 had central callus, and poor bone regeneration was observed in all of them with an average HI of 67 d/cm. In the other 3 patients without proximal tibial dysplasia, concave shaped callus was identified with an average HI of 52.7 d/cm. None of the patients had re-fracture, nonunion, axis deviation or angulation of the distraction area. Ankle joint stiffness was found in 2 of the patients. No evidence of knee contracture was detected. There were 5 cases with pin-tract infection which was managed by pin-tract nurse and oral administration of antibiotics. CONCLUSIONS: We concluded that proximal tibial lengthening after initial union of CPT was effective for management of tibial shortening, however it was characterized by poor bone regeneration with different types of callus from normal, greater healing index and prolonged fixator wearing. We recommended that tibial lengthening could be considered when the limb length discrepancy (LLD) was more than 4 cm in younger children after primary union of CPT.

The preliminary outcome of syndactyly management in children with a new external separation device.

To introduce a new external fixation device for the management of syndactyly in children. To evaluate its preliminary clinical result. From January 2011 to June 2012, 12 cases with cutaneous syndactyly of the middle/ring finger were managed with a new external fixator designed by our department. There were eight cases on the right side and four on the left side. The web space and soft tissue were stretched gradually using the new device. A Z-plasty of syndactylies was performed when the web space has reached the width that we required. The results were evaluated according to the clinical appearance and function of the fingers. Twelve cases had been followed up, with an average time of 16 months (range, 12-27 months). The web space and soft tissue in all the cases were stretched successfully using the new device. Skin grafting was not necessary in the reconstruction of syndactyly. In the last follow-up, the Vancouver Score averaged 0.6 (range, 0-2). Three cases had grade 1 web creep, whereas the other nine cases had grade 0 web creep. The total active motion averaged 130.4° for all affected fingers: 130.8° for the middle and 130.0° for the ring finger. Stiffness in the PIP joint preoperatively in two cases did not improve postoperatively. In 12 affected middle fingers, three cases had a supination deformity averaging 10.6° (range, 5°-15°) and one case had a pronation deformity of 5°. In 12 affected ring fingers, one case had a supination deformity of 18° and two cases had a pronation deformity averaging 7.5° (range, 5°-10°). The middle finger was not pronated in any patient. Among all the ring fingers, two had radial deviation of 8°and 25° and 1 had ulnar deviation of 10°. The surgeon-provided visual analog scale score for esthetics averaged 1.8 (range, 0-5). The parent-provided visual analog scale score was 2.7 (range, 1-5) for pain, 1.3 (range, 0-5) for appearance, and 1.3 (range, 0-5) for function. Displacement of the nail bed during distraction was found in two cases, which was resolved by the Winograd technique in the second surgery of syndactyly release. The clinical appearance and function were excellent. When we use the new external fixation device in the management of syndactyly, we can achieve a satisfactory outcome with little scar of the fingers. There was no need for skin grafting. However, the long-term result should be studied further.

Presumed Larsen syndrome in a child: a case with a 12-year follow-up.

Larsen syndrome (OMIM 150250) was first described in 1950 as an entity characterized by distinct facial features and dislocations of the multiple large joint, and cleft palate, hearing loss, and spinal abnormalities were occasionally observed. The prevalence of Larsen syndrome is estimated to be one in 100,000 live births . Management of multiple large-joint dislocations often proves difficult with a tendency toward recurrence, particularly if a patient has complete dislocation of the knee .We treated a boy with the clinical phenotype of Larsen syndrome using 10 orthopedic procedures, but failed to achieve a satisfactory outcome.The aim of this report is to review the surgical course and report results of surgical treatments for this patient with 12 years of follow-up.

[Effect of extracts from rabbit skin inflamed by vaccinia virus in the management of postherpetic neuralgia and on serum interleukin-6 level in aged patients].

OBJECTIVE: To observe the effect of the extracts from rabbit skin inflamed by vaccinia virus for injection, a commercially available agent (Analgecine), in the treatment of postherpetic neuralgia (PHN) in aged patients and its influence on serum interleukin-6 (IL-6) level. METHODS: A total of 44 elderly patients with PHN were randomly divided into two groups. In addition to the conventional antiviral therapy, patients in group A were given analgecine, and those in group B given indomethacin tablet. After the completion of the 14-day treatment course, the therapeutic effects were evaluated using visual analogue scale (VAS), and the changes in serum IL-6 levels after treatment were measured. RESULTS: The score of VAS decreased significantly after treatment in group A (P<0.01), but not in group B (P>0.05). In both groups, the serum IL-6 level before treatment was significantly higher than that in normal control subjects (P<0.001), and lowered significantly after treatment (P<0.01) in group A, but not in group B (P>0.05). CONCLUSION: The extracts from rabbit skin inflamed by vaccinia virus have definite effects for rapid pain relief, and can effectively decrease the serum IL-6 level in elderly patients with PHN.