Experiences of surgical complications and reoperations in nonsyndromic sagittal synostosis patients in Oulu.

OBJECTIVE: The purpose of this study was to evaluate the surgical complications of patients treated for nonsyndromic sagittal craniosynostosis and the necessity for reoperations due to craniocerebral disproportion. MATERIALS AND METHODS: The patient cohort of this study consisted of patients (N = 82) who were treated in the Oulu University Hospital using the open vault cranioplasty with a modified H-technique between the years 2008 to 2022. There were 69 males (84.1%) and 13 females (15.9%). The mean age at the primary operation was 6.1 months. Mean follow-up time was 9.0 years. RESULTS: There were no major complications related to the procedures. Two patients (2.4%) had a minor dural lesion. There were no postoperative wound infections. Of the 82 patients, seven patients with primary craniosynostosis (13.0%) developed symptomatic craniocerebral disproportion requiring reoperation to increase intracranial volume. In all these patients, invasive intracranial pressure (ICP) monitoring was performed prior to decision-making. In the majority of cases, the aesthetical outcome was considered good or excellent. CONCLUSION: The operative method used was feasible and safe. Thirteen percent of patients who were followed over 5 years required major surgery due to development of craniocerebral disproportion later in life.

Biodegradable biomaterials in orthopedic surgery: A narrative review of the current evidence.

BACKGROUND: Biomaterials are routinely used in orthopedic surgery to fill bone defects, improve bone healing, and as degradable fixation material. A wide range of materials are currently in use, and the materials are chosen according to their bioactive properties. Osteoinductive materials stimulate bone healing by promoting osteogenesis. Osteoconductive materials facilitate bone growth on the surface of the material. Despite the many materials in use and an increasing number of published studies, randomized controlled trials on the subject are scarce. METHODS: This review aims to summarize the history of biodegradable biomaterials and also the published level I evidence currently available on orthopedic biomaterials. RESULTS: Most of the studies have been superiority trials with non-significant differences compared to conventional treatment options, confirming that several biomaterials are suitable treatment options for multiple indications including bone and/or tendon fixation, filling bone defects, and spinal fusion. Biomaterials help to avoid donor site complications associated with autogenous bone grafts and often eliminate the need for implant removal. However, the surgical technique may in some cases be more demanding than with conventional methods. Careful consideration of the pros and cons is therefore recommended in clinical practice. CONCLUSION: Biodegradable biomaterials complement the range of available treatment options in several fields of orthopedic surgery. However, some biomaterials performed worse than expected and were not recommended for clinical use, emphasizing the need for high-quality randomized trials. It is also noteworthy that several trials included only a limited number of patients, rendering the interpretation of the results of these underpowered studies challenging.

Maternal Smoking During Pregnancy and Offspring's Risk for Bone Fracture in Childhood and Adolescence.

Conditions during gestation, such as maternal smoking, may affect offspring's bone structure. This could increase the offspring's risk of bone fractures during childhood. In this study, we aimed to assess the association between prenatal exposure to maternal smoking and childhood bone fracture risk. We used a register-based birth cohort that included all children born in Finland between January 1987 and September 1990. After exclusions, the final study population consisted of 220,699 persons. Using a unique national identification number, we linked the cohort data to the fracture diagnosis in specialty care and covariate data using the Medical Birth Register (MBR), Statistics Finland and Care Register for Health Care (CRHC). The fractures were analyzed in three groups: all fractures, non-high-energy fractures, and high-energy fractures. The analyses were adjusted for sex, parity, child's year of birth, mother's age at childbirth, mother's and father's educational level, and mother's fracture status. We tested the association in three age groups: <1 year, 1-<5 years, and 5-<15 years using Cox and (recurrent fractures) Poisson regression. A total of 18,857 (8.5%) persons had at least one bone fracture diagnosis before the age of 15 years. In the age group 5-<15 years, maternal smoking during pregnancy was associated with higher fracture risk in all of the studied fracture groups: hazard ratio (HR) = 1.12 (95% confidence interval [CI] 1.06-1.17) in all fractures, 1.13 (95% CI 1.07-1.19) in non-high-energy, and 1.15 (95% CI 1.00-1.32) in high-energy fractures. There were no significant associations in other age groups in any of the fracture groups. No statistically significant association between maternal smoking during pregnancy and offspring's risk of recurrent fractures was found. In conclusion, 5- to 15-year-olds whose mothers have smoked during pregnancy have an increased risk of bone fractures treated in specialty care. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

A randomized, controlled multicenter feasibility pilot trial on imaging confirmed uncomplicated acute appendicitis: Appendectomy vs. symptomatic treatment in pediatric patients (the APPSYPP) trial study protocol.

INTRODUCTION: Imaging-confirmed uncomplicated acute appendicitis can be effectively and safely treated with antibiotics in most adults and children. Symptomatic treatment may have similar efficacy and safety. METHODS AND ANALYSIS: The APPSYPP trial is a randomized national multicenter feasibility superiority pilot study comparing appendectomy with symptomatic treatment in children with imaging-confirmed uncomplicated acute appendicitis. INCLUSION CRITERIA: 1) age ≥ 7 and < 16 years, 2) imaging-confirmed uncomplicated acute appendicitis and 3) CRP ≤ 65 mg/l. Patients are randomized to receive emergency laparoscopic appendectomy or symptomatic treatment. To ensure patient safety, symptomatically treated patients are hospitalized for at least 24 h receiving standard practice intravenous fluids and analgesics according to standard clinical practice. Primary outcome is 30-day treatment success defined by the absence of any treatment failure criteria. In appendectomy, treatment failure is defined as normal appendiceal histopathology or any postintervention complication requiring general anesthesia. In symptomatic treatment, treatment failure is defined as 1) inability for hospital discharge without appendectomy within 48 h after randomization with a finding of histopathologically inflamed appendix, 2) appendectomy during the initial hospital stay due to clinical progression of appendicitis with complicated acute appendicitis both histopathologically and surgically, 3) appendectomy with a histopathological finding of acute appendicitis after hospital discharge, or 4) any complication of appendicitis requiring general anesthesia. Detailed predefined secondary outcomes will be analyzed. ETHICS AND DISSEMINATION: Study was approved by Ethics Committee of Helsinki University Hospital (ID:HUS/1993/2021), conducted in compliance with the declaration of Helsinki with results disseminated in peer-reviewed scientific journals. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05289713).

Retrograde intramedullary nailing of the radius in children: A pilot magnetic resonance imaging study of soft-tissue findings.

Purpose: Unstable forearm shaft fractures in children are preferably treated surgically using elastic stable intramedullary nails. The radius is nailed retrograde from the distal metaphysis. There is a risk of surgery-related soft-tissue complications during the operation. Close evaluation of occult surgery-related soft-tissue lesions has not been possible previously, due to the titanium alloy hardware used in the process. The aim of the present study was to evaluate the potential findings in the surrounding soft tissues after intramedullary nailing of the radius, by using magnetic resonance imaging. Methods: The study population comprised 15 pediatric patients with forearm shaft fractures treated by polylactide-co-glycolide biodegradable intramedullary nails and postoperatively evaluated via magnetic resonance imaging. The main outcome was signal abnormality in any tendon at the entry point postoperatively. Secondarily, other changes in the soft tissues related to nailing were determined. Furthermore, the precise location of the entry point and the anatomic characteristics of the soft-tissue tunnel were described. Results: In total, 5 of 15 patients (33.3%) had transient signal pathology in a tendon postoperatively. Edema around the superficial radial nerve was detected in 13 of 15 patients (86.7%). The most common surgical approach was between the extensor pollicis brevis and the extensor carpi radialis longus tendons, which was applied in 10 of 15 patients (66.7%). Conclusions: One in three patients exhibited transient and occult surgery-related intraparenchymal signal pathology in a tendon, after forearm intramedullary nailing. Caution with surgical prepare of the soft-tissue cleavage is recommended. Level of evidence: IV.

Increase in surgical fixation of pediatric midshaft clavicle fractures since 2008.

BACKGROUND: Clavicle fractures in children have traditionally been treated non-operatively. In adults, a great increase in operative treatment has been reported. We aimed to analyze the respective trend and potential explanatory factors in children. METHODS: This is a single-institution retrospective study in a subregion in Northern Finland. The ICD-code S42.0 was used to identify the cases in the hospital registry. Altogether, 214 children, aged < 16, with consecutive clavicle fractures were first enrolled in the area during 2008-2019. Hospital journals and radiographs were reviewed. After lateral and medial fractures and patients living outside the area were excluded, final study population was 172. The respective population at risk was extracted by Statistics Finland. Predictive factors and annual rates of operative treatment as adjusted for 100,000 children at risk were determined. RESULTS: The rate of the surgical treatment of clavicle fractures increased from zero in 2008 to 10.8 in 2019 per 100,000 age-adjusted children (ß = 0.864, 95% confidential intervals (CI) 0.4 to 1.4). There was a rise in the rate of surgery from 2.6% (2014-16) to 16.1% (2017-19) (diff. 13.5, 95% CI 1.7 to 23.3%). A displacement > 15 mm and a shortening of > 15 mm were associated with the increased risk of surgery but did not change during the study period. Age > 9 years increased the risk of surgery; the mean age increased from 5.5 years (2008-10) to 8.5 years (2017-19). There was a 3.6-fold increase in sports-related fractures (95% CI 7.4 to 26.4). The severity of the fractures did not change. CONCLUSIONS: There has been an increasing trend in the surgical fixation of pediatric middle shaft clavicle fractures since 2008. The available literature does not support the trend.

Calcaneal Bone Bruise After Surgery for Insertional Achilles Tendinopathy.

OBJECTIVE: Excision of the posterosuperior corner of the calcaneus (EPCC) is routinely undertaken in athletes after failure of conservative management of insertional Achilles tendinopathy. Some patients can experience sharp calcaneal pain during postoperative rehabilitation, a sign of a calcaneal bone bruise (CBB). DESIGN: Case series, level of evidence IV. SETTING: University teaching hospital. PATIENTS: This study reports 8 patients who developed postoperative CBB after having started impact training too early. INTERVENTION: Patients in whom a diagnosis of CBB had been formulated were followed to return-to-play and resolution of bone edema by MRI. MAIN OUTCOME MEASURES: Detection of CBB after EPCC. RESULTS: After routine EPCC for insertional Achilles tendinopathy, 8 patients presented with sharp pain for a mean 7.1 weeks (median 6 weeks, range 5-11 weeks) before clinical suspicion of CBB. At that stage, MRI showed clear evidence of a bone bruise, with a diagnosis of CBB formulated at an average of 10.8 postoperative weeks (range 6-16 weeks). Calcaneal bone bruise resolved with modified symptom-free loading. Patients returned to play at average on 5.6 months (range 2-9 months) after the diagnosis of postoperative CBB. CONCLUSIONS: We describe 8 athletes who developed painful CBB following routine EPCC for insertional Achilles tendinopathy after having increased their level of activities too soon after the index procedure. In these patients, the diagnosis of postoperative CBB can be formulated by MRI and more cautious rehabilitation implemented.

Craniofacial characteristics and cosmetic satisfaction of patients with sagittal and metopic synostosis: a case-control study using 3D photogrammetric imaging.

PURPOSE: The aim of this study was to investigate the craniofacial and aesthetic characteristics of adult metopic and sagittal craniosynostosis patients operated on in early childhood compared to controls. The goal was to find objective measurements that would correlate with the patient's subjective self-evaluation of their own cosmetic appearance. METHODS: The study population consisted of 49 patients from whom 41 had premature fusion of the sagittal and in 8 of metopic suture. There were 65 age and gender matching controls from The Finish National Register. The 3D photogrammetric models were created from all patients and controls. The images were analysed using Rapidform 2006. Facial landmarks were set by the standard Farkas points. Facial symmetry parameters were calculated by using the landmarks and the mirror shell of the face. Aesthetic evaluation was done from standard photographs using panels. Subjective satisfaction with one's own appearance was evaluated using questionnaires. RESULTS: Patients had the greatest asymmetry in the forehead area when compared to controls (symmetry percentage 59% versus 66%, p = 0.013). In the control group, the gap between the eyes was smaller than in the case group, resulting in an absolute 2 mm difference (p = 0.003). The area of the chin and the landmarks were more located on the left side in the patient group, resulting in up to a 1.1 mm difference between the groups (p = 0.003). Only a weak association was found between craniofacial symmetry and appearance evaluations. CONCLUSION: Patients operated on because of sagittal and metopic synostoses were found to have facial asymmetry at long follow-up. However, the differences were < 3 mm and not clinically important. The long-term aesthetical outcome of the surgery performed because of sagittal or metopic craniosynostosis based on the 3D image evaluation was good.

Long-Term Results of Pediatric Congenital Pulmonary Malformation: A Population-Based Matched Case-Control Study with a Mean 7-Year Follow-Up.

Symptomatic congenital pulmonary malformations (CPMs) are a group of anomalies involving the lungs. The long-term outcomes of these patients are not well known. The present research aimed to study the pulmonary function, respiratory morbidity, and health-related quality of life (QoL) of patients treated for CPMs. All children (<16 years of age) treated for CPMs in 2002−2012 (in Oulu University Hospital) were invited to the follow-up visit. Altogether, there were 22 patients, out of which 17 (77%) participated. The mean follow-up time was 6.6 (ranged from 3 to 16) years. Pulmonary function tests, diffusing capacity, respiratory morbidity, and QoL were determined as the primary outcomes. Potential residual malformations and lung anatomy were investigated using computer tomography (CT) imaging. The outcomes were compared to the age- and sex-matched healthy controls. The forced expiratory volume at 1 s (FEV1, Z-score) remained lower in operated patients compared to the healthy controls (−1.57 ± SD 1.35 vs. −0.39 ± SD −0.86, p-value 0.005). There were no differences in respiratory morbidity or QoL between the patients and the controls. The surgical approach (lobectomy vs. partial resection) did not affect lung function. A younger age (<1 year of age) at the time of the surgery seemed to result in a higher lung capacity, but the finding was not statistically significant. Patients with CPMs treated with surgery were satisfied with their wellbeing in the long-term. A lower lung function did not have an impact on their wellbeing. However, there was a slight decrease in lung function compared to the healthy controls, and a clinical follow-up of the patients was recommended.

Magnetic resonance imaging-guided biopsies in children.

BACKGROUND: Magnetic resonance imaging (MRI) is used far less as an imaging-guided method for percutaneous biopsies than computed tomography (CT) and ultrasound (US), despite its imaging benefits, particularly in children. PURPOSE: To evaluate the feasibility, accuracy and safety of MRI-guided biopsies in paediatric patient population. MATERIAL AND METHODS: The retrospective study included 57 consecutive paediatric patients (<18 years old). A percutaneous core needle biopsy (PCNB) or trephine biopsy was performed in 53 cases, and an additional fine-needle aspiration biopsy (FNAB) in 26 cases. In 4 cases, a stand-alone FNAB was taken. Biopsies were performed with 0.23 T open and 1.5 T closed MRI scanners. Statistical methods used for confidence intervals and p-values were Wilson score method and chi-square test. RESULTS: The overall diagnostic accuracy of histologic biopsy was 0.94, with sensitivity 0.82, specificity 1.00, positive predictive value (PPV) 1.00 and negative predictive value (NPV) 0.92. In histological bone biopsies, diagnostic accuracy was 0.96, with sensitivity 0.86, specificity 1.00, PPV 1.00 and NPV 0.94. The FNAB sample diagnosis was associated with the histological diagnosis in 79% of cases. There were no major primary complications and only a few late complications. After biopsy, 83% of the children were ambulatory in 6 h. Anti-inflammatory drugs and paracetamol provided satisfactory pain relief in 96% of the patients after biopsy. Most outpatients (71%) were discharged from hospital either on the same day or 1 day later. CONCLUSION: MRI is a technically feasible, accurate and safe guidance tool for performing percutaneous biopsies in children.

Casting versus flexible intramedullary nailing in displaced forearm shaft fractures in children aged 7-12 years: a study protocol for a randomised controlled trial.

INTRODUCTION: The forearm is the most common fracture location in children, with an increasing incidence. Displaced forearm shaft fractures have traditionally been treated with closed reduction and cast immobilisation. Diaphyseal fractures in children have poor remodelling capacity. Malunion can cause permanent cosmetic and functional disability. Internal fixation with flexible intramedullary nails has gained increasing popularity, without evidence of a better outcome compared with closed reduction and cast immobilisation. METHOD AND ANALYSIS: This is a multicentre, randomised superiority trial comparing closed reduction and cast immobilisation to flexible intramedullary nails in children aged 7-12 years with >10° of angulation and/or >10 mm of shortening in displaced both bone forearm shaft fractures (AO-paediatric classification: 22D/2.1-5.2). A total of 78 patients with minimum 2 years of expected growth left are randomised in 1:1 ratio to either treatment group. The study has a parallel non-randomised patient preference arm. Both treatments are performed under general anaesthesia. In the cast group a long arm cast is applied for 6 weeks. The flexible intramedullary nail group is immobilised in a collar and cuff sling for 4 weeks. Data are collected at baseline and at each follow-up until 1 year.Primary outcome is (1) PROMIS paediatric upper extremity and (2) forearm pronation-supination range of motion at 1-year follow-up. Secondary outcomes are Quick DASH, Paediatric Pain Questionnaire, Cosmetic Visual Analogue Scale, wrist and elbow range of motion as well as any complications and costs of treatment.We hypothesise that flexible intramedullary nailing results in a superior outcome. ETHICS AND DISSEMINATION: We have received ethical board approval (number: 78/1801/2020) and permissions to conduct the study from all five participating university hospitals. Informed consent is obtained from the parent(s). Results will be disseminated in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04664517.

Cast immobilisation in situ versus open reduction and internal fixation of displaced medial epicondyle fractures in children between 7 and 16 years old. A study protocol for a randomised controlled trial.

INTRODUCTION: Medial epicondyle fracture of the humerus is a common injury in childhood. There is uniform agreement that minimally displaced fractures (dislocation ≤2 mm) can be treated nonoperatively with immobilisation. Open fractures, fractures with joint incarceration or ulnar nerve dysfunction require surgery. There is no common consensus in treatment of closed medial epicondyle fractures with >2 mm dislocation without joint incarceration or ulnar nerve dysfunction. We hypothesise that there is no difference in treatment outcomes between nonoperative and operative treatment. METHODS AND ANALYSIS: This is a multicentre, controlled, prospective, randomised noninferiority study comparing operative treatment to non-operative treatment of >2 mm dislocated paediatric medial epicondyle fractures without joint incarceration or ulnar nerve dysfunction. A total of 120 patients will be randomised in 1:1 ratio to either operative or nonoperative treatment. The study will have a parallel nonrandomised patient preference arm. Operative treatment will be open reduction and internal fixation. Nonoperative treatment will be upper limb immobilisation in long arm cast for 4 weeks. Data will be collected at baseline and at each follow-up up to 2 years. Quick-DASH is used as primary outcome measure. Secondary outcomes are patient-reported pain, differences in range of motion, Pediatric Quality of Life Inventory, cosmetic visual analogue scale and Mayo Elbow Performance Score. ETHICS AND DISSEMINATION: Ethical approval has been obtained from Helsinki University Hospital (HUS) ethical board HUS/1443/2019. Each study centre has obtained their own permission for the study. A written authorisation from legal guardian will be acquired and the child will be informed about the trial. Results of the trial will be disseminated as published articles in peer-reviewed journals. TRIAL REGISTRATION: The trial has been registered at clinicaltrials.gov with registration number NCT04531085.

Tears of biceps femoris, semimembranosus, and semitendinosus are not equal-a new individual muscle-tendon concept in athletes.

OBJECTIVES: Hamstring injuries are common and can now be accurately diagnosed. In addition, novel surgical indications have been introduced. However, evidence-based guidelines on the hamstring injuries in management of top-level athletes are missing. METHODS: The management methods and outcomes of treatment are classically based on relatively small case series. We discuss a novel concept based on the fact that each tendon of the hamstrings muscle should be managed in an individual fashion. Furthermore, suitable indications for hamstring surgery in athletes are introduced. RESULTS: The present study introduces modern treatment principles for hamstring injury management. Typical clinical and imagining findings as well as surgical treatment are presented based on a critical review of the available literature and personal experience. CONCLUSIONS: Hamstring injuries should not be considered to be all equal given the complexity of this anatomical region: The three separate tendons are different, and this impacts greatly on the decision-making process and outcomes in athletes.

Intracranial bullet removal using O-arm navigation guidance.

PURPOSE: The purpose of this study is to report a new mini-invasive technique to remove an intracranial bullet in a child by using O-arm for intraoperative neuronavigation. CASE REPORT: A 14-year-old refugee boy had suffered a shooting injury 4 years earlier. O-arm imaging-assisted neuronavigation during craniotomy was performed in order to remove a bullet from the intracranial space in a paediatric patient. CONCLUSION: Navigation using O-arm is a feasible method in removing a foreign material in a child and gave an accurate location of the bullet in the adopted surgical operation position without significant imaging artefacts.

Maternal alcohol consumption during pregnancy associates with bone fractures in early childhood. A birth-cohort study of 6718 participants.

Fractures are common injuries in children, but their underlying biological and environmental risk factors are not well known. Maternal alcohol consumption during pregnancy is a known risk factor for bone malformations and impaired growth, in connection with Fetal Alcohol Spectrum Disorders (FASD). There is evidence that even lower doses of alcohol than what is needed for FASD can cause changes in the developing bone. Birth weight and length may also associate to childhood fractures. The aim of this study was to find out whether there exist associations between maternal alcohol use during pregnancy, birth weight or length and fractures of the long bones in childhood. A prospective birth cohort was performed, including all women in Northern Finland with an expected date of delivery between July 1985 and June 1986, and their offspring (N = 9432). The National Hospital Discharge Register (NHDR) provided the information on inpatient treated fractures. The subjects who declined participation or were treated as outpatient were excluded. The final study population consisted of 6718 children (71.2%). 98 (1.5%) of them suffered from inpatient treated fracture of a long bone (N = 105). Maternal alcohol consumption during pregnancy was inquired by questionnaires during late pregnancy or shortly after parturition. The birth length and weight were recorded immediately after birth. Binomial regression analysis was used to determine the association between the potential explanatory variables and bone fractures. Gender, socioeconomic status of the family, maternal age, premature birth, body mass index (BMI) of the children and maternal smoking during pregnancy were taken as possible confounders. In this study, the maternal alcohol consumption during pregnancy was associated to 2.22-fold (CI 1.09-4.12, p < 0.02) increased risk of a long bone fracture before the age of eight. Birth weight or length did not associate to childhood fractures. Bone fractures are an important cause of morbidity in childhood. Their prevention should start from the prenatal period by protecting the fetus from the alcohol exposure.

The Association of Metal Frame Construct of ESIN and radiographic bone healing of pediatric forearm fractures.

INTRODUCTION: The gold-standard surgical procedure of both-bone forearm shaft fracture repair is elastic stable intramedullary nailing (ESIN). Disadvantages effects of ESIN have suggested to be a consequence of inappropriate surgical techniques, while recommendations are not always followed. The purpose of the study was to analyze the effect of inadequate metal frame construct on impaired fracture healing, refracture and changing alignment. MATERIALS AND METHODS: It is a population-based study including all consecutive patients, aged less than 16 years, who had been treated for forearm shaft fracture by ESIN during the ten-year period 2009-2018. Altogether 71 patients were included. Non-union, delayed union, and re-fracture during the following 12 months were taken as the main outcome, while inferior metal frame construct of ESIN and the surgical technique characteristics were taken the explanatory factors. Radiographic loss of reduction was a secondary outcome and a change >5° in alignment at any postoperative follow-up exam was recognized. RESULTS: Two out of 71 fractures (3%) failed to unite, and ossifying operation was needed. Five cases (7%) showed delayed bone healing, but they ossified in five months without any intervention. These seven patients (10%) had been treated more often with larger nails (> 0.7x MCD) (p = 0.027) and by open reduction (p = 0.02), compared with thinner nails and closed reduction, respectively. Two (3%) patients had a second fracture; however, they happened 2 years after the initial injury. Other surgery or fracture related factors didn't associate with impaired ossifying. Regarding the secondary outcome, altogether 24 (35%) of the analyzed 67 patients showed >5° change in alignment during the postoperative follow-up but only one patient had clinically significant instability that required re-reduction. The alignment changed more usually in distal-third fractures, compared with middle or proximal third fractures (p = 0.019). CONCLUSIONS: ESIN resulted in good radiographic bone healing in the vast majority (90%) of the patients and completely perfect metal frame construct was not required.

Treatment of Unstable Pediatric Tibia Shaft Fractures in Finland.

BACKGROUND: Surgical treatment of pediatric tibia shaft fractures has gained popularity despite closed reduction and cast-immobilization providing good long-term results. There is no consensus about optimal methods and satisfactory quality of treatment. MATERIALS AND METHODS: During 2010 to 2014, 226 pediatric patients were treated under anesthesia for tibia shaft fractures in Finland's five university hospitals. A total of 164 (73%) patients had closed fractures of the tibia or both tibia and fibula without other injuries (62 tibia only and 102 both tibia and fibula). Forty-one (18%) had open tibia fractures, 16 had additional fractures, and 5 (2%) had sustained a polytrauma (Injury Severity Score [ISS] > 15). Treatment methods, follow-up protocols, complications, and the outcome were analyzed. RESULTS: A total of 143 (63%) of the tibia fractures were treated surgically: 87 (53%) closed fractures, 36 (88%) open fractures, 15 (94%) with additional fractures, and 5 (2%) polytrauma patients. The rate of surgical treatment of closed tibia fractures was significantly higher in patients older than 10 and in patients with a concomitant fibula fracture. Fasciotomy was done in 33 (15%) patients. Reoperations were performed in 13 (6%) patients because of unsatisfactory treatment (inappropriate primary reduction 6, malunion 6, and non-union 1). There were no differences between the five university hospitals in treatment or follow-up protocols. CONCLUSION: Internal fixation is used for the majority of tibia shaft fractures treated under anesthesia in university hospitals in Finland. Serious fracture or treatment related complications are very rare, but the percentage (6%) of re-operations because of unsatisfactory standard of treatment should be lower and could probably be improved by concentrating internal fixation to fewer hands. A prospective randomized controlled trial comparing non-operative treatment to intramedullary nailing in pediatric tibia fractures should be performed.

Outcomes of 40 Nonsyndromic Sagittal Craniosynostosis Patients as Adults: A Case-Control Study With 26 Years of Postoperative Follow-up.

BACKGROUND: While sagittal synostosis is the most common craniosynostosis, long-term follow-up of these patients is lacking. OBJECTIVE: To evaluate the results of surgical management of those patients with sagittal synostosis who attain adulthood. METHODS: An outcome study of surgically treated isolated sagittal synostosis patients operated between 1977 and 1998 was conducted at the Craniofacial Center of Oulu University Hospital, Oulu, Finland with an average follow-up time of 26.5 yr. Patients' socioeconomic situation, satisfaction with their own facial appearance and attractiveness as rated by 2 independent panels was evaluated and compared to controls. RESULTS: The self-satisfaction with the patients' own appearance scored a mean of 75 mm on a visual analog scale of 100 mm between the patients and 76 mm with the control group. The subjective satisfaction of the patients with their own appearance failed to correlate with the rating of their appearance by the panels. The panels rated the patients' appearance to be on average 6 to 7 mm out of 100 mm visual analog scale less attractive than the controls. Data on socioeconomic situation, including marital status, housing, education, employment of the patients, and controls are presented. CONCLUSION: Isolated sagittal synostosis patients treated surgically were as happy with their facial appearance as were individuals in an age and gender-matched control group. Two independent panels found the patients' appearance to be only somewhat less attractive. Analysis of the socioeconomic situation and general health revealed that patients equaled that of controls.

Intramedullary nailing of forearm shaft fractures by biodegradable compared with titanium nails: Results of a prospective randomized trial in children with at least two years of follow-up.

There are disadvantages in Elastic Stable Intramedullary Nailing (ESIN) of forearm-shaft fractures, such as the need of implant removal. Biodegradable Intramedullary Nailing (BIN) is a new technique developed for these fractures. We hypothesized that there is no difference in rotational ROM between the patients treated by BIN vs. ESIN. A randomized, controlled clinical trial included patients, aged 5-15 years, requiring surgery for forearm-shaft fractures. Biodegradable polylactide-co-glycolide (PLGA) nails (Activa IM-Nail™, Bioretec Ltd., Finland) were used in 19 and titanium nails (TEN®, SynthesDePuy Ltd., USA) in 16 patients. Rotational ROM of forearm after two years was the primary outcome. Elbow and wrist ROM, pain and radiographic bone healing were secondary outcomes. Forearm rotation was mean 162° and 151° in BIN and ESIN groups, respectively (P = 0.201). No difference between the groups was found in any other ROMs. Three cases in the ESIN vs. none in the BIN group reported pain (P = 0.113). There was no clinically significant residual angulation in radiographs. Two adolescents in the BIN group vs. none in the ESIN (P = 0.245) were excluded because of implant failure; another two with complete bone union suffered from re-injury. Therefore, satisfactory implant stability among older children needs to be studied.