Gene expressions in cerebral palsy subjects reveal structural and functional changes in the gastrocnemius muscle that are closely associated with passive muscle stiffness.

Cerebral palsy (CP) is a non-progressive motor disorder that affects posture and gait due to contracture development. The purpose of this study is to analyze a possible relation between muscle stiffness and gene expression levels in muscle tissue of children with CP. Next-generation sequencing (NGS) of gene transcripts was carried out in muscle biopsies from gastrocnemius muscle (n = 13 children with CP and n = 13 typical developed (TD) children). Passive stiffness of the ankle plantarflexors was measured. Structural changes of the basement membranes and the sarcomere length were measured. Twelve pre-defined gene target sub-categories of muscle function, structure and metabolism showed significant differences between muscle tissue of CP and TD children. Passive stiffness was significantly correlated to gene expression levels of HSPG2 (p = 0.02; R2 = 0.67), PRELP (p = 0.002; R2 = 0.84), RYR3 (p = 0.04; R2 = 0.66), C COL5A3 (p = 0.0007; R2 = 0.88), ASPH (p = 0.002; R2 = 0.82) and COL4A6 (p = 0.03; R2 = 0.97). Morphological differences in the basement membrane were observed between children with CP and TD children. The sarcomere length was significantly increased in children with CP when compared with TD (p = 0.04). These findings show that gene targets in the categories: calcium handling, basement membrane and collagens, were significantly correlated to passive muscle stiffness. A Reactome pathway analysis showed that pathways involved in DNA repair, ECM proteoglycans and ion homeostasis were amongst the most upregulated pathways in CP, while pathways involved in collagen fibril crosslinking, collagen fibril assembly and collagen turnover were amongst the most downregulated pathways when compared with TD children. These results underline that contracture formation and motor impairment in CP is an interplay between multiple factors.

The effects of rotation on radiological parameters in the spine.

BACKGROUND: Vertebral rotation in straight spines or in spines with small scoliosis may potentially affect measurement of radiological parameters in both the frontal and sagittal plane. This is important, since it could lead to potential misdiagnosis of scoliosis and other clinical consequences, and until now, this has not been examined. PURPOSE: To examine the effect of axial vertebral rotation of the spine on measurement of common radiological parameters. MATERIAL AND METHODS: Reconstructions from computed tomography scans of 40 consecutive included and anonymized patients with straight spines or small scoliosis. Fourteen sagittal and coronal reconstructions covering the whole pelvis and spine were executed. Radiographic parameters in both the frontal and sagittal plane were measured blinded and separately by three doctors. These parameters were evaluated for inter-rater reliability using intraclass correlation coefficient and mixed model analysis for the effects of rotation. The parameters were also analyzed sub-stratified according to "Lenke's classification" and 15 sub-categories of thoracic and lumbar Cobb's angle (CA). RESULTS: Vertebral rotation in general does not have any significant effects in both the frontal and sagittal plane. However, there are significant effects on CA and spinopelvic radiologic parameters in extreme rotation or for larger scoliosis. Inter-rater reliability was very good to good. CONCLUSION: In conclusion, axial spinal rotation does not influence common radiological parameters in the frontal and sagittal plane, except in cases of extreme rotation or large scoliosis for selected parameters; thus, this does not lead to potential misinterpretation in scoliosis diagnosis, treatment, or research.

Sequence variants in muscle tissue-related genes may determine the severity of muscle contractures in cerebral palsy.

Muscle contractures are a common complication to cerebral palsy (CP). The purpose of this study was to evaluate whether individuals with CP carry specific gene variants of important structural genes that might explain the severity of muscle contractures. Next-generation-sequencing (NGS) of 96 candidate genes associated with muscle structure and metabolism were analyzed in 43 individuals with CP (Gross Motor Function classification system [GMFCS] I, n=10; GMFCS II, n=14; GMFCS III, n=19) and four control participants. In silico analysis of the identified variants was performed. The variants were classified into four categories ranging from likely benign (VUS0) to highly likely functional effect (VUS3). All individuals with CP were classified and grouped according to their GMFCS level: Statistical comparisons were made between GMFCS groups. Kruskal-Wallis tests showed significantly more VUS2 variants in the genes COL4 (GMFCS I-III; 1, 1, 5, respectively [p < .04]), COL5 (GMFCS I-III; 1, 1, 5 [p < .04]), COL6 (GMFCS I-III; 0, 4, 7 [p < .003]), and COL9 (GMFCS I-III; 1, 1, 5 [p < .04]), in individuals with CP within GMFCS Level III when compared to the other GMFCS levels. Furthermore, significantly more VUS3 variants in COL6 (GMFCS I-III; 0, 5, 2 [p < .01]) and COL7 (GMFCS I-III; 0, 3, 0 [p < .04]) were identified in the GMFCS II level when compared to the other GMFCS levels. The present results highlight several candidate gene variants in different collagen types with likely functional effects in individuals with CP.

Stability and migration across femoral varus derotation osteotomies in children with neuromuscular disorders.

Background and purpose - Studies have indicated that one-third of children with cerebral palsy (CP) develop dislocation of the hip that needs surgical intervention. When hip dislocation occurs during childhood surgical treatment consists of tenotomies, femoral varus derotation osteotomy (VDRO), and acetabuloplasty. Relapse is observed in one-fifth of cases during adolescence. In this prospective cohort study, we performed a descriptive evaluation of translation and rotation across VDROs in children with neuromuscular disorders and syndromes by radiostereometric analysis (RSA). We assessed "RSA stability" and migration across the VDROs. Patients and methods - Children with a neuromuscular disorder were set up for skeletal corrective surgery of the hip. RSA follow-ups were performed postoperatively, at 5 weeks, and 3, 6, and 12 months after surgery. Results - 27 femoral VDROs were included; 2 patients were excluded during the study period. RSA data showed stability across the VDRO in the majority of cases within the first 5 weeks. At the 1-year follow-up, the mean translations (SD) of the femoral shaft distal to the VDRO were 0.51 (1.12) mm medial, 0.69 (1.61) mm superior, and 0.21 (1.28) mm posterior. The mean rotations were 0.39° (2.90) anterior tilt, 0.02° (3.07) internal rotation, and 2.17° (2.29) varus angulation. Interpretation - The migration stagnates within the first 5 weeks, indicating stability across the VDRO in most patients.

Does elite swimming accelerate lumbar intervertebral disc degeneration and increase low back pain? A cross-sectional comparison.

PURPOSE: The aim was to elucidate elite swimming's possible influence on lumbar disc degeneration (DD) and low back pain (LBP). METHODS: Lumbar spine MRI was performed on a group of elite swimmers and compared to a matched Finnish population-based no-sport group. RESULTS: One hundred elite swimmers and 96 no-sport adults, mean age 18.7/20.8, respectively, participated. Overall, the two groups had similar prevalence of DD. Swimmers had more DD in the upper lumbar spine but tended to have less DD at the lowest level. Prevalence of bulges and disc herniations were similar, but swimmers had significantly more bulges at L4-5. The swimmers reported less LBP, although not significantly (N.S.). If degenerative findings were present, the association between them and LBP was stronger in the no-sport group. CONCLUSION: Elite swimmers and controls had similar prevalence of DD and LBP, although the pattern of DD differed between the groups. In case of DD, swimmers reported less LBP, although N.S.

Using Electric Stimulation of the Spinal Muscles and Electromyography during Motor Tasks for Evaluation of the Role in Development and Progression of Adolescent Idiopathic Scoliosis.

Introduction: The role of the spinal muscles in scoliogenesis is not fully substantiated. Do they act scoliogenic (inducing scoliosis) or counteract scoliosis in adolescent idiopathic scoliosis (AIS)? In this study, we will examine this by using selectively placed Transcutaneous Electric Stimulation (TES) combined with a cinematic radiographic technique and by performing electromyographic (EMG) evaluations during various motor tasks. Method: This is a cross-sectional study of subjects with small-curve AIS. Using cinematic radiography, they were evaluated dynamically either under electrical stimulation or when performing motor tasks of left and right lateral bending and rotation whilst measuring the muscle activity by EMG. Results: Forty-five patients with AIS were included as subjects. Five subjects volunteered for TES and six subjects performed the motor tasks with EMG. At the initial visual evaluation, and when stimulated with TES, the frontal plane spatial positions of the vertebral bodies showed discrete changes without an apparent pattern. However, analyzing the spatial positions when calibrated, we found that the spinal muscles exert a compressive 'response' with a minor change in the Cobb angle (CA) in small-curve AIS (CA = 10-20°). In larger curves (CA > 20°), TES induced a 'larger deformity' with a relative four-fold change in the CA compared to small-curve AIS with a ratio of 0.6. When evaluating local amplitude (peak) or cumulative (mean) EMG signals, we were unable to find consistent asymmetries. However, one subject had rapid progression and one regressed to a straight spine. When adding the absolute EMG ratios for all four motor tasks, the subject with progression had almost 10-fold less summed EMG ratios, and the subject with regression had more than 3-fold higher summed EMG ratios. Discussion: Based on these findings, we suggest that the spinal muscles in small-curve AIS have a stabilizing function maintaining a straight spine and keeping it in the midline. When deformities are larger (CA > 20°), the spine muscle curve exerts a scoliogenic 'response'. This suggests that the role of the muscles converts from counteracting AIS and stabilizing the spine to being scoliogenic for a CA of more than 20°. Moreover, we interpret higher EMG ratios as heightened asymmetric spinal muscle activity when the spinal muscles try to balance the spine to maintain or correct the deformity. When progression occurs, this is preceded or accompanied by decreased EMG ratios. These findings must be substantiated by larger studies.

Assessment of somatosensory profiles by quantitative sensory testing in children and adolescents with and without cerebral palsy and chronic pain.

OBJECTIVE: We investigated differences in somatosensory profiles (SSPs) assessed by quantitative sensory testing in children and adolescents with cerebral palsy (CCP) with and without chronic pain and compared these differences to those in a group of typically developed children and adolescents (TDC) with and without chronic pain. METHOD: All included subjects were consecutively recruited from and tested at the same outpatient orthopedic clinic by the same investigator. The subjects had their reaction times tested. The SSP consisted of the following tests: warmth (WDT), cool (CDT), mechanical (MDT), and vibration (VDT) detection thresholds; heat (HPT), pressure (PPT), and mechanical (MPT) pain thresholds; wind-up ratio (WUR); dynamic mechanical allodynia (DMA) and cold pressor test (CPT) using a conditioned pain modulation (CPM) paradigm. RESULTS: We included 25 CCP and 26 TDC. TDC without chronic pain served as controls. In TDC with chronic pain, WDT, HPT, HPT intensity, and PPT were higher than in controls. No differences in SSPs between CCP with and without chronic pain were observed. In CCP, the MDT, WDT, CDT, and HPT intensity were higher than in controls. CCP had longer reaction times than TDC. There were no differences regarding the remaining variables. DISCUSSION: In CCP, the SSPs were independent of pain status and findings on MR images. In all CCP the SSPs resembled TDC with chronic pain, compared to TDC without chronic pain. This suggests that CCP do not have the normal neuroplastic adaptive processes that activate and elicit functional changes in the central and peripheral nervous systems.

Recently introduced qacA/B genes in Staphylococcus epidermidis do not increase chlorhexidine MIC/MBC.

OBJECTIVES: Chlorhexidine is used as a disinfectant to prevent surgical infections. Recently, studies have indicated that chlorhexidine usage has selected methicillin-resistant Staphylococcus aureus strains that are tolerant to chlorhexidine and that this may be related to the presence of the qacA/B-encoded efflux pumps. Here, we evaluated if high-level exposure to chlorhexidine selects for tolerant colonizing Staphylococcus epidermidis and we addressed the consequences of long-term exposure to chlorhexidine. METHODS: Chlorhexidine susceptibility and carriage of qacA/B was determined for colonizing S. epidermidis isolated from scrub nurses heavily exposed to chlorhexidine and were compared with isolates from non-users of chlorhexidine hand rubs. S. epidermidis blood isolates from the 1960s, before the wider introduction of chlorhexidine to the market, were also tested and compared with recently collected S. epidermidis blood isolates. RESULTS: There was no correlation between the use of chlorhexidine in scrub nurses and the presence of qacA/B genes in S. epidermidis isolates or increased MICs/MBCs of chlorhexidine for S. epidermidis isolates. While 55% of current blood isolates harboured the qacA/B genes, none of the 33 historical S. epidermidis isolates did, although their MICs and MBCs of chlorhexidine were comparable to those for current isolates. CONCLUSIONS: Chlorhexidine used as a hand rub does not select for S. epidermidis isolates with increased MICs or MBCs of chlorhexidine. However, the absence of qacA/B genes in S. epidermidis isolates obtained in the 1960s suggests that long-term use of biocides like chlorhexidine or related compounds may select for the presence of qacA/B genes.

The Relationship between Pain and Spasticity and Tell-Tale Signs of Pain in Children with Cerebral Palsy.

Pain and quality of life are closely interrelated in children with cerebral palsy (CCP). Even though 67% of CCP experience pain, it is overlooked and untreated. In this study, our purpose was two-fold: first, to examine the relationship between pain and spasticity by evaluating the effects of AbobotulinumtoxinA/Dysport (BoNT), and second, to describe the symptoms and location of pain in CCP. The subjects were 22 CCP in at least moderate pain. They were evaluated for spasticity by the modified Ashworth and Tardieu scale and for pain by the r-FLACC and the pediatric pain profile. After one injection of BoNT, the subjects were re-evaluated. We found a significant reduction in pain, but no significant relationship between the reduction of pain and spasticity. We found no association between the dose of BoNT and pain or spasticity. Pain in the lower extremity was located primarily in the hip region. The effect of ultrasound-guided intermuscular injections of BoNT suggests that pain in CCP has an extra-articular component. We found that pain in CCP manifests as specific tell-tale signs and problems in daily living. In conclusion, we found no relationship between pain and spasticity. Signs and manifestations of pain are described in detail. Lower extremity (hip) pain seems to have a soft tissue/extra-articular component.

Presence and grade of undertreatment of pain in children with cerebral palsy.

OBJECTIVES: To investigate if chronic pain in children with cerebral palsy is undertreated with the current pharmacological/non-pharmacological interventions using a pain management index. METHODS: Parents of 120 children with cerebral palsy between the ages of 2-19 years from our region in Denmark answered a questionnaire about whether their child had everyday pain. When answering in pain, we inquired about pain status and pharmacological/non-pharmacological pain coping interventions. Everyday pain was viewed as chronic pain with acute exacerbations. Pain experienced was divided into worst pain (highest moments of pain intensity) and least pain (lowest moments of pain intensity). To describe and evaluate the effectiveness of pain interventions used, a pain management index was utilized. Everyday pain was assessed using a logistical regression by adjusting for age, sex, and gross motor function classification system level. RESULTS: 59/115 (0.51) of parents answering the questionnaire reported everyday pain. Of those, the median age was 10 years. For pain alleviation, massage was reported by parents as being used by 29/59 (0.49) children and paracetamol by 21/59 (0.36). Pain affected daily life in 44/59 (0.75). By our evaluation 44/59 (0.75) were inadequately treated for their pain. Our evaluation also revealed that 19/59 (0.32) of children in pain had inadequately treated pain combined with an undesirable intensity of least pain. CONCLUSIONS: Half of the children with cerebral palsy experienced chronic pain according to our pain questionnaire answered by parents. Among these children three-quarters were insufficiently treated for their pain. In the same group, one-third were impacted by pain felt at both its highest and lowest moments of intensity. Massage therapy and paracetamol were the most frequently utilized pain-alleviating interventions. In our cohort, pain was undertreated and likely underdiagnose (Protocol number H-17008823).

Regulation of XPC Binding Dynamics and Global Nucleotide Excision Repair by p63 and Vitamin D Receptor.

p63 and the vitamin D receptor (VDR) play important roles in epidermal development and differentiation, but their roles and relationship in the response to ultraviolet (UV) radiation are less clear. Using TERT-immortalized human keratinocytes expressing shRNA targeting p63 in concert with exogenously applied siRNA targeting VDR, we assessed p63 and VDR's separate and combined effect on nucleotide excision repair (NER) of UV-induced 6-4 photoproducts (6-4PP). Knockdown of p63 reduced VDR and XPC expression relative to nontargeting controls, while knockdown of VDR had no effect on p63 and XPC protein expression, though alone it modestly reduced XPC mRNA. Upon UV irradiation through filters with 3 µm pores to create spatially discrete spots of DNA damage, keratinocytes depleted of p63 or VDR exhibited slower removal of 6-4PP than control cells over the first 30 min. Costaining of control cells with antibodies to XPC revealed that XPC accumulated at DNA damage foci, peaking within 15 min and gradually fading over 90 min as NER proceeded. In either p63- or VDR-depleted keratinocytes, XPC overaccumulated at spots of DNA damage so that 50% more XPC was retained at 15 min and 100% more XPC was retained at 30 min than in control cells, suggesting dissociation of XPC after binding was also delayed. Concurrent knockdown of VDR and p63 resulted in similar impairment of 6-4PP repair and XPC overaccumulation but even slower release of XPC from DNA damage sites such that 200% more XPC was retained relative to controls at 30 min post-UV. These results suggest that VDR accounts for some of p63's effects in delaying 6-4PP repair associated with overaccumulation and slower dissociation of XPC, though p63's regulation of basal XPC expression appears to be VDR-independent. The results are consistent with a model where XPC dissociation is an important step during NER and that failure to do so may inhibit subsequent repair steps. This work further links two important regulators of epidermal growth and differentiation to the DNA repair response to UV.

Diagnostics, evaluation and treatment of flat feet in children.

Pes planovalgus (PV) in early childhood is a common physiological state, and usually resolves throughout childhood. Parental concern often leads to seeking medical advice. This review summarises the current knowledge of the different types of PV. Asymptomatic PV does not need treatment, but corrective footwear can be utilised for painful PV. Orthopaedic referral is needed if conservative treatment is not sufficient. It is important to distinguish between flexible and rigid PV, since rigid PV can be a sign of underlying pathologies and needs referral to orthopaedic surgeons. Further studies are needed to investigate for predictive factors to develop painful PV.

Vitamin D receptor cross-talk with p63 signaling promotes epidermal cell fate.

The vitamin D receptor with its ligand 1,25 dihydroxy vitamin D3 (1,25D3) regulates epidermal stem cell fate, such that VDR removal from Krt14 expressing keratinocytes delays re-epithelialization of epidermis after wound injury in mice. In this study we deleted Vdr from Lrig1 expressing stem cells in the isthmus of the hair follicle then used lineage tracing to evaluate the impact on re-epithelialization following injury. We showed that Vdr deletion from these cells prevents their migration to and regeneration of the interfollicular epidermis without impairing their ability to repopulate the sebaceous gland. To pursue the molecular basis for these effects of VDR, we performed genome wide transcriptional analysis of keratinocytes from Vdr cKO and control littermate mice. Ingenuity Pathway analysis (IPA) pointed us to the TP53 family including p63 as a partner with VDR, a transcriptional factor that is essential for proliferation and differentiation of epidermal keratinocytes. Epigenetic studies on epidermal keratinocytes derived from interfollicular epidermis showed that VDR is colocalized with p63 within the specific regulatory region of MED1 containing super-enhancers of epidermal fate driven transcription factor genes such as Fos and Jun. Gene ontology analysis further implicated that Vdr and p63 associated genomic regions regulate genes involving stem cell fate and epidermal differentiation. To demonstrate the functional interaction between VDR and p63, we evaluated the response to 1,25(OH)2D3 of keratinocytes lacking p63 and noted a reduction in epidermal cell fate determining transcription factors such as Fos, Jun. We conclude that VDR is required for the epidermal stem cell fate orientation towards interfollicular epidermis. We propose that this role of VDR involves cross-talk with the epidermal master regulator p63 through super-enhancer mediated epigenetic dynamics.

Protocol Article: A Cross-Sectional Evaluation of Children's Feet and Lower Extremities.

BACKGROUND: The health of children's lower extremities and feet is a focus area for caregivers and healthcare professionals such as doctors, school nurses, and podiatrists. Our study aims to investigate the general health status of Danish children's lower extremities and feet to identify anthropometric parameters that might be preconditions for pain and evaluate for foot diseases and whether they are associated with pain intensity and location, three-dimensional foot dimensions and foot pressure mapping, shoe dimensions, types and intensity of sports activity, quality of life, and foot health. The aim is that we will be able to identify parameters pre-dispositioning for pain, thus providing recommendations for sports activities in relation to the anthropometric conditions of a child as a potential preventive measure for pain. This analysis will be stratified by socioeconomic status on a group level, and this perspective will be able to provide preventative recommendations to prevent pain. METHODS: This study is a cross-sectional examination of a thousand children in the first, fifth, and ninth grades in randomized selected Danish primary schools. We will perform a clinical examination of the lower extremities and feet for misalignments, deformities, and diseases as well as rotational status and range of motion. Moreover, we will evaluate their pain levels, sports activities, three-dimensional foot dimensions, plantar pressure, footwear, and patient-related outcome measures (PROMs) for foot health and quality of life. RESULTS: We aim to provide an anthropometrical overview of the lower extremities and feet in children. The obtained basic understanding of healthy normal material in children will be analyzed for its relationships with pain level, sports activities, and socioeconomic status on a group level. This could potentially provide us with an understanding of the factors that impact lower extremity and foot diseases in children. In conclusion, examining children's lower extremities and feet in Danish primary schools is a step toward identifying areas of improvement in self-care and shoe fitting, mapping podiatry-related needs of care in children's feet, and providing parental recommendations for preventive actions on shoe fitting and the choice and intensity of sports activity concerning pain. CONCLUSIONS: The tenet of this study is a long-term follow-up to evaluate the long-term socioeconomic course on a group level, foot status, and sports activity, using patient-related outcome measures evaluating quality of life and other lifestyle factors such as emotional functioning, social functioning and interaction, and school functioning. Potentially, this will improve children's quality of life and prevent future diseases.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Chinese American Patients.

The Chinese American population is one of the fastest-growing communities in the United States, composed of ∼5.4 million people, and represents ∼5.5% of overseas Chinese populations. With an expected exponential population rise, Chinese American patients who experience serious illness or approach end-of-life (EOL) may find their cultural values influencing the medical care they receive. Palliative care clinicians must recognize diverse cultural beliefs and preferences of Chinese American patients and their families. In this study, we provide 10 cultural pearls to guide the provision of palliative and EOL care for Chinese American patients, including discussions of Chinese traditions, communication strategies for Chinese patients and families, advance care planning, and EOL care beliefs.

Biomechanical performance of a novel light-curable bone fixation technique.

Traumatic bone fractures are often debilitating injuries that may require surgical fixation to ensure sufficient healing. Currently, the most frequently used osteosynthesis materials are metal-based; however, in certain cases, such as complex comminuted osteoporotic fractures, they may not provide the best solution due to their rigid and non-customizable nature. In phalanx fractures in particular, metal plates have been shown to induce joint stiffness and soft tissue adhesions. A new osteosynthesis method using a light curable polymer composite has been developed. This method has demonstrated itself to be a versatile solution that can be shaped by surgeons in situ and has been shown to induce no soft tissue adhesions. In this study, the biomechanical performance of AdhFix was compared to conventional metal plates. The osteosyntheses were tested in seven different groups with varying loading modality (bending and torsion), osteotomy gap size, and fixation type and size in a sheep phalanx model. AdhFix demonstrated statistically higher stiffnesses in torsion (64.64 ± 9.27 and 114.08 ± 20.98 Nmm/° vs. 33.88 ± 3.10 Nmm/°) and in reduced fractures in bending (13.70 ± 2.75 Nm/mm vs. 8.69 ± 1.16 Nmm/°), while the metal plates were stiffer in unreduced fractures (7.44 ± 1.75 Nm/mm vs. 2.70 ± 0.72 Nmm/°). The metal plates withstood equivalent or significantly higher torques in torsion (534.28 ± 25.74 Nmm vs. 614.10 ± 118.44 and 414.82 ± 70.98 Nmm) and significantly higher bending moments (19.51 ± 2.24 and 22.72 ± 2.68 Nm vs. 5.38 ± 0.73 and 1.22 ± 0.30 Nm). This study illustrated that the AdhFix platform is a viable, customizable solution that is comparable to the mechanical properties of traditional metal plates within the range of physiological loading values reported in literature.

Does the use of polymethyl-methacrylate cement after intralesional curettage of giant cell tumors of appendicular bone guarantee reduced local recurrence rates? A retrospective analysis.

PURPOSE: Polymethyl-methacrylate cement (PMMA) is often used as bone defect reconstruction material after surgical removal of giant cell tumors. The purpose of this study was to investigate if the application of PMMA improves the local recurrence rates for giant cell tumors (GCT) of appendicular bone treated with intralesional curettage. METHODS: A retrospective analysis of all appendicular GTCs treated at two major Danish sarcoma centres between the 1st of January 1998 and December 31st 2013; minimum follow-up of 3.0 years (median: 8.9; 1.3-18.7 years). Kaplan-Meier survival model, log-rank and multivariate Cox regression were used to calculate and compare local recurrence rates. p-values <0.05 were considered statistically significant. RESULTS: 102 patients (M59/F43), median age 31Y (11-84) were included in this study. The overall 3-years local recurrence-rate was 19.9% (95%CI: 11.9-27.9%); 91% had occurred within 3 years. In patients treated with intralesional curettage (n = 64), the 3-years recurrence-rate was 30.6% (95%CI: 18.8-42.4%), compared to 2.6% (95%CI: 0.0-7.8%) in patients treated with wide resection or amputation (n = 38), p < .001. The 3-years recurrence-rate for patients treated with intralesional curettage and reconstruction using PMMA was 29.0% (95%CI: 12.6-45.4%) and without PMMA: 31.8% (95%CI: 15.2-48.4%), p = .83. CONCLUSION: We found that the use of PMMA for bone defect reconstruction after intralesional curettage of GTCs in the appendicular skeleton did not ensure a reduced risk of local recurrence.

Biomechanical Variability and Usability of a Novel Customizable Fracture Fixation Technique.

A novel in situ customizable osteosynthesis technique, Bonevolent™ AdhFix, demonstrates promising biomechanical properties under the expertise of a single trained operator. This study assesses inter- and intra-surgeon biomechanical variability and usability of the AdhFix osteosynthesis platform. Six surgeons conducted ten osteosyntheses on a synthetic bone fracture model after reviewing an instruction manual and completing one supervised osteosynthesis. Samples underwent 4-point bending tests at a quasi-static loading rate, and the maximum bending moment (BM), bending stiffness (BS), and AdhFix cross-sectional area (CSA: mm²) were evaluated. All constructs exhibited a consistent appearance and were suitable for biomechanical testing. The mean BM was 2.64 ± 0.57 Nm, and the mean BS was 4.35 ± 0.44 Nm/mm. Statistically significant differences were observed among the six surgeons in BM (p < 0.001) and BS (p = 0.004). Throughout ten trials, only one surgeon demonstrated a significant improvement in BM (p < 0.025), and another showed a significant improvement in BS (p < 0.01). A larger CSA corresponded to a statistically significantly higher value for BM (p < 0.001) but not for BS (p = 0.594). In conclusion, this study found consistent biomechanical stability both across and within the surgeons included, suggesting that the AdhFix osteosynthesis platform can be learned and applied with minimal training and, therefore, might be a clinically viable fracture fixation technique. The variability in BM and BS observed is not expected to have a clinical impact, but future clinical studies are warranted.

Evaluation of Brace Treatment Using the Soft Brace Spinaposture: A Four-Years Follow-Up.

The braces of today are constructed to correct the frontal plane deformity of idiopathic adolescent scoliosis (AIS). The Spinaposture brace© (Spinaposture Aps, Copenhagen, Denmark) is a soft-fabric brace for AIS and is designed to enhance rotational axial stability by inducing a sagittal plane kyphotic correction. This prospective observational study evaluated the brace in fifteen patients with AIS. The initial average CA was 16.8° (SD: 2.8). They were followed prospectively every 3 to 6 months during their brace usage until skeletal maturity of 25 months and at long-term follow-up of 44 months. In- and out-of-brace radiographs were performed in six subjects at inclusion. This resulted in an immediate in-brace correction of 25.3 percent in CA (14.3°â†’10.8°) and induced a kyphotic effect of 14.9 percent (40.8°â†’47.9°). The average in-brace improvement at first follow-up was 4.5° in CA, and the CA at skeletal maturity was 11° (SD: 7.4°) and long-term 12.0° (SD: 6.8°). In conclusion, the Spinaposture brace© had an immediate in-brace deformity correction and a thoracic kyphotic effect. At skeletal maturity, the deformities improved more than expected when compared to that of the natural history/observation and similar to that of other soft braces. No long-term deformity progression was seen. To substantiate these findings, stronger designed studies with additional subjects are needed.

Testing a new method of osteosynthesis of forearm fractures in children; a prospective randomized controlled longitudinal study.

Purpose: Displaced children's forearms fractures are commonly treated surgically with Kirschner Wires or Elastic Stable Intramedullary Nails. The osteosynthesis system "Minimally Invasive Reduction and Osteosynthesis System" might be beneficial in the treatment of these fractures due to being minimally invasive while achieving fracture stability. In this exploratory prospective randomized controlled longitudinal study, we compared Minimally Invasive Reduction and Osteosynthesis System to Kirschner Wires and Elastic Stable Intramedullary Nails osteosynthesis. Methods: Twenty children were included consecutively to treatment with either conventional surgery (5 Kirschner Wires/5 Elastic Stable Intramedullary Nails) or Minimally Invasive Reduction and Osteosynthesis System (10). Evaluation of radiographic alignment and clinically of range of motion, pain status, grip strength, level of physical activity and scar size were compared after 3 months and after 5 years. Results: Surgical parameters of the duration of insertion- and removal-surgery, the need for postoperative casting and scar size were significantly better for Minimally Invasive Reduction and Osteosynthesis System. All osteosynthesis systems maintained radiographically fracture alignment at three months and 5 years follow-up. Clinical status regarding pain, grip strength difference, and return to recreational activities were not significantly different. The complication rates were nonsignificant, but MIROS had moderate severe complications of refractures, while mild complications occurred when operated on with Kirschner Wires/Elastic Stable Intramedullary Nails. Our study was sufficiently powered at 3 months, but the comparisons are suggestive at 5 years. Conclusion: In conclusion, Minimally Invasive Reduction and Osteosynthesis System is not significantly different to other surgical methods in radiological outcomes for forearm fractures in children. Minimally Invasive Reduction and Osteosynthesis System has the clinical benefit of omitting casting after surgery, obtaining reduced scar size, and shorter insertion and removal time without general anesthesia. However, moderately severe complications occurred. Level of evidence: Level II-a prospective comparative study.