Reduced Number of Pediatric Orthopedic Trauma Requiring Operative Treatment during COVID-19 Restrictions: A Nationwide Cohort Study.

BACKGROUND AND AIMS: The coronavirus outbreak significantly changed the need of healthcare services. We hypothesized that the COVID-19 pandemic decreased the frequency of pediatric fracture operations. We also hypothesized that the frequency of emergency pediatric surgical operations decreased as well, as a result of patient-related reasons, such as neglecting or underestimating the symptoms, to avoid hospital admission. MATERIALS AND METHODS: Nationwide data were individually collected and analyzed in all five tertiary pediatric surgical/trauma centers in Finland. Operations related to fractures, appendicitis, and acute scrotum in children aged above 16 years between March 1 and May 31 from 2017 to 2020 were identified. The monthly frequencies of operations and type of traumas were compared between prepandemic 3 years and 2020. RESULTS: Altogether, 1755 patients were identified in five tertiary hospitals who had an emergency operation during the investigation period. There was a significant decrease (31%, p = 0.03) in trauma operations. It was mostly due to reduction in lower limb trauma operations (32%, p = 0.006). Daycare, school, and organized sports-related injuries decreased significantly during the pandemic. These reductions were observed in March and in April. The frequencies of appendectomies and scrotal explorations remained constant. CONCLUSION: According to the postulation, a great decrease in the need of trauma operations was observed during the peak of COVID-19 pandemic. In the future, in case similar public restrictions are ordered, the spared resources could be deployed to other clinical areas. However, the need of pediatric surgical emergencies held stable during the COVID-19 restrictions.

Treatment of Distal Forearm Fractures in Children.

BACKGROUND AND AIMS: Distal forearm is the most common fracture location in the growing skeleton. The aim of this article is to describe the current practice of these fractures. MATERIALS AND METHODS: Case series accompanied by experts' opinion. RESULTS AND CONCLUSION: Most of these injuries are benign incomplete distal metaphyseal torus fractures best treated with a dorsal below elbow splint for 2-3 weeks with no follow-up. Completely displaced metaphyseal fractures in prepubertal children can be either immobilized in bayonet position after axial alignment or fixed with K-wires after reduction. Complete fractures of distal metaphysis in adolescents should heal in near anatomic alignment because remodeling is uncertain. We advocate reduction of most greenstick and complete fractures at the distal metaphyseal diaphyseal junction and radiographic follow-up to monitor fracture alignment. Physeal fractures in adolescents and intra-articular fractures in children of all ages should be anatomically reduced. We perform most of our osteosyntheses with K-wires.

Hospital Care and Surgical Treatment of Children With Congenital Upper Limb Defects.

BACKGROUND AND AIMS: To evaluate hospital care of children with congenital upper limb defects. MATERIALS AND METHODS: Three hundred and sixty-two children with an upper limb defect, born 1993-2005, and alive after birth admission were identified in the Finnish Register of Congenital Malformations. The data on hospital care, with focus on operative treatment, were collected from the National Hospital Discharge Register, until 31 December 2009. Mean follow-up was 10.2 years (range: 4-17 years). The results were compared with data on the whole children population (1.1 million) in Finland. RESULTS: Most children (321, 87%) with upper limb defects had hospital admissions: on average, one admission/year (range: 0-36), and they were treated in hospital 5 days/year (range: 0-150), which is 11-fold compared with an average child in Finland. Four surgical procedures/child were done (range: 0-45), including one hand surgical procedure. The most common procedures were orthopedic (513); gastrointestinal (263); ear, nose, and throat (143); dental (118); thoracic (48); and urologic (44). Of the 513 orthopedic procedures, 326 were directed to upper limbs, 107 to the lower limbs, and 10 to the spine. Median operation age was 2 years 7 months. Altogether, 60% of hospital admissions were non-surgical. Leading causes of non-operative hospital admissions were congenital anomalies (32%), gastroenterological problems (20%), respiratory tract conditions (13%), neurological problems (7%), perinatal conditions (5%), and infectious diseases (5%). CONCLUSION: Treatment of children with upper limb defects is teamwork between pediatric and surgical subspecialties. Burden of hospital care is 11-fold as compared with an average child.

Hospital admissions and surgical treatment of children with lower-limb deficiency in Finland.

BACKGROUND AND AIMS: There are no population-based studies about hospital admissions and need for surgical treatment of congenital lower-limb deficiencies. The aim is to assess the impact children with lower-limb deficiencies pose to national hospital level health-care system. MATERIALS AND METHODS: A population-based study was conducted using the national Register of Congenital Malformations and Care Register for Health Care. All 185 live births with lower-limb deficiency (1993-2008) were included. Data on hospital care were collected until 31 December 2009 and compared to data on the whole pediatric population (0.9 million) live born in 1993-2008. RESULTS: The whole pediatric population had annually on average 0.10 hospital admissions and the mean length of in-patient care of 0.3 days per child. The respective figures were 1.5 and 5.6 in terminal lower-limb amputations (n = 7), 1.1 and 3.9 in long-bone deficiencies (n = 53), 0.6 and 1.9 in foot deficiencies (n = 26) and 0.4 and 2.6 in toe deficiencies (n = 101). Orthopedic surgery was performed in 72% (5/7) of patients with terminal amputations, in 62% (33/53) of patients with long bone, in 58% (14/24) of patients with foot and in 25% (25/101) of patients in toe deficiencies. Half (54%) of all procedures were orthopedic operations. CONCLUSION: In congenital lower-limb deficiencies the need of hospital care and the number of orthopedic procedures is multiple-fold compared to whole pediatric population. The burden to the patient and to the families is markedly increased, especially in children with terminal amputations and long-bone deficiencies of lower limbs.

One in Three of Pediatric Tibia Shaft Fractures is Currently Treated Operatively: A 6-Year Epidemiological Study in two University Hospitals in Finland Treatment of Pediatric Tibia Shaft Fractures.

BACKGROUND: Internal fixation of pediatric tibia shaft fractures has become increasingly popular despite the fact that non-operative treatment results in satisfactory outcome with few exceptions. Indications for surgery and benefits of internal fixation are however still debatable. MATERIALS AND METHODS: All 296 less than 16-year-old patients treated for a tibia shaft fracture between 2010 and 2015 in two of the five university hospitals in Finland were included in the study. Patient data were analyzed in three treatment groups: cast immobilization in emergency department, manipulation under anesthesia, and operative treatment. Incidence of operative treatment of pediatric tibia shaft fractures was calculated in the cities of Helsinki and Kuopio. RESULTS: A total of 143 (47.3%) children's tibia shaft fractures were treated with casting in emergency department, 71 (22.3%) with manipulation under anesthesia, and 82 (30.4%) with surgery. Mean age of the patients in these treatment groups was 6.2, 8.7, and 12.7 years. Fibula was intact in 89%, 51%, and 27% of the patients, respectively. All 6 patients with multiple fractures and 16 of 18 patients with open fractures were treated operatively. In eight patients, primary non-operative treatment was converted to internal fixation. Operatively treated patients with isolated closed fractures were more likely to have a fibula fracture (46/66 vs 52/214, p < 0.001), be older in age (13.08 ± 2.4 vs 6.4 ± 3.7, p < 0.001), and have more primary angulation (6.9 ± 5.8 vs 0.48 ± 3.1, p < 0.001). Re-operations were done to eight and corrective osteotomy to two operatively treated children. CONCLUSION: Operative treatment of a pediatric tibia shaft fracture is currently nearly a rule in patients with open or multiple fractures. Surgical treatment of closed tibia shaft fractures is based on surgeon's personal preference, type of fracture and age of the patient.

Treatment of Aneurysmal Bone Cysts with Bioactive Glass in Children.

BACKGROUND AND AIMS: Aneurysmal bone cysts represent about 1% of primary bone tumors. The standard treatment is curettage, followed by local adjuvant treatments and bone grafting. The problem is the high recurrence rate. The purpose of this study was to evaluate retrospectively the use of bioactive glass as a filling material in the treatment of aneurysmatic bone cysts in children. MATERIAL AND METHODS: A total of 18 consecutive children (mean 11.3 years at surgery; 10 males; 11 lower, 6 upper limb, 1 pelvis; 15 with primary surgery) with histologically proven primary aneurysmal bone cysts operated with curettage and bioactive glass filling between 2008 and 2013 were evaluated after a mean follow-up of 2.0 years (range, 0.7-5.1 years). RESULTS: Two (11%) patients showed evidence of aneurysmal bone cyst recurrence and both have been re-operated for recurrence. Bone remodeling was noted in all patients with remaining growth and no growth plate disturbances were recorded. Two patients needed allogeneic blood transfusion. No intraoperative or postoperative complications were recorded. CONCLUSION: We conclude that bioactive glass is a suitable filling material for children with primary aneurysmal bone cyst. Bioactive glass did not affect bone growth and no side effects were reported.

The function of the hand after operations for obstetric injuries to the brachial plexus.

Hand function was evaluated in 105 patients who had been operated on in early infancy for brachial plexus birth palsy. The mean follow-up after surgery was for 13.4 years (5.0 to 31.5). Fine sensation, stereognosis, grip and pinch strength and the Raimondi scale were recorded. Fine sensation was normal in 34 of 49 patients (69%) with C5-6 injury, 15 of 31 (48%) with C5-7 and in 8 of 25 (32%) with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand in 12 of 105 patients (11%). Normal stereognosis was recorded in 88 of the 105 patients (84%), whereas only 9 of the 105 (9%) had normal grip strength. The mean Raimondi scale scores were 4.57 (3 to 5) (C5-6), 4.26 (1 to 5) (C5-7) and 2.16 (0 to 5) in patients with total injury. The location of impaired sensation was related to the distribution of the root injury. Avulsion type of injury correlated with poor recovery of hand function.

Microvascular temporomandibular joint and mandibular ramus reconstruction in hemifacial microsomia.

Microvascular temporomandibular joint (TMJ) and mandibular ramus reconstruction was performed in a 4-year-old hemifacial microsomia patient with multiple craniofacial and extracranial anomalies (Goldenhar syndrome). Her major craniofacial anomalies included bilateral cleft lip and palate, left macrostomia, left microtia, and complete absence of the left vertical mandibular ramus and TMJ. Most of her other anomalies had been corrected surgically before TMJ and vertical mandibular ramus reconstruction, which was accomplished with a metatarsophalangeal (MTP) joint transplantation. The MTP joint was placed in hyperextended position in the skull base inserting the proximal phalanx under the remnants of the zygomatic arch and replacing the vertical mandibular ramus with the metatarsal bone. Straight mouth opening, correction of the midline, and normalized lateral movements of the mandible were accomplished. The graft includes two epiphyseal plates, which should maintain growth of the transplant. During the follow-up period (16 months) the achieved results have been maintained without adverse effects. The present technique appears to be a promising alternative in the treatment of children with Pruzansky type 3 hemifacial microsomia.

Increased interleukin-8 (IL-8) expression is related to aseptic loosening of total hip replacement.

Aseptic loosening is an increasing problem in total hip replacement (THR). Chronic inflammatory reaction against implant wear particle results in collageno- and osteolysis, leading to loosening of the implant. Cytokines are known to play a major role in this particular inflammatory process. The aim of the present study was to examine interleukin-8 (IL-8) in the synovial-like interface membrane (SLIM) and pseudocapsular tissue of THRs and to compare it to normal knee synovial membrane. Eleven patients suffering from aseptically loosened THRs were included. All the SLIM and pseudocapsular tissue samples were obtained during revision operations. Ten control samples of normal synovium were collected per arthroscopy from the superior recessus of the knee. For immunohistochemical IL-8 detection, polyclonal mouse anti-human immunoglobulin (Ig)G1 IL-8-primary antibody was used with the alkaline phosphatase anti-alkaline phosphatase (APAAP) method. Results were quantitated using the Vidas image analysis system. The highest count levels (mean +/- SEM) were detected in SLIM tissue (386+/-82 cells/mm2). The difference was statistically significant compared with pseudocapsular tissue (193+/-36 cells/mm2) and control samples (18+/-5 cells/mm2). Count levels in control tissue were on average 5% of the SLIM tissues values. The present study determines for the first time the cellular origin of IL-8 in aseptically loosened THRs and also quantitates the IL-8-producing cells in the periprosthetic tissue. The results reveal a high rise in IL-8 concentration in SLIM and in synovial tissues. This finding moves us one step forward in solving the complex network of multiple factors affecting loosening of hip implants.

Operative versus closed treatment of primary dislocation of the patella. Similar 2-year results in 125 randomized patients.

To assess whether initial surgery is beneficial for patients with primary dislocation of the patella, we carried out a prospective randomized study. Knee stability was examined under anesthesia, and associated injuries were excluded by diagnostic arthroscopy. 55 patients then had closed treatment and 70 patients were operated on with individually adjusted proximal realignment procedures. Surgery gave no benefit based on 2 years of follow-up. The subjective result was better in the non-operative group in respect of mean Houghston VAS knee score (closed 90, operative 87), but similar in terms of the patient's own overall opinion and mean Lysholm II knee score. Recurrent instability episodes (redislocation or recurrent subluxation) occurred in 20 nonoperated and in 18 operated patients. Of these, 15 and 12, respectively, then suffered redislocations. Function was better after closed treatment. Serious complications occurred after surgery in 4 patients. In conclusion, the recurrence of patellar dislocation may be more frequent than reported, whatever the form of treatment. Routine operative management cannot be recommended for primary dislocation of the patella.

The cartilaginous femoral sulcus in children with patellar dislocation: an ultrasonographic study.

One hundred and sixteen knees of 33 patients with patellar dislocation and 25 normal children 12-18 years of age were examined by ultrasonography to measure the cartilaginous sulcus angle on the patellar surface of the femur. In knees with patellar dislocation, the cartilaginous sulcus angle measured between 154 and 195 degrees, exceeding the corresponding values of normal knees (134-153 degrees). In patient knees, the cartilaginous sulcus was also consistently wider than the underlying osseous sulcus. This suggests that in pediatric patients with patellar dislocation, the actual patella-stabilizing ability of the femoral sulcus is weaker than the osseous outline in axial radiographs would lead one to suppose. It would appear also that by measuring the cartilaginous sulcus angle of the femur, a clear distinction can be made between normal knee joints and joints displaying patellar instability.

The femoral sulcus in children. An ultrasonographic study.

Both knees of 50 normal children aged from birth to 18 years were examined by ultrasonography to measure the angles of the bony intercondylar and the cartilaginous sulcus on the patellar surface of the femur. The osseous angle was inversely related to the age of the child and was completely flat in the youngest children. During growth it gradually gained depth to assume the shape of the overlying articular cartilage by adolescence. At all ages, however, the angle of the cartilaginous sulcus was between 134 degrees and 155 degrees. This suggests that the configuration of the patellar articulation is already well developed at birth.

Acute patellar dislocation in children: incidence and associated osteochondral fractures.

In a prospective two-year study on urban (city of Helsinki) Finnish children, 72 acute patellar dislocations were observed. The calculated annual incidence rate was 43/100,000 in children under 16 years. A total of 28 knees (39%) had associated osteochondral fractures. These fractures comprised 15 capsular avulsions of the medial patellar margin and 15 loose intra-articular fragments detached from the patella and/or lateral femoral condyle. The intra-articular fragments were found only after spontaneous relocation of the patella. The femoral fracture constantly involved the edge of the articular surface in the middle third of the condylar arc.

Cultured rat kidney parenchymal components are damaged by cytotoxic lymphocytes produced in MLC.

Donor-specific cytotoxic lymphocytes (CTL) can be recovered from rejecting allografts both in animal models and in humans. These allograft infiltrating CTL expressing specific cytotoxicity to relevant MHC-restricted target cells in vitro most likely constitute the major effector arm during rejection. Effector cells with similar phenotype, specificity and function can be produced in mixed lymphocyte cultures (MLC). Despite the pivotal importance of CTL in allograft rejection, there is limited information about the susceptibility of different parenchymal graft cells to CTL-mediated damage. We used cultured rat glomerular epithelial cells (GEPC), glomerular mesangial cells (GMC), tubular cells (TC) and heart endothelial cells (HEC) as distinct parenchymal target components in 4 h Chromium release assays. All of these graft components were damaged by CTL produced in 6-day MLC (specific release: 10-25%). Three-day gamma-interferon (IFN-G) treatment enhanced MHC class I and II surface expression on all our targets and increased their susceptibility for CTL-mediated lysis in our experiments (specific release: 20-60%).

Lymphokine-activated killer (LAK) activity to cultured rat kidney parenchymal components in vitro.

The susceptibility of cultured rat kidney parenchymal components to natural killer (NK) cell and lymphokine-activated killer (LAK) cell-mediated lysis in a 4-h in vitro 51chromium assay was investigated. Large granular lymphocytes (LGL) in the spleen and in the kidney allograft were able to lyse YAC cells during rejection, but they did not damage target endothelial, glomerular mesangial, glomerular epithelial, or tubular cells in resting state. Stimulation of the target cells with gamma-interferon - known to induce MHC (class II) antigens on the target cell surface - did not make the target cells susceptible to NK-mediated lysis. LAK cells generated by a 3-day incubation with interleukin-2 (IL-2) effectively lysed both YAC and P815 target cell lines. LAK cells were also slightly cytotoxic to all tested parenchymal target components in resting state. Gamma-interferon treatment of the cultured parenchymal cells prior to the chromium release assay, however, reduced LAK-mediated parenchymal cell cytotoxicity to nearly nondetectable levels. Obviously, many lymphokines, including IL-2 and gamma-interferon, are produced during rejection at the site of inflammation. This might induce the generation of LAK cells in situ as the lymphokines induce the production of MHC antigens in the graft. We interpret these findings as indicating that regardless of the generation of LAK, the protective effect of gamma-interferon neutralizes the LAK effect, and we suggest that neither LGL nor LAK cells play any essential role in rat kidney allograft rejection.

Antigen expression in different parenchymal cell types of rat kidney and heart.

Rat glomerular epithelial, and mesangial and tubular cells were isolated by steel meshes of different pore sizes and enzymatic treatment. Rat heart endothelial cells were isolated by enzymatic disaggregation. Endothelial, glomerular mesangial, glomerular epithelial and tubular cells were cultured in Minimum essential medium until they reached confluency (5 to 9 days). These different rat parenchymal cell types were characterized by morphology and antibody stainings. Endothelial cells were characterized by factor VIII positivity and mesangial cells were desmin positive. Both glomerular epithelial and tubular cells expressed the brush border and Tamm-Horsfall antigens, but in vivo injected trypan blue accumulated selectively to proximal tubular cells. Class I expression was high (84 to 95% of about 10(5) cells grown in Lab-Tek culture chambers were reactive with anti-class I antibody) in unstimulated endothelial, glomerular epithelial and tubular cells and was even higher (100%) after incubation with gamma-interferon for three days. Mesangial cells expressed class I considerably less in normal state (34%), but gamma-interferon induction upregulated it to 95%. Both the surface and intracytoplasmic expression of class I antigens were upregulated with three-day gamma-interferon treatment. Class II expression was low in all unstimulated cells (5 to 10%). The three-day gamma-interferon treatment upregulated both surface as well as cytoplasmic expression of class II antigens in all cell types.