Radiographic Outcomes of Immobilization using Boston Brace for Pediatric Spondylolysis.

BACKGROUND AND AIMS: Spondylolysis is a common cause of lower back pain during youth. The aim of this study is to report the bony union rate and risk factors for non-union of the lumbar spondylolysis of pediatric patients treated with a rigid thoracolumbosacral orthosis (Boston brace). MATERIALS AND METHODS: A retrospective review of 68 children (mean age = 13.9 years) treated for spondylolysis with a thoracolumbosacral orthosis. Patient charts and imaging studies were evaluated to identify the bony union rate of the spondylolysis after a minimum of 3 months of immobilization (mean = 4.2 months). Laterality, grade, level, and presence of high signal intensity in the magnetic resonance imaging were evaluated as prognostic factors. RESULTS: Sixty-eight patients presented with 110 defects. Of them, 46 (42%) were incomplete fractures, 38 (35%) complete fractures, and 26 (24%) pseudoarthrosis. Of these defects, 38 (82.6%), 11 (28.9%), and 0 (0.0%) had bony union at the end of the treatment (p < 0.001). Unilateral defects healed significantly better than bilateral ones (relative risk = 1.71, 95% confidence interval = 1.16-2.54, 17/26 (65%) vs 32/84 (38%), p = 0.014). High signal intensity in the magnetic resonance images before the treatment predicted healing (relative risk = 13.24, 95% confidence interval = 1.93-91.01, 48/87 (55%) vs 1/24 (4.3%), p < 0.001). The level of the spondylolysis (L5 vs above L5) did not affect the healing rate. CONCLUSION: The union rates of spondylolysis with a thoracolumbosacral orthosis were similar as compared to earlier studies done with a low thoracolumbosacral orthosis. The grade of the defect, laterality, and presence of high signal intensity increased the probability of bony union. A high thoracolumbosacral orthosis (underarm) does not seem to improve the healing rate of pediatric spondylolysis defects.

Posterior Spinal Fusion Extended to Stable Vertebra Provides Similar Outcome in Juvenile Idiopathic Scoliosis Patients Compared with Adolescents with Fusion to the Touched Vertebra.

BACKGROUND AND AIMS:: To compare outcomes between posterior spinal fusion of juvenile idiopathic scoliosis and adolescent idiopathic scoliosis patients with a minimum of 2-year follow-up. The juvenile idiopathic scoliosis patients were fused to the stable vertebra and adolescent idiopathic scoliosis to the touched vertebra. We hypothesized that extending the spinal fusion to the stable vertebra in juvenile patients would provide similar outcomes compared with fusion to the touched vertebra in adolescents. MATERIALS AND METHODS:: A prospective comparative study of 21 consecutive children with juvenile (Risser 0) and 84 adolescent (Risser ⩾2) idiopathic scoliosis (1:4 ratio) undergoing bilateral segmental pedicle screw instrumentation and direct vertebral derotation with a minimum of 2-year follow-up. RESULTS:: Juvenile patients had a significantly larger main curve (58° vs 53°, p = 0.003), more fused levels (p = 0.012) and posterior column osteotomies (p = 0.014) than adolescent patients. Distal adding-on (>10°) was observed in one (4.7%) juvenile and three (3.6%) adolescent patients (p = 0.80), without the need for revisions. Scoliosis Research Society 24 total score averaged 101 in juvenile and 97 in adolescent group at 2-year follow-up (p = 0.047). CONCLUSION:: Posterior spinal fusion with bilateral segmental pedicle screw instrumentation to the stable vertebra provides similar clinical and radiographic outcomes in juvenile patients as compared with adolescents with fusion to the touched vertebra in idiopathic scoliosis. Health-related quality of life as measured using the Scoliosis Research Society 24 questionnaire at the end of follow-up was better in the juvenile as compared with the adolescent group.

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.

Gelatine matrix with human thrombin decreases blood loss in adolescents undergoing posterior spinal fusion for idiopathic scoliosis: a multicentre, randomised clinical trial.

AIMS: In a multicentre, randomised study of adolescents undergoing posterior spinal fusion for idiopathic scoliosis, we investigated the effect of adding gelatine matrix with human thrombin to the standard surgical methods of controlling blood loss. PATIENTS AND METHODS: Patients in the intervention group (n = 30) were randomised to receive a minimum of two and a maximum of four units of gelatine matrix with thrombin in addition to conventional surgical methods of achieving haemostasis. Only conventional surgical methods were used in the control group (n = 30). We measured the intra-operative and total blood loss (intra-operative blood loss plus post-operative drain output). RESULTS: Each additional hour of operating time increased the intra-operative blood loss by 356.9 ml (p < 0.001) and the total blood loss by 430.5 ml (p < 0.001). Multiple linear regression analysis showed that the intervention significantly decreased the intra-operative (-171 ml, p = 0.025) and total blood loss (-177 ml, p = 0.027). The decrease in haemoglobin concentration from the day before the operation to the second post-operative day was significantly smaller in the intervention group (-6 g/l, p = 0.013) than in the control group. CONCLUSION: The addition of gelatine matrix with human thrombin to conventional methods of achieving haemostasis reduces both the intra-operative blood loss and the decrease in haemoglobin concentration post-operatively in adolescents undergoing posterior spinal fusion for idiopathic scoliosis. TAKE HOME MESSAGE: A randomised clinical trial showed that gelatine matrix with human thrombin decreases intra-operative blood loss by 30% when added to traditional surgical haemostatic methods in adolescents undergoing posterior spinal fusion for idiopathic scoliosis.

Pitfalls of femoral titanium elastic nailing.

BACKGROUND AND AIMS: Despite several potential complications of elastic intramedullary nailing, it is currently the treatment of choice for femoral diaphyseal fractures in school-aged children. This study aimed to critically evaluate the complications of titanium elastic nailing in pediatric femoral shaft fractures. MATERIAL AND METHODS: This study evaluated patients with a diaphyseal femoral fracture treated with titanium elastic nailing (TEN) in Tampere University Hospital in Finland. The study group included 32 children with a mean age of 9 years during a 5-year period, from 1 January 2003 to 31 December 2007. Data were collected from medical records and x-rays. Mean follow-up time was 42 months. RESULTS: Of 32 patients, 9 (28%) reported a postoperative complication. Complications were associated with nail prominence in five (16%) patients and instability in four (12%) patients. In patients with nail prominence, the titanium elastic nailing-nail ends were unbent and 10-35 mm outside the cortex of the distal femur. The nail prominence caused pain and delayed knee mobilization until the nail was removed after a mean time of 4 months. In patients with fracture instability, the mean titanium elastic nailing-nail/medullary canal diameter ratio was 46% and periosteal callus formation was 5.4 mm at the first control. In those with stable fractures, the values were 66% and 9.2 mm, respectively. CONCLUSIONS: Based on this study, two types of pitfalls in a small volume center were found. Titanium elastic nail ends were left unbent and too long. We recommend palpating the nail ends to exclude nail prominence and to verify free movement of the knee after nail cutting and bending. Fracture instability was caused by inserting titanium elastic nailing-nails that were too narrow. To avoid this complication, careful preoperative planning to select the proper-size titanium elastic nailing-nails and intraoperative testing of fracture stability under continuous fluoroscopy after the operation is advised.

Stable incidence of surgical treatment and hospitalisation for humeral shaft fractures among 0- to 16-year-old patients in Finland from 1987 to 2010.

BACKGROUND: Studies among children experiencing fractures report an increasing trend toward operative management. In the present study, we examined whether the same trend has occurred for humeral shaft fractures in accordance with increasing interest toward intramedullary nailing and other operative treatments. The number, incidence and treatment of all hospitalised 0- to 16-year-old patients with humeral shaft fractures in Finland was assessed over a recent 24-year period. METHOD: The study included the entire adolescent (0-16 years) population in Finland during the 24-year period from January 1, 1987, to December 31, 2010. Data on hospitalised patients who sustained humeral shaft fractures were obtained from the nationwide National Hospital Discharge Register (NHDR) of Finland. RESULTS: During the study period, there were a total of 1,165 hospitalisations with a main or secondary diagnosis of humeral shaft fracture. The incidence of hospitalisation due to humeral shaft fractures was 4.8 per 100,000 person-years. The incidence increased only slightly among girls from 3.3 per 100,000 person-years in 1987 to 5.3 per 100,000 person-years in 2010. The incidence of reposition and casting was 1.1 per 100,000 person-years and the incidence of reposition with osteosynthesis, including intramedullary nailing, was 1.4 per 100,000 person-years. The specific incidence of intramedullary nailing remained low with no signs of increased incidence, and the incidence was 0.3 per 100,000 person-years. There were no significant changes in the incidence of surgical treatment during the 24-year study period. CONCLUSION: Despite an overall increasing trend toward operative management of fractures in children, conservative management remains the treatment of choice for humeral shaft fractures based on the low and steady incidence of surgical treatment during the 24-year study period. In addition, the incidence of hospitalisation for fractures remained low without a significant increase during the study period.

Normal behavior of plasma procalcitonin in adolescents undergoing surgery for scoliosis.

BACKGROUND AND AIMS: Surgical site infections are relatively common after spinal deformity surgery. Early detection of deep wound infections is important, since it may allow retention of spinal instrumentation. However, serum C-reactive protein and erythrocyte sedimentation rate may remain elevated for almost 6 weeks, making differential diagnosis of systemic inflammatory response and acute deep bacterial wound infection difficult. Plasma procalcitonin has been suggested to be a useful indicator for bacterial infection. However, there are no studies evaluating behavior of procalcitonin in patients undergoing major spine surgery with instrumentation. MATERIALS AND METHODS: A total of 50 consecutive adolescents (37 idiopathic scoliosis and 13 neuromuscular scoliosis, mean age = 15 years at surgery and follow-up time = 21 months (range = 12-29 months)) undergoing scoliosis surgery participated in this prospective follow-up study. White blood cell count, serum C-reactive protein, and plasma procalcitonin levels were measured on the day before surgery, on the day of surgery, and daily thereafter for 1 week. None of the patients developed signs of acute or delayed wound infection during the follow-up period; however, two neuromuscular scoliosis patients developed severe postoperative pneumonia, and their inflammatory parameter data will be reported separately. RESULTS: Plasma procalcitonin levels peaked on the first postoperative day (mean = 0.19 ng/mL, range = 0.04-1.29 ng/mL), and mean values were less than 0.5 ng/mL during the whole first postoperative week, while C-reactive protein remained elevated during the whole first postoperative week (highest mean value = 63.8 mg/L (range = 5-248 mg/L) on third postoperative day). Patients with idiopathic scoliosis had lower C-reactive protein levels (p < 0.05 from first to sixth postoperative day) and lower procalcitonin levels (p < 0.05 from third to seventh postoperative day) than neuromuscular scoliosis patients. Two patients with postoperative pneumonia showed elevated procalcitonin values over the whole postoperative week (22.34 ng/mL and 0.72 ng/mL highest values, respectively). CONCLUSIONS: Elevated plasma procalcitonin levels seem useful when excluding acute deep wound infection from systemic inflammatory response.

Increased incidence of distal humeral fractures and surgical treatment in 0- to 18-year-old patients treated in Finland from 1987 to 2010.

BACKGROUND: Studies of pediatric and adolescent fractures in general report a significant increase in the incidence of upper-extremity fractures as well as in their surgical treatment. The aim of this study was to determine the trends of the incidence and treatment of distal humeral fractures in hospitalized 0- to 18-year-old patients in Finland. METHOD: The study included the entire pediatric and adolescent (<19 years) population in Finland during the 24-year period from 1 January 1987 to 31 December 2010. Data on hospitalized patients were obtained from the nationwide National Hospital Discharge Registry where information is collected from all hospital categories (private, public, and other). Surgical treatment was categorized into three groups; (1) reposition with casting; (2) reposition or reduction and osteosynthesis; (3) reposition or reduction and external-fixation and other fixation methods. Patients were classified into three groups according to age: 0-6 years, 7-13 years, and 14-18 years. Annual incidences were calculated using the annual mid-year population census obtained from the Official Statistics of Finland. RESULTS: During the 24-year study period, there were a total of 12,590 hospitalizations with a main or secondary diagnosis of distal humeral fracture. In children aged 0-12 years the overall incidence of hospitalization increased 30 % during the 24-year study period, from 4.5 per 10,000 person-years in 1987 to 5.8 per 10,000 person-years in 2010. There were a total of 5,548 operations. During the study period, surgical treatment by repositioning or reduction with osteosynthesis due to a distal humeral fracture increased by fivefold in patients aged <6 years and by twofold in patients aged 7-12 years of age. The incidences of fracture and treatment in children older than 13 years did not change. CONCLUSION: The incidence of distal humeral fractures and the incidence of repositioning with osteosynthesis increased remarkably in prepubertal children during the 24-year study period in Finland.

Hybrid versus total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis: a comparative study with matched cohorts.

We compared the clinical, radiological and quality-of-life outcomes between hybrid and total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis. A matched comparison using prospectively collected data was undertaken. A total of 66 patients underwent posterior or anteroposterior correction and fusion with hybrid (n = 33, mean age at surgery 15.8 years (9.10 to 19.6)) or total pedicle screw instrumentation (n = 33, mean age 14.7 years (7.0 to 20.7)) with a minimum follow-up of two years. The major curve pre-operatively was a mean of 87° (SD 29, 25° to 141°) and 81° (SD 18, 47° to 116°) in the hybrid and total pedicle screw groups, respectively (p = 0.29) and at a minimum of two years it was 33° (SD 20; 2° to 87°) and 20° (SD 12; 1° to 55°), respectively (p = 0.0016). The mean correction of the major curve was 59% (41% to 88%) in the hybrid and 75% (43% to 99%) in the total pedicle screw groups at two-year follow-up (p = 0.0011). The mean operating time was 7.45 hours (SD 2.18) and 6.04 hours (SD 1.71) in the hybrid and total pedicle screw groups, respectively (p = 0.001), and the mean intra-operative blood loss was 3760 ml (SD 2790) and 1785 ml (SD 1110), respectively (p = 0.001). Total pedicle screw instrumentation provided shorter operating times, less blood loss and better correction of the major curve compared with hybrid constructs in patients undergoing surgery for neuromuscular scoliosis.

A critical analysis of postoperative complications of antebrachium TEN-nailing in 35 children.

BACKGROUND: Unstable antebrachium diaphyseal fractures in children are nowadays increasingly treated operatively by elastic intramedullary nailing. AIM: Aim of the study was to critically assess both radiological and functional outcome of antebrachium fractures treated by titanium elastic nail (TEN) in a pediatric cohort. MATERIAL AND METHODS: This retrospective study investigated 75 consecutive children, who were treated for antebrachium shaft fractures at Tampere University Hospital during the time period from January 2001 to December 2005. All the fractures were classified according to OTA. Thirty-five children (mean age 12.3 years) were treated by TEN-nailing. Twenty four of the forearm fractures were instable, five were open, five were re-fractures and one had ulnar nerve deficit. In all but one patient both forearm bones were fractured. Twelve (34%) operations were managed by closed reduction, open reduction was needed in 23 (66%) patients. In 29 cases both bones were fixed with TEN-nail. In the four patients with re-fracture in both ulna and radius only the radius was TEN-nailed. In one case radius was fixed with TEN-nail and ulna with K-wire and in another case radius was fixed with TEN-nail and ulna with plate. Fracture pattern, mode of reduction, surgical approach, short- and long-term complications and outcome were recorded. RESULTS: Twenty three (66%) patients achieved healing of the fractures without any limitation in range of motion. Twelve patients with postoperative complication were followed up 31-74 (median of 54) months. Eleven (31%) patients had minor postoperative complications and one (0,3%) patient had a Volkmann's ischemic contracture. Five of complicated patients had more than one problem. Immediate post-operative problems were noted in these five patients. At follow-up visits four patients complained of ulnar nail discomfort, two had neural symptoms. Additionally, three children suffered from re-fractures. DISCUSSION: Despite various minor complications, TEN-nailing is considered suitable treatment for unstable forearm shaft fractures. Most of the problems were related to poor technical performance in nailing.

The incidence and outcomes of vertebral column resection in paediatric patients: a population-based, multicentre, follow-up study.

We report the results of vertebral column resection (VCR) for paediatric patients with spinal deformity. A total of 49 VCRs in paediatric patients from four university hospitals between 2005 and 2009 with a minimum two-year follow-up were retrospectively identified. After excluding single hemivertebral resections (n = 25) and VCRs performed for patients with myelomeningocele (n = 6), as well as spondylectomies performed for tumour (n = 4), there were 14 patients who had undergone full VCR at a mean age of 12.3 years (6.5 to 17.9). The aetiology was congenital scoliosis in five, neuromuscular scoliosis in three, congenital kyphosis in two, global kyphosis in two, adolescent idiopathic scoliosis in one and secondary scoliosis in one. A total of seven anteroposterior and seven posterolateral approaches were used. The mean major curve deformity was 86° (67° to 120°) pre-operatively and 37° (17° to 80°) at the two-year follow-up; correction was a mean of 54% (18% to 86%) in the anteroposterior and 60% (41% to 70%) in the posterolateral group at the two-year follow-up (p = 0.53). The mean Scoliosis Research Society-24 total scores were 100 (92 to 108) for the anteroposterior and 102 (95 to 105) for the posterolateral group. There was one paraparesis in the anteroposterior group necessitating urgent re-decompression, with a full recovery. Patients undergoing VCR are highly satisfied after a successful procedure.

Non-absorbable interrupted versus absorbable continuous skin closure in pediatric appendectomies.

BACKGROUND AND AIMS: appendectomy wounds are still commonly closed with non-absorbable sutures. Stitch removal has financial costs and causes anxiety in children. Our aim was to compare interrupted non-absorbable (NA) and continuous intradermal absorbable (A) sutures in appendectomy wounds to evaluate whether absorbable suturing increases the risk of complications. MATERIAL AND METHODS: 198 children (age 4-18 years) including perforated cases were prospectively randomized into two groups (NA and A skin closure). The wounds and inflammatory markers were evaluated on the first two postoperative days. The appearance of the wound was evaluated one week postoperatively by a district nurse. Follow-up data were obtained from 166 patients (87 in NA group and 79 in A group). RESULTS: in NA group 86 % and in A group 81 % had appendicitis (8 % and 15.6 % perforated and 9.3 % and 25 % gangrenous cases in NA and A groups, respectively). The total wound infection rate was low, 1.8 % (2.3 % in NA Group and 1.3% in A Group). No differences in the inflammatory markers or the appearance of the wound were noted between the groups, but nine children in NA Group (10.3 %) had a partial wound dehiscence after stitch removal. CONCLUSION: appendectomy wounds in children can be closed with continuous, absorbable sutures, even in complicated cases.

Effects of post-operative pain treatment using non-steroidal anti-inflammatory analgesics, opioids or epidural blockade on systemic and local immune responses in children.

BACKGROUND: Many studies have been carried out on the effects of anaesthetic drugs and methods on the immune response, but pain and its relief also affect the immune response. We measured systemic immune responses in the blood circulation and local responses in the surgical wound when non-steroidal anti-inflammatory analgesics (NSAIDs), opioids or epidural blockade was used in the peri-operative treatment of pain. METHODS: Responses were measured in 51 children, aged from 2 to 12 years and undergoing major surgery under balanced anaesthesia. Bolus doses of diclofenac intravenously (i.v.) and rectally (NSAID group), continuous i.v. infusion of oxycodone (opioid group) or continuous epidural infusion of bupivacaine + fentanyl (epidural group) were used peri-operatively for pain relief. RESULTS: The only difference related to the analgesic method was shorter duration of post-operative leucocytosis and lower phytohaemagglutinin (PHA)-induced lymphocyte proliferative responses in peripheral blood in the opioid group than in the NSAID or epidural groups. By contrast, time-related alterations were seen overall in leucocyte and differential counts, lymphocyte and their subset counts, lymphocyte proliferative responses, and in serum cortisol, C-reactive protein, plasma interleukin-6 and group II phospholipase A2 concentrations and in the appearance of different cell types in the wound. CONCLUSIONS: Post-operative pain treatments using diclofenac (NSAID), oxycodone (opioid) and epidural blockade have basically similar effects on systemic and local immune responses with only slight, probably clinically unimportant differences in children undergoing surgery under general anaesthesia.

Laparoscopic versus open appendectomy in children: a prospective randomised study.

43 children between the ages of 7 and 15 years with clinical symptoms of acute appendicitis were randomised to an open appendectomy (OA) or a laparoscopic appendectomy (LA). There were 15 acute cases of appendicitis and 5 perforated appendices in the OA group and 17 acute appendicitis, 3 cases of perforated appendices and 3 other diagnoses in the LA group. The operative time was a little shorter in the OA group. There were no differences in hospital stay or the postoperative course of the patients. In the LA group, there were two minor complications, no other complications were seen. When comparing the two surgical methods in the consistent group of patients with non-perforated acute appendicitis no statistical differences were seen in the operative time, hospital stay or in the recovery of the patients between the OA and the LA groups.We conclude that LA has no significant benefit over OA in routine use. In paediatric patients we recommend an open approach for clinically typical acute appendicitis, but there should be no hesitation to choose laparoscopic approach when the clinical diagnosis is unclear.

Hyaluronic acid in incision wound fluid: a clinical study with the Cellstick device in children.

When inserted into a human incision wound, the Cellstick device harvests inflammatory cells and collects wound fluid, reflecting time-related changes in cell populations and in wound fluid composition. Hyaluronic acid has been postulated to be an important factor in scar reduction in wound healing and in scarless fetal wound healing. The aim of this work was to determine the concentration and variation of hyaluronic acid and proportions of wound cells in closed surgical wounds in children at two time points. The Cellstick device was inserted subcutaneously into the wound at the end of an elective inguinal hernia operation on 37 healthy boys, and the devices were removed 3+/-1 or 24+/-3 hours after surgery. Haluronic acid concentration was measured from the wound fluid and a differential count of the wound cells was performed. There was a significant decrease in hyaluronic acid concentration from 3+/-1 to 24+/-3 hours after surgery (p<0.001, Kruskal-Wallis anova). The variance of hyaluronic acid concentration in wound fluid differed between the wounds at the two time points (p<0.01, Levene test for homogeneity of variance). A positive correlation between hyaluronic acid concentration and patient age (r=0.91, p<0.05, Spearman) at 3+/-1 hours post surgery and between HA and wound lymphocytes (r=0.38, p<0.05, Spearman) was also found. We conclude that the hyaluronic acid concentration in wound fluid peaks early in children and decreases significantly by 3 to 24 hours after surgery, and the concentrations in the wound fluid of healthy boys are more variable 3 hours than at 24 hours after surgery.

Wound cell variation in closed surgical wounds as measured with two independent methods.

BACKGROUND AND AIMS: It is not known, to what extent the observed cellular changes in healing surgical wounds are species-, individual- or site-specific or whether they depend on the research method used. The aim of this study was to compare two independent methods for harvesting wound cells from porcine wounds after two time intervals, and to assess individual changes of wound cell composition. MATERIAL AND METHODS: In a standardised wound model in six pigs, with eight dorsal skin incision wounds in each, the Cellstick device and the Wound Edge Contact (WEC) method were used to collect inflammatory cells from the same wounds at hour 6 or 24 post-surgery. The wound cells were stained by the May-Grünwald-Giemsa (MGG) -method and counted differentially. RESULTS: A significant difference was found between the 6 and 24 hour Cellstick specimen in the proportions of wound neutrophils (p = 0.007), lymphocytes (p = 0.02) and monocytes (p < 0.001). The differential counts of wound cells within each individual animal did not significantly differ from each other. Instead, a significant difference was found in the wound neutrophils (p = 0.001), lymphocytes (p = 0.04) and monocytes (p < 0.001) between the wounds of individual animals. The WEC method revealed the same significant differences in the wound cell proportions. CONCLUSIONS: The Cellstick and the WEC method gave analogous results with equal variances from the incision wounds for up to at least 24 hours after injury.

Local and systemic immune response to surgery under balanced anaesthesia in children.

We studied perioperative changes in the immune response and compared changes in the peripheral blood with those in the wound in 20 boys (0.5-3 years) during elective inguinal surgery under balanced anaesthesia. Blood samples were drawn before premedication, immediately, and 4 or 24 h after anaesthesia. Cells from the wound were harvested with the Cellstick device, removed from the wound 4 (n=10) or 24 h (n=10) after anaesthesia. We found decreased lymphocyte counts in the peripheral blood, increased percentages of activated T lymphocytes and B lymphocytes, and decreased percentages of total T lymphocytes, T helper cells and T cytotoxic cells. The percentages of T helper cells and B lymphocytes were lower in the wound than in blood. Mitogen-induced lymphocyte proliferative responses decreased. This study demonstrates perioperative changes in the immune response in children and, as a new finding, that immune effector cells in the blood and in the wound are in a dynamic balance.

Duration of surgery and patient age affect wound healing in children.

The migration of inflammatory cells into a wound and their subsequent changes during wound healing are essential for the complex processes of tissue repair to occur. The aim of this work was to investigate the number of wound leukocytes during early wound healing at different time periods in children. Wound cells of 184 children aged 0-15 years, operated on for a benign disease in the lower abdominal region, were harvested with the Cellstick(R) device. The device was removed from the wound at 3, 6, or 24 hours after surgery and differential cell counts were performed. The cellular patterns were significantly influenced by the age of the patient and by the duration of the surgery. The proportions of neutrophils, lymphocytes, and monocytes changed significantly from 3-24 hours. Our results suggest that there is a distinct time-related change in the pattern of inflammatory cells in the early phase of wound healing in children. This pattern is affected by the age of the child and by the duration of the surgery.

Pancreatic injuries in children.

AIMS: There are several different philosophies in the diagnostics of blunt abdominal trauma (BAT), yet none of them has been shown to be superior, although enhanced computed tomography (CT) and diagnostic ultrasonography (US) seem to be the most used methods today. Treatment of pancreatic injury (PI) in children is a matter of controversy, whether operative treatment is needed and to what extent. MATERIAL AND METHODS: Seventeen pancreatic injuries were found in a retrospective analysis of 111 paediatric patients, aged 2-14 years, who underwent a laparotomy because of BAT, between 1968 and 1995 in Turku University Central Hospital. The number of non-operated BAT patients was calculated as 287. RESULTS: During the past two decades, the number of BATs and operations diminished by more than two thirds, but the number of PIs remained the same. Twelve acute operations led to four pancreatic resections, two external drainages and two explorations. PI was present but not the main reason for operation in four cases. Five PIs were operated on later due to postraumatic pseudocyst of the pancreas. CONCLUSIONS: PI was rare (15%) in laparotomies done because of BAT, operations which have diminished by 74% during the last twenty years. When PI was found, a variety of operative procedures was needed.

Correlation between interleukin-6 and matrix metalloproteinase-9 in early wound healing in children.

Interleukin-6 and matrix metalloproteinase-9 concentrations in the wound fluid and their associations to cellular changes were determined in early wound healing. Wound healing of 75 children who underwent elective operations was studied with the Cellstick(R) device, which was inserted into the wound at the end of the operation and removed 3 or 24 hours post-wounding. Differential counts of the wound cells and interleukin-6 and matrix metalloproteinase-9 concentrations in the wound fluid were analyzed. Interleukin-6 and the matrix metalloproteinase-9 concentrations increased in parallel (r = 0.81). The proportion of wound neutrophils increased (p < 0.0001) and lymphocytes decreased (p < 0. 0001) between the observation times. The number of wound neutrophils had a strong correlation with both interleukin-6 (adjusted R2 = 0.41, p < 0.0001) and matrix metalloproteinase-9 concentrations (adjusted R2 = 0.37, p < 0.0001). The extracellular matrix degradation process of the early wound healing seems to be closely linked to the inflammatory response. Both of these measured markers are associated significantly with the neutrophil proportion in the wound.