Lateral hemiepiphysiodesis of the first metatarsal for juvenile hallux valgus.

BACKGROUND: Juvenile hallux valgus (JHV) frequently results in an impaired quality of life because of pain and deformity. We used a validated clinical score to investigate the efficacy of lateral hemiepiphysiodesis of the first metatarsal base as a treatment for JHV. METHODS: We conducted a prospective, nonrandomized, single center cohort study of children who underwent lateral hemiepiphysiodesis for 31-IV, with a clinical and radiologic follow-up of at least 2 years. The efficiency of the procedure was assessed with the Hallux Metatarsophalangeal Interphalangeal Scale (HMIS), the metatarsophalangeal angle (MPA), and intermetatarsal angle (IMA). RESULTS: Twelve patients (22 feet) with JHV were treated by lateral hemiepiphysiodesis between 2012 and 2015. Average age at surgery was 10 years, and average follow-up was 3.5 years. The average HMIS score increased from an average of 56 at baseline, to 92 at last follow-up ( p < 0.01). The average IMA decreased by 2°, from 13° preoperatively to 11° postoperatively. Average MPA decreased from 26° at baseline to 22° after surgery. No complications occurred in the immediate postoperative period, and no patient needed an additional procedure. CONCLUSION: The HMIS score was significantly improved after lateral hemiepiphyslodesis, with a clear improvement in pain and functional impairment at last follow-up. We noted a stabilization of the IMA and MPA, but the radiologic benefit did not reach statistical significance. Our data support the use of lateral hemiepiphysiodesis as an effective and safe treatment of JHV.

Outcomes of Gartland type III supracondylar fractures treated using Blount's method.

BACKGROUND: Supracondylar fractures of the elbow with major displacement are usually treated by surgical pinning and less often non-operatively as described by Blount. The objective of this study was to assess the clinical and radiological outcomes of Gartland type III supracondylar fractures treated at least 3 years earlier using Blount's method. HYPOTHESIS: Blount's method produces good outcomes after more than 3 years when used to treat Gartland type III supracondylar fractures of the humerus. METHODS: A single-centre retrospective study was done in paediatric patients who were seen within 24hours after sustaining a Gartland type III supracondylar fracture then re-evaluated at least 36 months after treatment. Closed reduction was performed either in the operating room under general anaesthesia or in the radiology suite under procedural sedation. The upper limb was then immobilised for 4 weeks using the cuff-and-collar method described by Blount (mean elbow flexion, 134°). The child was evaluated and radiographs obtained at the outpatient clinic on days 7 and 14. Functional outcomes were assessed using the 1962 SoFCOT criteria and Flynn's criteria and the radiological outcome using Baumann's angle, the humero-condylar angle, and distal fragment rotation. From 2009 to 2013, 22 patients met the inclusion criteria. Mean follow-up was 57 months. RESULTS: Clinical outcomes assessed using the 1962 SoFCOT criteria were very good in 15 patients and good in the remaining 7 patients. The rate of satisfactory outcomes according to Flynn's criteria was 100%. At last follow-up, mean Baumann's angle was 68°, mean humerocondylar angle was 42°, and 2 patients had residual rotation of the distal fragment. CONCLUSION: This work confirms the effectiveness of Blount's method for treating Gartland type III supracondylar fractures. We advocate routine first-line treatment of these fractures using Blount's method in the absence of vascular compromise and instability. LEVEL OF EVIDENCE: IV, retrospective study.

Initial treatment of congenital idiopathic clubfoot: Prognostic factors.

BACKGROUND: The initial treatment of congenital idiopathic clubfoot (CIC) is nonoperative. Either the French physiotherapy method or the Ponseti casting method may be used. Whether either method is superior over the other remains unclear. However, the method used initially is not the only determinant of the final outcome. OBJECTIVE: The primary objective was to identify determinants of the final outcome as evaluated based on the need for surgical treatment and on the Ghanem-Seringe score. HYPOTHESIS: Factors associated with the final outcome can be identified. METHODS: Between 2004 and 2011, 100 CICs in 79 patients were treated in two centres, 47 using the French method and 53 the Ponseti method. The Dimeglio grade was determined at baseline and the Ghanem-Seringe score at last follow-up. Surgical procedures (if any), splinting duration, and rehabilitation therapy duration were recorded. The two groups showed no statistically significant differences for Dimeglio grade distribution, time from birth to treatment initiation, or mean follow-up. RESULTS: Factors significantly associated with a poor outcome by univariate analysis were use of the Ponseti method (P=0.0027), older age at last follow-up (P=3×10-4), initial Dimeglio grade (P=7×10-5), and need for surgery (P=10-5); no significant effect was found for splinting duration, rehabilitation duration, bilateral involvement, or antenatal diagnosis. By multivariate analysis, factors independently associated with a poor prognosis were older age at last follow-up, Dimeglio grade, and need for surgery. CONCLUSION: This study confirms the major prognostic significance of initial severity (Dimeglio grade) on the final outcome. The data do not firmly establish that one method is superior over the other. Nevertheless, the need for percutaneous Achilles tenotomy with the Ponseti method leads us to prefer the French physiotherapy method. LEVEL OF EVIDENCE: IV, retrospective study.

Too-long calcaneal process: Results of surgical treatment and prognostic factors.

INTRODUCTION: The too-long anterior process (TLAP) can be responsible for ankle pain or repeated sprains in children or adolescents. The objective of this study was to assess the results of TLAP surgical treatment and to analyze influencing factors in case of this surgery's failure. MATERIAL AND METHODS: Retrospective single-center study conducted from 2009 to 2012 including all patients under 18 years of age for a TLAP with follow-up equal to or longer than 1 year. The results of surgical treatment were assessed using the AOFAS score. Failure was defined as no significant improvement in the AOFAS score at the last follow-up. HYPOTHESIS: Predictive factors of the result of surgical treatment for TLAP can be identified. RESULTS: At the mean follow-up of 2.5 years, 35 patients (43 feet) fulfilled the inclusion criteria. Thirteen feet (30%) presented surgical failure. According to the AOFAS score, the results were excellent in 30 feet (70%), good in four (9%), fair in five (12%), and poor in four (9%). Surgical failure was influenced by the patient's age at the onset of symptoms and at the time of surgery, the degree of functional limitation, the duration of symptoms before surgery, the number of sprains, and gender (P<0.05). CONCLUSION: Firstly, in this pediatric population with its high functional demand, the overall rate of failure of TLAP surgery was 30%. Secondly, the factors associated with failure demonstrated made it possible to identify the ideal patient for this surgery: male, with symptom onset between 7 and 10 years of age, who had experienced fewer than 15 sprains, and undergone surgery in the 3 years following the beginning of symptoms. LEVEL OF EVIDENCE: IV.

Epidermal aquaporin-3 is increased in the cutaneous burn wound.

INTRODUCTION: Aquaporins (AQP) are a family of transmembrane proteins that transport water and small solutes such as glycerol across cell membranes. It is a mediator of transcellular water flow and plays an important role in maintaining intra/extracellular fluid homeostasis by facilitating water transport in response to changing osmotic gradients. In the skin, AQPs permit rapid, regulated, and selective water permeability and have been demonstrated to play a role in skin hydration, cell proliferation, migration, immunity, and wound healing. However, the expression of AQP-3 in the cutaneous burn wound has never been elucidated. We sought to assess the expression of AQP-3 in patients with burn wounds. METHODS: A fresh full thickness biopsy sample was taken from the center of the burn wound, the burn wound edge, and the graft donor site in 7 patients (n=21), approximately 3-7 days post injury. Fixed, paraffin embedded sections were stained using AQP-3 specific antibody and examined by immunofluorescence. Fresh samples were processed to quantify AQP-3 protein expression with Western blot analysis. RESULTS: The central portion of the burn wound revealed destruction of the epidermis and dermis with no AQP-3 present. Along the burn wound edge where the epidermal architecture was disrupted, there was robust AQP-3 staining. Western blot analysis demonstrated deeper staining along the burn wound edge compared to unburned skin (control). Quantification of the protein shows a significant amount of AQP-3 expression along the burn wound edge (3.6±0.34) compared to unburned skin (2.1±0.28, N=7, *p<0.05). There is no AQP-3 expression in the burn wound center. CONCLUSION: AQP-3 expression is increased in the burn wound following injury. While its role in wound healing has been defined, we report for the first time the effect of cutaneous burns on AQP-3 expression. Our data provides the first step in determining its functional role in burn wounds. We hypothesize that development of AQP3 targeted therapies may improve burn wound healing.

Foxp3+ regulatory T cells promote lung epithelial proliferation.

Acute respiratory distress syndrome (ARDS) causes significant morbidity and mortality each year. There is a paucity of information regarding the mechanisms necessary for ARDS resolution. Foxp3(+) regulatory T cells (Foxp3(+) T(reg) cells) have been shown to be an important determinant of resolution in an experimental model of lung injury. We demonstrate that intratracheal delivery of endotoxin (lipopolysaccharide) elicits alveolar epithelial damage from which the epithelium undergoes proliferation and repair. Epithelial proliferation coincided with an increase in Foxp3(+) T(reg) cells in the lung during the course of resolution. To dissect the role that Foxp3(+) T(reg) cells exert on epithelial proliferation, we depleted Foxp3(+) T(reg) cells, which led to decreased alveolar epithelial proliferation and delayed lung injury recovery. Furthermore, antibody-mediated blockade of CD103, an integrin, which binds to epithelial expressed E-cadherin decreased Foxp3(+) T(reg) numbers and decreased rates of epithelial proliferation after injury. In a non-inflammatory model of regenerative alveologenesis, left lung pneumonectomy, we found that Foxp3(+) T(reg) cells enhanced epithelial proliferation. Moreover, Foxp3(+) T(reg) cells co-cultured with primary type II alveolar cells (AT2) directly increased AT2 cell proliferation in a CD103-dependent manner. These studies provide evidence of a new and integral role for Foxp3(+) T(reg) cells in repair of the lung epithelium.

The expression and immunohistochemical localization of periostin in odontogenic tumors of mixed epithelial/mesenchymal origin.

OBJECTIVE: The object of this study was to determine the expression and localization of periostin in the major mixed odontogenic tumors and to correlate any differential staining of the mesenchymal components to the interrelationship of these tumors. STUDY DESIGN: Five ameloblastic fibromas, 8 ameloblastic fibro-odontomas and 10 odontomas were assessed immunohistochemically for periostin staining. Because mesenchymal tissues were consistently present in all studied cases, these tissues were selected for statistical analysis of differential periostin staining. RESULTS: Periostin was variably localized to the mesenchymal component of the tumors as well as to preameloblasts and ameloblasts. Analysis of the mesenchymal staining intensity was statistically significantly different between ameloblastic fibro-odontomas and odontomas (P < .001; Dunn multiple comparisons test). CONCLUSIONS: Our results document periostin staining in human mixed odontogenic tumors. Statistical analysis of differential stromal staining supports the concept that the ameloblastic fibroma is a histogenetically distinct neoplasm as compared to ameloblastic fibro-odontoma and odontoma.

TGF-ß1 and FAK regulate periostin expression in PDL fibroblasts.

Recently identified as a key component of the murine periodontal ligament (PDL), periostin has been implicated in the regulation of collagen fibrillogenesis and fibroblast differentiation. We investigated whether periostin protein is expressed in the human PDL in situ and the mechanisms regulating periostin expression in PDL fibroblasts in vitro. With immunohistochemistry, periostin protein was identified in the PDL, with expression lower in teeth with reduced occlusal loading. In vitro application of uniaxial cyclic strain to PDL fibroblasts elevated periostin mRNA levels, depending on the age of the patient. Treatment with transforming growth factor-beta1 (TGF-ß1) also significantly increased periostin mRNA levels, an effect attenuated by focal adhesion kinase (FAK) inhibition. FAK-null fibroblasts contained no detectable periostin mRNA, even after stimulation with cyclic strain. In conclusion, periostin protein is strongly expressed in the human PDL. In vitro, periostin mRNA levels are modulated by cyclic strain as well as TGF-ß1 via FAK-dependent pathways.

Children distal humerus supracondylar fractures: the Blount Method experience.

INTRODUCTION: Extension-type supracondylar fractures of the humerus in children are frequent lesions whose orthopaedic treatment remains under debate in Rigault and Lagrange type III fractures and highly controversial in type IV fractures. The objective of this study was to extend the Blount method to fractures with substantial displacement even in patients presenting significant swelling and to evaluate the results. PATIENTS AND METHODS: We conducted a prospective continuous study from December 2005 to August 2007 on 67 children: 49 boys and 18 girls with a mean age of 6 years (range, 3-14 years). The mean time lapsed from consultation to treatment was 30 h. The mean hospital stay was 72 h. In 50 children, the limb was elevated preoperatively for a mean 48 h. The fracture was reduced under fluoroscopy-guided general anesthesia with mask and immobilized with 5-cm cloth banding padded with foam. The follow-up was clinical and radiological. The mean follow-up was 16 months (range, 6-26 months). Assessment followed the 1969 SOFCOT guidelines. RESULTS: At union, mean flexion was 124 degrees , the mean extension lag was 26 degrees . At last follow-up, the mean flexion was 146 degrees , the extension lag was 0.5 degrees , and pronation and supination were free. Immediately after surgery, the mean Baumann and anteflexion angles were 75 degrees and 43 degrees , respectively; at union they were 76 degrees and 44 degrees and at follow-up 79 degrees and 42 degrees . We found no vascular or nerve lesions. According to the SOFCOT criteria, at follow-up we obtained 80.6% very good results and 19.4% good results. LEVEL OF EVIDENCE: Level IV. Therapeutic study.

Iatrogenic Tako-Tsubo cardiomyopathy.

We report a rare case of Tako-Tsubo cardiomyopathy developed after excision of left atrial myxoma and adrenaline infusion given for blood pressure augmentation in a 56-year-old lady. Although the risk for developing Tako-Tsubo cardiomyopathy associated with adrenaline use has not been established, caution is still warranted.

[Percutaneous surgical treatment of two epiphyseal plate fractures of the proximal humerus]. / Réduction et embrochage percutanés de deux décollements épiphysaires de l'humérus proximal.

We report two cases of Salter 2 displaced epiphyseal detachment of the proximal humerus treated successfully by percutaneous reduction and centromedular nailing. This surgical treatment was required because of the irreducibility of the lesion in one patient and instability in the other. This percutaneous technique can be recommended after failure of orthopedic treatment and is an attractive alternative to open surgery.

Cardiac sarcoidosis: a potentially fatal but treatable form of infiltrative heart disease.

Cardiac sarcoidosis is a rare but important differential diagnosis in patients who present with progressive heart failure and arrhythmia. It may be diagnosed on endomyocardial biopsy. An excellent response can be achieved with steroid therapy in the early acute inflammatory stage. Progression of the disease may lead to end-stage heart failure that requires implantation of a permanent pacemaker, implantable cardioverter-defibrillator, or mechanical circulatory support as a bridge to heart transplantation. We present three Hong Kong Chinese patients with cardiac sarcoidosis.

[Congenital pseudarthrosis of the forearm in a neurofibromatosis patient: case report and review of the literature]. / Pseudarthrose congénitale de l'avant-bras associée à la neurofibromatose: à propos d'un cas et revue de la littérature.

We report a case of congenital pseudarthrosis of the forearm associated with neurofibromatosis type 1 which was treated by free vascularized periosteal flap transplant and repeated bone grafting. The young female patient recovered good hand and forearm function. A review of the literature revealed the rare occurrence of this disease (approximately 100 cases reported to date), which probably explains the wide variety of surgical proposals.

Combined atrial septostomy and oral sildenafil for severe right ventricular failure due to primary pulmonary hypertension.

Management of primary pulmonary hypertension is usually difficult because the disease is uncommon and the aetiology of the disease is not well understood. The disease is potentially lethal because it can lead to failure of the right ventricle, low cardiac output, and ensuing multiple organ failure. We report the successful treatment of a case of low-output syndrome due to primary pulmonary hypertension using combined drug therapy and atrial septostomy. Latest developments in the treatment of this disease are also discussed.

Post-transplantation lymphoproliferative disease in Chinese: the Queen Mary Hospital experience in Hong Kong.

Post-transplantation lymphoproliferative disease (PTLD) is an unique iatrogenic complication after bone marrow transplantation (BMT) and solid organ transplantation (SOTx). The pattern of EBV related lymphoma in Chinese is different from Caucasians. We surveyed the incidence, clinical and pathological spectrum of PTLD among 541 cases of allogeneic BMT, 145 cases of renal transplant, 35 cases of heart/lung transplantation and 146 cases of orthotopic liver transplantation (OLT). From 1994 to 2001, 13 consecutive cases of PTLD were diagnosed, ranging from disseminated NK cell lymphoma to localized plasmacytoma. Both donor and recipient derived PTLD was documented. Disease was often heralded by cytomegaloviral disease and antithymocyte globulin (ATG) usage. Two cases were diagnosed post-mortem, and six patients died of PTLD at a median of 3 months. Complete and partial remission was only achieved in 3 and 2 cases, respectively, despite a range of treatment (reduced immunosuppression, explantation, radiotherapy, combination chemotherapy, donor lymphocytes, autologous marrow infusion and rituximab). Most responding patients died subsequently of rejection, infection and graft versus host disease (GVHD). The incidence of PTLD is not increased in Chinese patients. However, some patients may be at increased risk, especially mismatched allogeneic BMT, parental OLT (especially involving young infants) and heavy ATG exposure.

Severe mitral regurgitation due to mitral valve prolapse associated with Bland-White-Garland syndrome.

Bland-White-Garland syndrome refers to the rare congenital cardiac abnormality whereby the left coronary artery arises from the pulmonary artery. The natural history of this condition is highly variable, ranging from death in early infancy to asymptomatic adult survival. It is sometimes diagnosed in adults with mitral regurgitation thought to be of ischaemic origin. We report a case of a 29-year-old man with Bland-White-Garland syndrome and concomitant mitral valve prolapse, and review the literature on the appropriate investigations and management of this abnormality. Recognition and diagnosis of this condition is important because of the potentially life-threatening complications, which may be prevented by surgical intervention.

Transcatheter closure of atrial septal defect using Amplatzer septal occluder in Chinese adults.

Amplatzer septal occluder (AGA Med. Co., USA) is a novel device for occlusion of atrial septal defect. We present our experience of transcatheter closure of atrial septal defects using Amplatzer septal occluder in 45 adult Chinese patients (age range 18-69 years). The size of atrial septal defect varied from 14-28 (23 +/- 4) mm. Cardiac catheterization revealed a pulmonary-to-systemic shunt ratio ranging from 1.4-2.8 (mean 2.0 +/- 0.4). The procedure was successful in 44 (98%) patients. Displacement of the device requiring surgical removal occurred in one (2%) patient and minor wound complication occurred in two (4%) patients. Total procedure time was 67 +/- 16 minutes and the fluoroscopy time was 25 +/- 8 min. Immediate post-procedure and pre-discharge echocardiography revealed complete abolition of shunt in 42 (93%) and trivial residual shunt in 3 (7%) patients. The average follow-up period was 16 +/- 6 months (range 2 months to 3 years) months. None of the patients had developed other major complication at follow-up. Cathet Cardiovasc Intervent 2001;52:373-377.