Six-year outcome after non-surgical versus surgical treatment of acute primary patellar dislocation in adolescents: a prospective randomized trial.

PURPOSE: There is only one prospective randomized trial on acute primary patellar dislocation in adolescents comparing the long-term outcome after conservative versus operative procedures. Therefore, the long-term outcome, patellar redislocation rate, and functional outcome after conservative versus operative procedures were investigated in a prospective randomized study. METHODS: Initially, 36 patients with acute primary patellar dislocation were prospectively randomized to conservative (n = 20) versus operative procedures (n = 16) and 30 of them (83%), 15/20 with conservative and 15/16 with operative procedures, were reached for a follow-up interview 6 years after primary procedure. RESULTS: Baseline and clinical parameters were similar in the two groups. The prevalence of patellar redislocation rate at 3 and 6 years after primary procedure was higher in the conservative group (7/20, 35%, 3 years and 11/15, 73%, 6 years) versus in the operative group (0/16, 0%, 3 years and 5/15, 33%, 6 years) (p = 0.02). The knee function was slightly better 6 years after primary treatment in the operative group than in the conservative group. Most patients in both groups had excellent or good knee function at 6-year follow-up, but four patients (4/15, 27%) in conservative group and two patients (2/15, 13%) in operative group had poor knee function at 6-year follow-up. Four patients in conservative group (4/15, 27%) and two patients in the operative group (2/15, 13%) were unsatisfied with the procedure at 6-year follow-up. CONCLUSIONS: In conclusion, the results suggest that both conservative and operative procedures are feasible options for treatment of acute primary patellar dislocation in adolescents. A new finding with clinical relevance in the present work is a significantly higher redislocation rate in conservative group compared to operative group after 6-year follow-up in acute primary patellar dislocation in adolescents. LEVEL OF EVIDENCE: II.

The impact of age and sex adjusted body mass index (ISO-BMI) in obese versus non-obese children and adolescents with cholecystectomy.

BACKGROUND: The impact of the age and sex adjusted body mass index (ISO-BMI) in the obese vs. non-obese children and adolescents with cholecystectomy for cholelithias is rarely reported. PATIENTS AND METHODS: The national database was searched for cholecystectomies performed in paediatric patients between 1997 and 2011, and the 59 paediatric and adolescent patients having cholecystectomy in the Kuopio University Hospital district were divided in two groups by age and sex adjusted BMI (ISO-BMI) using the cut-off point of overweight (ISO-BMI 25 kg/m(2)) based on the Finnish growth standards. RESULTS: Nationwide a total of 840 cholecystectomies were performed during the 15 years study period in Finland, most of which included females (77%), resulting in a mean of annual frequency of 4.8 (range: 3.9-6.1) procedures/100,000 population. In the study sample, most of the patients with the cholelithiasis were female (50/59, 85%). The gender distribution was equal among the younger patients, but among adolescents 6/52 (12%) of the patients with cholelithiasis were boys and 46/52 (88%) of the patients with cholelithiasis were girls. Obesity did not affect on operative parameters. The median operative time was 70 min (range, 30-155) and 66 min (44-130) in the high ISO-BMI-group. The recovery was similar in the two groups: the median length of hospital stay was 4 days in both groups. The patients in the low ISO-BMI-group vs. high ISO-BMI-group had a trend of higher serum bilirubin (p=0.16) and serum AFOS values (p=0.19). In the histological examination of the gallbladders 19/28 (68%) patients in the low ISO-BMI-group had inflammation vs. 26/31 (84%) patients in the high ISO-BMI-group (p=0.15). CONCLUSION: Our results between obese and non-obese children and adolescents with cholelithiasis are not statistically significant. The obese adolescents with female gender are in greater risk for cholelithiasis.

Dynamic KINE-MRI in patellofemoral instability in adolescents.

PURPOSE: The impact of kinematic MRI (KINE-MRI) in the patellofemoral instability and anterior knee pain of the adolescents is rarely reported. Our special interest was to evaluate the patellofemoral joint biomechanics with KINE-MRI in adolescents with affected and unaffected knees in a case-control study. METHODS: KINE-MRI was performed in 29 adolescents (affected knee group, n = 29 and unaffected knee group, n = 26) aged 11-16 years with unilateral patellofemoral instability. For the control group, we enrolled ten healthy age- and sex-matched volunteers (healthy knee group, n = 19). The study parameters, bisect offset, lateral patellar displacement, patellar tilt angle, sulcus angle and Insall-Salvati ratio at 0, 10, 20 and 30° of flexion-extension, were measured for the affected knee patients (n = 29), unaffected knee patients (n = 26) and the healthy knee subjects (n = 19). RESULTS: The affected knee and the healthy knee subjects had a significant difference in the bisect offset ratio, lateral patellar displacement test and patellar tilt angle test. In these parameters, the difference between the affected knee patients and the healthy knee subjects progressively increased towards the full extension of the knee. In the affected knee and unaffected knee patients, bisect offset ratio at 0° ranged between 0.50 and 1.20 in both groups, whereas the bisect offset ratio in the healthy knee subjects ranged between 0.33 and 0.75 (p < 0.001). At the 0°, the lateral patellar displacement test ranged between 0 and 10 mm in the affected knee patients and between 0 and 35 mm in the unaffected knee patients, whereas the lateral displacement test ranged between 0 and 5 mm in the healthy knee subjects (p = 0.003). Patellar tilt angle test ranged between -30 and 20° in the affected knee patients and between -30 and 24° in the unaffected knee patients, and in the healthy knee subjects, the patellar tilt angle test ranged between 10 and 24° (p < 0.001). CONCLUSIONS: The KINE-MRI was able to detect significant differences in patellofemoral joint kinematics between the patients and the healthy subjects. A new finding with clinical relevance in our work is that the unaffected knee is very similar to the dislocated knee in adolescents and this should be taken in account in rehabilitation of patients. LEVEL OF EVIDENCE: II.

Severe gastro-oesophageal reflux necessitating fundoplication after percutaneous endoscopic and open gastrostomy in children.

PURPOSE: The three major techniques for a gastrostomy in children are open gastrostomy (OG), percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy. Here, we have evaluated the outcome after OG and PEG in 69 children operated in Kuopio University Hospital. METHODS: The medical records of 69 consecutive children who had either PEG (n = 56) or OG (n = 13) over an 18-year period (1990-2008) were reviewed. RESULTS: There was no difference between the PEG- and OG-groups in the patients' characteristics, indications for tube placement and hospital stay. The mean procedure time was 43 min shorter in the PEG-group (28 ± 38 min) than in the OG-group (71 ± 58 min) (P = 0.003). Four children (8%) in the PEG-group and one (8%) in the OG-group required later surgical interventions related to gastrostomy. Severe gastro-oesophageal reflux (GER) necessitating fundoplication was detected in 15 children (27%) in the PEG-group and in 7 children (54%) in the OG-group (P = 0.06). CONCLUSION: The results of this study indicated a higher incidence for severe GER leading to fundoplication in children with OG, while no difference with complications and clinical outcome between the two techniques, OG and PEG, were observed.

Laparoscopic dismembered pyeloplasty in a child with a relatively inaccessible intrarenal pelvis.

Laparoscopic pyeloplasty is an accepted way of dealing with pelviureteric junction obstruction in children with extrarenal pelvis. However, intrarenal pelvis has been considered a relative contraindication for laparoscopic pyeloplasty. Here, we describe the technique of laparoscopic dismembered pyeloplasty in a child with intrarenal pelvis. The key when one embraces laparoscopic dismembered pyeloplasty is to ensure that outcomes are not compromised. A successful outcome requires a widely patent, well-vascularised anastomosis performed free of tension.

Diagnostic score in acute appendicitis. Validation of a diagnostic score (Lintula score) for adults with suspected appendicitis.

PURPOSE: We have previously constructed and validated a diagnostic score to reduce the negative appendicectomy rate in children with suspected appendicitis. The purpose of this prospective study was to validate the diagnostic score (Lintula score) in adults with suspected appendicitis. METHODS: A total of 177 patients with suspected appendicitis were randomly assigned to either the appendicitis-score-group (n = 96) or the no-score-group (n = 81). The management decision was based on the use of the diagnostic scoring system in the appendicitis-score-group and on a sole clinical assessment in the no-score-group. The main diagnostic performance parameters were the diagnostic accuracy, specificity and sensitivity, the positive and negative predictive values, and the rate of negative appendicectomies. RESULTS: There was no difference between the appendicitis-score-group and the no-score-group in the diagnostic accuracy (92% vs. 91%; P = NS) and the negative appendicectomy rate (13% vs. 16%). Following repeated clinical examination, the diagnostic accuracy improved in both groups, 74% vs. 92% in the appendicitis-score-group (P = 0.01), and 84% vs. 91% in the no-score-group (P = 0.01). The application of the Lintula score yielded a higher positive predictive value (98% vs. 84%; P = 0.02) and specificity (98% vs. 84%; P = 0.028), but a lower negative predictive value (86% vs. 100%; P = 0.016) and sensitivity (87% vs. 100%; P = 0.022) than unaided clinical examination in the no-score-group. There were no differences in terms of the length of hospital stay, rate of complications and appendiceal histology between the two groups. CONCLUSION: The use of the acute appendicitis score developed for paediatric patients seems to provide some benefits compared to an unaided clinical diagnosis and may, thus, be a useful diagnostic tool for general surgeons.

Appendicitis score for children with suspected appendicitis. A randomized clinical trial.

BACKGROUND/PURPOSE: Appendicectomy is often performed without certainty of diagnosis. We have previously constructed and validated a diagnostic score for acute appendicitis in children. The purpose of this prospective study was to determine whether diagnosis by using the appendicitis score may improve clinical outcomes for children with suspected appendicitis. METHODS: A total of 126 children with suspected appendicitis were randomly assigned to either the appendicitis-score group or the no-score group. The attending general surgeon indicated a provisional diagnosis, a differential diagnosis and a provisional disposition on admission at 3 h and, if necessary, at 6, 9 and 12 h. The decision to operate was based on a clinical assessment in the no-score group and on the use of the diagnostic scoring system in the appendicitis-score group. The main outcome measures were the diagnostic accuracy (primary endpoint), the rate of unnecessary appendicectomies and adverse events between the two groups. RESULTS: The diagnostic accuracy was significantly greater in the appendicitis-score group compared with that in the no-score group (92% vs 80%; P = 0.04). A significantly higher rate of unnecessary appendicectomies was observed in the no-score group compared with that in the appendicitis-score group (29% vs 17%; P = 0.05). In the appendicitis-score group, the sensitivity was 100%, specificity was 88%, positive predictive value was 83% and negative predictive value was 100%, compared to sensitivity of 96%, specificity of 67%, positive predictive value of 70% and negative predictive value of 96% observed in the no-score group. There were no differences in terms of the length of hospital stay, rate of complications and appendiceal histology between the two groups. The only case with missed appendicitis was in the no-score group. CONCLUSION: The use of the appendicitis score can reduce the unnecessary appendicectomy rate in general surgeons treating children with suspected appendicitis.

Laparoscopic versus open orchidopexy in children with intra-abdominal testes.

BACKGROUND/PURPOSE: The management of intra-abdominal testis has been controversial but has changed significantly since the introduction of the laparoscopic technique. The aim of our study was to evaluate the success rate of laparoscopic orchidopexy (LO) compared with that of open orchidopexy (OO). MATERIALS AND METHODS: In Kuopio University Hospital, 35 of 357 children with undescended testes treated between January 1992 and December 2004 had intra-abdominal testes. A retrospective review was performed to compare the outcomes of children having LO with those who had undergone OO. RESULTS: Sixteen children with 19 intra-abdominal testes underwent LO and 18 children with 18 intra-abdominal testes underwent OO. Primary LO was performed in 14 children with 17 testes and staged Fowler-Stephens LO in 2 children. One LO was converted to OO. The mean (+/- standard deviation) operating time was 62 (+/- 30) minutes in the LO group and 43 (+/- 12) minutes in the OO-group (mean difference of 19 minutes, 95% confidence interval of the difference of 2 to 34 minutes; P = 0.025). There were no differences in the length of hospital stay between the two groups. Two major intra-abdominal complications occurred: 1 child in the LO-group had spermatic vessels torn, which led to a one-stage Fowler-Stephens orchidopexy, and the other child, one who had undergone a conversion from LO to OO, had a transection of the vas. One child in both groups was lost to follow-up. The overall success rate (acceptable scrotal position of the testis without testicular atrophy) was 88% in the LO group and 82% in the OO group. CONCLUSIONS: Although marginally longer in duration, primary LO appears to be a feasible, safe technique for the management of the low intra-abdominal testes, whereas the staged Fowler-Stephens LO may be more safe than primary LO in cases with high intra-abdominal testes.

Oxycodone vs placebo in children with undifferentiated abdominal pain: a randomized, double-blind clinical trial of the effect of analgesia on diagnostic accuracy.

BACKGROUND: Analgesics for children with acute abdominal pain are often withheld for fear that they might mask physical examination findings and thus might be unsafe. This viewpoint has been challenged recently. OBJECTIVE: To evaluate the effects of buccal oxycodone on pain relief, physical examination findings, diagnostic accuracy, and final clinical outcomes in children with acute abdominal pain. DESIGN: Prospective, randomized, double-blind, and placebo-controlled trial between December 2001 and November 2003. SETTING: University teaching hospital in Finland. Patients A total of 104 children aged 4 to 15 years with abdominal pain of less than 7 days' duration were screened, and 63 children with pain scores of 5 or higher on a 10-cm visual analog scale were eligible for the trial. Intervention Children were randomized to receive buccally either 0.1 mg/kg(-1) of oxycodone hydrochloride (n = 32) or the same volume of normal saline (n = 31). The same surgeon described the physical findings and indicated a provisional diagnosis and a provisional disposition before the children received the study medication and at 1 hour and 3.5 hours after initial dosing. Pain scores were recorded at baseline and every 30 minutes for 3.5 hours after the first study drug administration. MAIN OUTCOME MEASURES: Pain intensity difference, presence or absence of abdominal guarding, and diagnostic accuracy. RESULTS: The demographic characteristics, initial pain scores, and physical signs and symptoms were similar between the 2 groups. Both study drugs were associated with decreasing pain scores. The summed pain intensity difference over 7 observations was significantly greater in the oxycodone group, 22 +/- 18 cm, than in the placebo group, 9 +/- 12 cm (mean difference 13 cm, with a 95% confidence interval of 2-24 cm; P = .04). The diagnostic accuracy increased from 72% to 88% in the oxycodone group and remained at 84% in the placebo group after study drug administration. Laparotomy was performed in 17 patients in the oxycodone group and in 14 patients in the placebo group. Four patients without appendicitis underwent exploratory laparotomy in each group. One patient in the placebo group was initially diagnosed as having nonspecific abdominal pain, but at 14 hours, she was operated on for appendiceal perforation. CONCLUSIONS: Early administration of buccal oxycodone provides a significant pain relief to children with acute abdominal pain, without adversely altering the clinical signs or obscuring the surgical diagnosis.

A diagnostic score for children with suspected appendicitis.

BACKGROUND/PURPOSE: Appendicectomy is an operation that is often performed without certainty of diagnosis. This study aimed to construct and to validate a prognostic score for the diagnosis of acute appendicitis in children. METHODS: Data for 35 symptoms and signs were prospectively recorded for 131 consecutive children with suspected appendicitis. Logistic regression analysis of the variables yielded a diagnostic score: gender (male 2 points, female 0) + intensity of abdominal pain (severe 2, mild or moderate 0) + relocation of pain (yes 4, no 0) + vomiting (yes 2, no 0) + pain in the right lower abdominal quadrant (yes 4, no 0) + fever (yes 3, no 0) + guarding (yes 4, no 0) + bowel sounds (abnormal 4, normal 0) + rebound tenderness (yes 7, no 0). The cut-off level for recommendation of appendicectomy was > or =21, and the cut-off level for non-appendicitis was < or =15. The score was prospectively validated on 109 children. RESULTS: In the validation sample, based on clinical judgment, unnecessary appendicectomy was performed in ten (27%) children, and one (4%) child was misdiagnosed as not having appendicitis. By application of the score, unnecessary appendicectomies would have been reduced to four (13%), and three children (11%) with appendicitis would have been discharged. CONCLUSION: The use of a predictive mathematical model may facilitate the diagnosis of appendicitis to avoid unnecessary operations.

The costs and effects of laparoscopic appendectomy in children.

BACKGROUND: Laparoscopic procedures are performed commonly in children. In general, the cost containment of laparoscopic surgery in children has not been evaluated. OBJECTIVE: To compare the costs of laparoscopic appendectomy with those of open appendectomy. DESIGN: Prospective clinical trial between November 1, 1997, and April 30, 2000. For analysis, cost of supplies, operation room use, and recovery in the hospital and after discharge was evaluated. Costs common to both groups were not determined. SETTING: Operations performed in a university hospital.Patients Eighty-seven children aged 4 to 15 years who underwent appendectomy for suspected appendicitis. Patients were randomized to laparoscopic or open appendectomy. Intervention Laparoscopic appendectomies performed with the same standard set of reusable equipment. MAIN OUTCOME MEASURES: Cost surplus of the laparoscopic procedure and recovery after surgery were evaluated, to determine the costs and effects of laparoscopic appendectomy compared with those of open appendectomy in children. RESULTS: Excess operating and complication costs per procedure were 96 euros (EUR) in laparoscopic appendectomy. The increased operative expenses were offset by a shorter hospital stay, resulting in a marginal difference of 53 EUR in itemized total costs between the 2 procedures (total cost, 1023 EUR in the laparoscopic appendectomy group and 970 EUR in the open appendectomy group). After laparoscopic appendectomy, children returned to school and sports earlier than those who had had an open appendectomy. CONCLUSION: Laparoscopic appendectomy was marginally more expensive, but it allowed earlier return to normal daily activities than open appendectomy.

Laparoscopic fundoplication in children with a preexisting gastrostomy.

BACKGROUND: Children with a gastrostomy may require laparoscopic fundoplication (LF). METHODS: Children with a gastrostomy who underwent LF between 1998 and 2002 were reviewed. The outcomes of children undergoing LF were compared with a group of children without a gastrostomy who had the same operation during the same period. RESULTS: Ten children with a gastrostomy in place and eight children without a gastrostomy underwent LF. The median operating time was 198 minutes (range, 115-300 minutes) in the gastrostomy group and 110 minutes (range, 80-130 minutes) in the non-gastrostomy group (P =.002). In the gastrostomy group, two children had ventriculoperitoneal shunts and two had extensive intra-abdominal adhesions due to peritonitis. One laparoscopic procedure in each group was converted to an open approach. A successful LF was performed in nine of the ten children without taking down the gastrostomy. One child with a gastrostomy experienced recurrent vomiting that was managed with a gastrojejunal tube. One child in the non-gastrostomy group required reoperation due to an esophageal stricture. CONCLUSION: It seems that LF can be performed safely and effectively in children with a preexisting gastrostomy. LF in children with a gastrostomy seems to be as efficacious as LF in children without a gastrostomy.

Laparoscopy in children with complicated appendicitis.

BACKGROUND/PURPOSE: Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role of laparoscopy in complicated acute appendicitis is more controversial. The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis. METHODS: A total of 102 children with suspected acute appendicitis were selected randomly to undergo either a laparoscopic or an open appendectomy. The outcomes of 25 children with complicated appendicitis, 13 in the laparoscopic group and 12 in the open appendectomy group, were analyzed. Children, their parents, and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation. All 25 children completed a 30-day follow-up. RESULTS: There were no differences in terms of patients' age, sex, weight, height, and appendiceal histology between the 2 groups. All laparoscopic procedures were completed without conversion. The mean (+/-SD) operating time was 63 (+/-31) minutes in the laparoscopic group and 37 (+/-18) minutes in the open appendectomy group (mean difference 26 minutes, 95% CI 5 to 47 minutes, P =.02). There were 2 major complications in the laparoscopic group in children with appendiceal masses. One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation. Another child had a pelvic abscess that resolved with antibiotic treatment. Superficial wound infections were encountered in 2 patients in the open appendectomy group. CONCLUSIONS: Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis. Good surgical judgement is necessary in patients with an established appendiceal abscess.