Flexible intramedullary nailing for treatment of proximal humeral and humeral shaft fractures in children: A retrospective series of 118 cases.

BACKGROUND: The aim of this study was to analyze outcomes of treatment and complications in children treated with flexible intramedullary nailing (FIN) due to humeral fracture. HYPOTHESIS: The FIN for treatment of humeral fractures in children would allow an early functional and cast-free follow-up with a quick pain reduction and low complication rate. PATIENTS AND METHODS: From May 2002 until May 2016 case records of all children who underwent fixation with titanium intramedullary nails because of humeral fracture were retrospectively reviewed. The study included 118 patients treated with FIN for proximal humeral or humeral shaft fracture. The average age at the time of trauma was 12 years. Mean follow-up was 77 months. Left hand was affected in 51% of patients. The most common mechanism of injury was fall (n=58), followed by sports injuries, road traffic accidents, pathological fractures, motorbike accidents and bicycle riding. RESULTS: There were no residual valgus/varum deformities. All patients achieved complete radiographic healing at a mean of 7.5 weeks. Nine complications were recorded: 1 humeral shaft fracture in patient with osteogenesis imperfecta, 4 entry site skin irritations, 2 skin infections and 2 radial nerve injuries. There were no cases of delayed union, nonunion or mal-union. After removal of the nails, all patients regained full function and all complications resolved. DISCUSSION: The FIN for humeral fractures is a minimally invasive, simple and well reproducible technique with very low complication rate. CONCLUSION: The FIN for treatment of humeral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. LEVEL OF EVIDENCE: Level IV - retrospective study.

Expression of Ki-67 and p53 in meningiomas.

UNLABELLED: Meningiomas account for about 30% of all primary brain tumors. It is difficult to predict the behaviour of meningiomas, and identification of protein markers responsible for the regulation of cell proliferation can be very helpful. The aim of this study was to evaluate immunohistochemical expression of Ki-67 and p53 in 170 meningiomas.A total number of 170 meningioma samples were classified according to WHO, immunohistochemically stained for Ki-67 and p53 and analysed using light microscope. Of 170 meningiomas analysed, 142 were grade I, 17 grade II and 11 grade III. Female to male ratio was 1.42:1. Statistically significant correlation was found between tumor grade and Ki-67 (p<0.001). There was significant correlation between Ki-67 levels and tumor subtypes (p=0.009). The optimal cut-off value for Ki-67 was 3.195. Tumors with Ki-67 ≤3.195 were 2 cm smaller than tumors with Ki-67 >3.195. Statistically significant correlation was found regarding p53 expression and tumor size (p=0.034). No correlation was established between Ki-67 or p53 and location of the tumor.According to positive correlation between tumor grade and subtype with Ki-67 levels, as well as positive correlation between Ki-67 and p53 with tumor size, indicate that Ki-67 and p53 might have influence on meningioma development and progression. KEYWORDS: meningioma, Ki-67, p53, immunohistochemistry.

Unusual cause of small intestine obstruction in a child: small intestine anisakiasis: report of a case.

INTRODUCTION: Anisakiasis is caused by human infection by the anisakis larvae, a marine nematode found in undercooked or raw fish. Infection with the parasite Anisakis simplex is common in Japan and northern European countries. With the increased popularity of eating sushi and raw fish infection with anisakis is expected to rise. CASE PRESENTATION: We present the case of a 14-year-old boy who had eaten sushi 3 days before the onset of symptoms and had small bowel obstruction caused by enteric anisakiasis. To the best of our knowledge this is the first reported case of intestinal anisakiasis presenting as a bowel obstruction in a child. CONCLUSION: Enteric anisakiasis is very rare, and its diagnosis is usually made after laparotomy. Nevertheless, when signs of acute abdomen develop after the ingestion of raw fish, such as sushi or sashimi, the possibility of enteric anisakiasis should be considered.

Bilateral abdominoscrotal hydrocele in a 5-month-old infant presented with a left leg edema and cyanosis.

A 5-month-old infant presented with bilateral abdominoscrotal hydroceles since birth and left leg edema and cyanosis. An ultrasound of the abdomen showed a cystic mass. Computed tomography showed a fluid filled mass extending intra-abdominally through the inguinal canal from the scrotum. A bilateral hydrocelectomy was performed, and the proximal sac was completely excised through the inguinal incision. The edema of the left leg resolved 2 days after surgery. The postoperative course was uneventful, without complication.

Unusual cause of palpable mass in upper abdomen--giant gastric trichobezoar: report of a case.

A trichobezoar is a ball of swallowed hair that accumulates in the stomach and fails to pass through the intestines. Usually a trichobezoar presents in early satiety and malnutrition. Obstructive symptoms and manifestations of gastric outlet obstruction may occur. While small gastric trichobezoars may be removed via gastroscopy, large trichobezoars require surgical removal by gastrotomy through abdominal incision. We present a case of a successful mini-laparotomy removal of a giant gastric trichobezoar in a 15-year-old girl with a history of trichophagia for a long time and marginal psychological disturbances.

Influence of inguinal hernia mesh repair on testicular flow and sperm autoimmunity.

BACKGROUND: The incidence of infertility caused by the mesh inguinal hernia repair is not known. The aim of this study was to determine circulation and immunological testicular disorders after inguinal hernia mesh repair which can be related with infertility. METHODS: From February 2010 to December 2010, 43 male patients who underwent inguinal hernia mesh repair were included in a prospective study. Testicular, capsular and intratesticular arterial flow dynamics were measured by Color Doppler ultrasound before the operation, in early and late postoperative period. The antisperm antibodies were analyzed before hernia repair and 5 months after. RESULTS: The difference between patients who underwent laparoscopic (Group I) and anterior open tension-free hernia repair (Group II) in age, duration of symptoms and hernia characteristics were not significant. Statistically significant differences were found in peak-systolic and end-diastolic velocity in testicular and intratesticular arteries in Group II and in peak-systolic velocity on all levels in Group I. Only Group I had significant differences in resistive index of intratesticular arteries. All the values returned to basal in late postoperative period except testicular peak-systolic velocity in Group I which stayed in normal range. Wilcox matched pair test showed significant difference between preoperative and late postoperative measurements of the antisperm antibodies only in Group II, but it was within normal range in all cases. CONCLUSIONS: Inguinal hernia mesh repair do not have clinically significant influence on testicular flow and immunological response.

Synchronous bilateral infiltrating syringomatous adenoma of the breast.

Infiltrating syringomatous breast adenoma is an uncommon mammary neoplasm composed of angulated glandular structures with a variable amount of epidermoid differentiation which proliferate in a background of dense collagenous stroma. The patient presented with bilateral hardness and oedema of the nipples. Ultrasound and mammography revealed microcalcifications in retromammilary regions of both nipples. Histological examination of the resected specimens showed angulated glands and solid cords, lined by an inner layer of epithelial cells and an outer layer of myoepithelial cells, immersed in desmoplastic stroma. Within the solid cords reminiscent of squamous cells, occasionally aggregated in keratinizing cysts were found. To the best of our knowledge this is the first described case of bilateral infiltrating syringomatous breast adenoma with synchronous presentation. Infiltrating syringomatous adenoma is a rare lesion. A finding of infiltrating syringomatous adenoma in one breast should prompt careful examination of the opposite breast with adequate follow-up.

Elastic stable intramedullary nailing for pediatric long bone fractures: experience with 175 fractures.

PURPOSE: To demonstrate the effectiveness of intramedullary fixation of displaced long bones shaft fractures in skeletally immature children using the elastic stable intramedullary nails. PATIENTS AND METHODS: The case records of 173 children who underwent fixation with titanium intramedulary nails because of long bones fractures were reviewed. The average age of the patients was 11.7 years, and mean follow-up was 41.3 months. There were 55 humeral, 42 forearm, 42 femoral and 36 tibial fractures. Subjective satisfaction was assessed. RESULTS: All patients achieved complete healing at a mean of 7.5 weeks. Complications were recorded in 11 (6.3%) patients and included: one neuropraxia, six entry site skin irritations, two protrusions of the wires through the skin and two skin infections at the entry site. In a subjective measure of outcome at follow-up, 89% of patients were very satisfied and 11% satisfied; no patients reported their outcome as not satisfied. The implants were removed at a median time of six months from the index operation. CONCLUSION: Elastic Stable Intra-medullary Nailing is the method of choice for the pediatrics patients, because it is minimaly invasive and shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction.

Management of cement vertebroplasty in the treatment of vertebral hemangioma.

BACKGROUND: The vertebral hemangiomas are benign vascular lesions occurring in spine. Although uncommon, symptomatic vertebral hemangiomas can be painful and can limit daily activities. A number of methods have been used in the treatment of symptomatic and aggressive vertebral hemangioma, but none of them is optimal. Treatment with cement vertebroplasty showed very good results. This study aims to illustrate the validity of the treatment with cement vertebroplasty in patients with painful vertebral hemangiomas. PATIENTS AND METHODS: From January 2000 to January 2007, 24 patients were treated by percutaneous vertebroplasty because of hemangioma: 16 thoracic, 8 lumbar. There were 11 males and 13 females. The average age at the time of surgery was 48 years. All the patients complained of a pain syndrome resistant to continuing medication. All patients underwent X-ray examination, CT-scan and MR of the involved level preoperatively. A unipedicular approach under fluoroscopic guidance has been performed in all patients. All procedures have been carried out under the local anesthesia. The mean follow-up was 5.8 years. RESULTS: In all the patients a successful outcome has been observed with a complete resolution of pain symptom. Extravertebral vascular cement leakage has been observed in 3 patients, without any clinical radicular syndrome onset due to the epidural diffusion. Clinical and radiological follow-up showed stability of the treatment and absence of pain in all patients. CONCLUSION: Percutaneous treatment with vertebroplasty for symptomatic vertebral hemangiomas is a valuable, less-invasive, and a quick method that allows a complete and enduring resolution of the painful vertebral symptoms without findings of the vertebral body's fracture.

High-pressure injection injuries of the hand--report of two cases.

High-pressure injection injuries to the hand are work-related injuries that can take a devastating toll on the functionality of the affected extremity. We present two cases of high-pressure injection hand injuries due to paint and sand. The patients were managed operatively and switch to intensive physiotherapeutic training, with excellent outcome.

Titanium intramedullary nailing for treatment of simple bone cysts of the long bones in children.

BACKGROUND: Simple or unicameral bone cysts are common benign fluid-filled lesions usually located in the long bones of children before skeletal maturity. Pathological fracture is common, and is often the presenting feature. AIM: The objective of the present study was to evaluate the results of titanium intramedullary nailing for the treatment of unicameral bone cysts with or without a pathological fracture. METHODS: During the period 2001 to 2007, flexible intramedullary nailing for the treatment of a unicameral bone cyst was performed in 18 children. Four of these patients presented with a pathological fracture. The cyst was located in the humerus in 14 patients, in the femur in three, and in the tibia in one. The diagnosis was based on typical radiographs and computed tomography. The mean age of the patients at the time of surgery was 9.4 years, and the mean duration of follow-up was 53 months. Radiographic evaluation was performed, and the cyst was classified as completely healed, healed with residual radiolucency, recurred, or having no response. RESULTS: Mean hospital stay was 24 hours. At one to four weeks postoperatively, all patients were pain free and had full range of motion of adjacent joints. Radiographic signs of cyst healing were present at three months in all patients, and all cysts healed completely. All of the cysts responded to treatment, with no cyst recurrence. No major complications were observed. CONCLUSION: Elastic intramedullary nailing has the twofold benefits of continuous cyst decompression, and early immediate stability to the involved bone segment, which permits early mobilization and return to normal activities.

Traumatic heterotopic ossification of the elbow in children--a case report.

Heterotopic ossification is defined as the formation of mature, lamellar bone within soft tissues other than the periosteum. We present a case of a 9-year-old girl with formation of heterotopic bone tissue in the elbow after surgical treatment of a fracture of the lateral humeral condyle. Eight months after the first operation the girl was re-operated to resect the heterotopic bone tissue. We believe that radical surgical excision of heterotopic bone, following physiotherapy around the elbow in children can improve the function of the extremity.

Pediatric tibial eminence fractures: arthroscopic treatment using K-wire.

BACKGROUND: Fractures of the tibial intercondylar eminence are observed mostly in children and adolescents, often after minimal trauma. The purpose of this paper is to evaluate the use of K-wire fixation for the arthroscopic treatment of tibial eminence fractures in children. PATIENTS AND METHODS: From January 2002 through January 2009 ten patients were treated arthroscopically because of the intercondylar eminence fracture in a Department of pediatric surgery, University Hospital Split. Arthroscopically controlled reposition was done, and using mobile X-ray two crossed K-wires were introduced percutaneously from the proximal part of the tibia to the fractured intercondylar eminence. Subjective outcome was obtained using IKDC subjective questionnaire. RESULTS: Average hospitalization time was 11 days. Average duration of treatment was 12.5 weeks. Average follow-up was 42 months. Follow-up radiographs showed union in all cases. The mean IKDC subjective score was 96/100. Clinically, all patients exhibited a solid endpoint on the Lachman test. The global IKDC objective score was normal in eight knees and nearly normal in two knees. CONCLUSION: Arthroscopic reduction and fixation by Kirschner wires or a small fragment screw is the best way for treatment intercondylar tibial eminence fractures, in the pediatric population, because is not crossing the epiphyseal plate.

How to prevent lateral thermal damage to tissue using the harmonic scalpel: experimental study on pig small intestine and abdominal wall.

INTRODUCTION: When using a harmonic scalpel, the lower amount of energy that is transduced to the tissue reduces the chance of lateral thermal damage. METHODS: Pigs (weight: 40 kg) were used as the experimental model. After anesthesia, tissue was coagulated using different application regimens for each group. The width of tissue necrosis was measured from the point of incision by the harmonic scalpel. RESULTS: The pig abdominal tissues suffered mean thermal damage of 0.0825 (output power 3) and 0.2969 mm (output power 5) when used for 5 s; at 10 s these values were 0.3850 and 0.4793 mm, respectively. In a third experimental condition, with 10 s of application broken down into 2 parts of 5 s with a 5-second pause in-between, these values were 0.1876 and 0.2013 mm, respectively. The small intestine tissues suffered mean thermal damage of 0.1302 (output power 3) and 0.1771 mm (output power 5) at a duration of 5 s. After 10 s of application, these values changed to 0.2655 (output power 3) and 0.2983 mm (output power 5). In the third condition (activity for 5 s, pause for 5 s, activity for 5 s), they were 0.2011 and 0.2258 mm, respectively. CONCLUSION: Coagulation necrosis is bigger if the usage is continuous rather than if it is disconnected/reconnected.

Lateral thermal damage to rat abdominal wall after harmonic scalpel application.

BACKGROUND: Use of the Harmonic Scalpel transduces a lower amount of energy to tissues, thereby limiting the potential for lateral thermal damage and deep penetration because only low temperatures are reached. The working principle of the Harmonic Scalpel is the transformation of electric power into the longitudinal mechanical movement of the instrument tip. This study aimed to determine the effects from varying durations of Harmonic Scalpel application on the experimental model of rat abdominal wall without skin. METHODS: After the rats had been anesthetized, and a laparotomy was performed. The Harmonic Scalpel shears were used on the muscular part of the abdominal wall without skin. Different durations of output power 3 were applied: a single 5-s application, a single 10-s application, and a regimen of two sequential 5-s applications. Each animal in each group of 10 received five individual activations, after which the animals were killed. Tissue samples were fixed and embedded in paraffin before sections were taken and stained. Using light microscopy and morphometric imaging analysis, the width of tissue lateral thermal damage was measured from the point of Harmonic Scalpel incision. RESULTS: The rat abdominal wall showed lateral thermal damage over a mean width of 0.0522 +/- 0.0097 mm after a 5-s Harmonic Scalpel application, a damage width of 0.1544 +/- 0.0419 mm after a 10-s application, and a damage width of 0.1020 +/- 0.0430 mm after a 5-s application followed by 5 s of inactivity and another 5 s of activity. These differences in thermal damage width between all the groups are statistically significant. CONCLUSIONS: The findings lead to the conclusion that tissue lateral thermal damage after Harmonic Scalpel application at standard output power is greater when a longer sustained period of application is used. Lateral thermal damage also is greater if the Harmonic Scalpel application time is continuous rather than of the same total duration with a brief midpoint interruption.