[Treatment of femoral shaft fractures in children and adolescents ≥50 kg : A retrospective multicenter trial]. / Behandlung der Femurschaftfraktur bei Kindern und Jugendlichen mit einem Körpergewicht ≥50 kg : Eine retrospektive multizentrische Erhebung.

BACKGROUND: Operative treatment of diaphyseal fractures of the femur in older children and adolescents remains controversial due to multiple surgical options and higher complication rates in single-center studies compared to younger children. This retrospective multicenter study aimed to register early and late complications in day-by-day treatment. MATERIAL AND METHODS: Sixteen hospitals with particular expertise in pediatric orthopedic trauma participated in this study. Patients with diaphyseal femur fractures, a body weight ≥50 kg (aged 10-16 years) and treated between 2008 and 2012 were included. Age, weight, fracture type, and choice of operative treatment were correlated to complication rate and type. Patients with pathologic fractures and/or metabolic bone disorders were excluded. RESULTS: Fifty-three children (15 females and 38 males; mean age: 14.2 y [SD 1.4 y]; mean body weight: 60.5 kg [max. 95 kg]) with 54 fractures were included. Elastic stable intramedullary nailing (ESIN) was the treatment of choice in 31 of 42 fractures with open growth plates. In the subgroup with two nails, 7 of 12 patients experienced revision surgery due to instability or shortening. Three patients with ESIN and end caps had no complications. In the subgroup with three inserted nails (11 patients), one patient was converted to external fixation. Nine patients received primary or secondary plate osteosyntheses. Within this group, two patients had deep infections; one implant failure, and one peri-implant fracture were recorded. Adolescent lateral femoral nailing (ALFN), when used as the primary treatment option in two patients, was free of complications. When used as a secondary treatment option in three patients, one patient had a pseudarthrosis and one an infection. Both were treated in further operative procedures. In a group of eight patients with closed physes, regular intramedullary nailing as primary or secondary treatment of choice resulted in one locking screw change. As late complications, leg length discrepancy (LLD) over 15 mm (n = 2) and loss of range of motion (ROM) (n = 4; two knee and three hip) were noted in patients receiving multiple revisions or serious postoperative complication. CONCLUSIONS: Children older than 10 years of age with a body weight ≥50 kg and open physes are prone to complications regardless of treatment choice. A smaller revision rate occurred in patients treated with ESIN and end caps or a third nail compared to the other treatment options. When physes are closed, rigid intramedullary nailing is the treatment of choice.

Femoral shaft fractures in young children (<5 years of age): operative and non-operative treatments in clinical practice.

BACKGROUND: Femoral shaft fractures comprise around 4 % of all long-bone fractures in childhood. There is controversy about the treatment of fractures in children below 5 years, between those preferring non-operative methods, such as casting or traction, and those supporting elastic stable intramedullary nailing (ESIN). METHODS: This retrospective study evaluates the day-by-day treatment of femoral shaft fractures in children aged 6-60 months in four major paediatric surgery trauma centres in Germany from 1 January 2004 to 31 December 2011 by chart review. We analysed all patient-related data, causes of fracture, fracture type, treatment method and potential post-treatment complications. RESULTS: We identified 225 patients (male to female 2:1) with femoral shaft fractures. Around 2/3 of these resulted from falls of less than 1 m or 1-3 m, the most frequent result (>40 %) being a long spiral fracture. All 19 children below 1 year of age were treated by casting or traction. Between the ages of 12 and 24 months (n = 56), different treatment concepts were preferred (1/5 ESIN, 2/5 traction and 2/5 spica casting). Between 24 and 36 months, operative and non-operative therapies were equally distributed. In children older than 36 months (n = 64), most fractures were treated by ESIN: six children by external fixation and 14 by other treatments like spica casting, plate osteosynthesis or a combination of methods. 42 changes of treatment were performed: traction to spica casting or secondary operative treatment and 21 complications occurred (nails left in place for too long, skin defects or wound infections). CONCLUSIONS: Spica casting of femoral shaft fractures or, in some cases, traction is still the preferred treatment in the first and second years of life. In the third year, children are treated operatively as well as non-operatively, although now there is no current evidence of better short-term outcomes in operatively treated children. But elastic stable intramedullary nailing is the standard treatment for femoral shaft fractures in children older than 3 years of age.

Treatment outcome in 60 children with pathological fractures of the humerus caused by juvenile or aneurysmal bone cysts.

The treatment of pathological fractures of the humerus caused by juvenile or aneurysmal bone cysts (JBC/ABC) should be a single approach with a high success rate and low complication rate. This study evaluates how day by day treatment concepts fulfil these aims. Children below 15 years of age with a pathological fracture of the humerus caused by a JBC or ABC between 01.01.2001 and 31.12.2010, were investigated by chart review in four major paediatric trauma centres. Age, gender, fracture localisation, X-ray findings, treatment and outcome - assessed by the Capanna classification (I to IV), were analysed. 60 children [41male, 19 female; mean age: 9 years (4-14 years)] with 43 JBC and 12 ABC were included as well as five cysts, who could not be classified definitively. First treatment was non-operatively in 33 children. Of these 27 cysts did not improve; likewise the supportive installation of cortisone in six patients did not change the outcome. The first treatment consisted of elastic stable intramedullary in 13 children; up to three nail exchanges included. But only six of these reached (nearly) complete resolution (I/II). Overall the combined mechanical and biological treatment with curettage, elastic stable intramedullary nailing, (artificial) bone substitute and in some cases growth factors was performed as the 1st-line treatment in nine patients and further in 2nd or 3rd-line treatments in 13 humeral cysts. More than half of these reached a complete or nearly complete resolution of the cyst (12x I, 5x II, 1x III, 4x IV). Major complications in all operated patients were six nails not removable and two children with upper extremities length differences. Healing rates are low for non-operative treatment, elastic stable intramedullary nailing alone and by using cortisone for cysts resolution in pathological fractures of the humerus. Data support a combined mechanical and biological treatment with curettage, elastic stable intramedullary nailing, (artificial) bone substitute and the use of growth factors.

A comprehensive analysis of peptides presented by HLA-A1.

Human leukocyte antigen (HLA)-A1 is one of the most common Caucasian HLA-A alleles. Here, we describe the comprehensive analysis of the HLA-A*01:01 ligand repertoire with the identification of 4735 naturally processed and presented peptides derived from 2477 source proteins. We found HLA-A*01:01 bound an equivalent number of ligands of 9 or 10 amino acids in length as well as being remarkably tolerant of even longer peptides. Indeed close to half of the HLA-A1 bound peptides identified ranged between 11 and 13 amino acids in length. These longer peptides contained the strong canonical motif of and acidic E/D residue at position 3 (P3) and Y at the C-terminus (CΩ), a motif that was still apparent in peptides of up to 18 amino acids in length. The identification of this large database of natural ligands will facilitate the refinement of predictive algorithms particularly with respect to longer peptide ligands.

Long-term results of Rehbein's procedure: a retrospective study in German-speaking countries.

AIM: In contrast to other countries, no collective study of Rehbein's procedure in German-speaking nations has been performed. Therefore, our intention was, analogously to Goto and Ikeda's (10) Japanese study in 1984, Kleinhaus's (13) study on Swenson's procedure in 1979, Bourdelat's (2) French-Canadian investigation into Duhamel's technique in 1997 and Martuciello's (11) and Teitelbaum's (16) follow-up in the year 2000, to perform a follow-up study of Rehbein's technique of deep anterior resection. METHODS: The data of 200 patients from 22 German-speaking centers in Switzerland, Austria and Germany were collected. These data were gathered by questionnaire and the children were followed up in the individual participating hospitals for at least 3.5 years after the procedure. The procedure was performed between 1993 and 1997, over a 5-year period. The questionnaire contained 74 items including anamnestic data, diagnostic postoperative treatment and reoperations. RESULTS: Concerning the incidence of anastomotic leaks and resolving anastomotic strictures there was no significant difference between the results in our series and those of the collective analyses made by Hofmann von Kap-herr (7), Holschneider (9) and Sherman (18). In 6.6 % of the 191 patients an anastomotic leak and in 9.9 % a rectal stricture, which had to be dilated, was observed. Concerning late complications, 22.8 % of the children suffered from constipation, 4.3 % from encopresis, 10.6 % from enterocolitis and only 0.5 % from enuresis. The frequency of constipation diminishes over the years. A comparison of the different large series in the literature clearly shows that the incidence of constipation is higher after Rehbein's procedure and the frequency of urinary incontinence and encopresis higher following Swenson's, Soave's and Duhamel's techniques. The incidence of enterocolitis is less after Rehbein's procedure than after Swenson's, Soave's and Duhamel's techniques. CONCLUSIONS: The different results in the literature are due to the individual experience of the author, the very different follow-up methods and the date of follow-up. Therefore, the different results are hard to compare with our study. Nevertheless, Rehbein's anterior resection still could be presented as an adequate and important method to treat Hirschsprung's disease.

Special programs for special groups.

Special groups of persons with mental illness require individually tailored programs.

A critical review of the optimum duration of chronic rodent testing for the determination of non-tumourigenic toxic potential: a report by the BTS Working Party on Duration of Toxicity Testing.

This review indicates that for the detection of non-neoplastic toxic effects: 1. Four decades of accumulated literature provide no lead as to the optimum duration of repeat dose toxicity testing required for all classes of chemicals, although 6 months repeated administration appears adequate for pharmaceuticals. 2. Three month studies predicted the 2 year outcome for 70% of the compounds evaluated in this pilot study using data published by the US National Toxicology Program. 3. In spite of the limitations of this pilot study, this finding is considered encouraging as it is close to that generated previously on more detailed confidential pharmaceutical data. This suggests that the exercise should now be expanded using confidential surveys of industrial data to determine the concordance resulting from the evaluation of a larger group of chemicals.

[Surgical therapy of neonatal necrotizing enterocolitis]. / Die operative Therapie der neonatalen nekrotisierenden Enterocolitis.

Between 1972 and 1988, a total of 57 patients with an average birth weight of 1988 g and an average gestational age of 34.1 weeks were operated on for neonatal necrotizing enterocolitis. In 48% of the cases, the critical indication for surgery was determined by clinical examination; in 52% of the cases, the indication was based upon a radiological diagnosis of pneumoperitoneum. The affected intestinal portions were first resected. Then, the proximal and distal limbs were sewn together and brought out through a separate short incision. Utilizing this procedure, the lethal rate sank from above 80% to below 30%. Taking into account unrelated causes of death, no significant increase in risk has been associated with the use of this procedure on prematurely born patients and patients exhibiting acute intestinal perforations.

[Diagnosis, therapy and follow-up of infants with urethral valves, treatment concept in the 1st year of life]. / Diagnostik, Therapie und Verläufe von Säuglingen mit Harnröhrenklappen, Behandlungskonzept im 1. Lebensjahr.

Within the framework of a joint follow-up we report on the treatment of 57 infants with urethral valves (35 babies from Munich and 22 from Siegen) in the first year of life, studied between 1974 and 1986. In 16 newborn the diagnosis and initiation of treatment was effected during the first four weeks of life (Group I) and in 41 babies during the 2nd to 12th month (Group II). In three cases, diagnosis of suspected urethral valve was made prenatally. Primary management and the concept of further treatment are described. Primary therapy is determined by the general condition after birth, presence of urosepsis and the extent of any existing renal insufficiency. 2 children died, both from Risk Group I. 5 children are in a state of compensated renal insufficiency. In 2 newborn we were compelled to perform supravesical urinary drain and in 3 children a suprapubic drain. Secondary nephrectomy became necessary in 4 children, 3 of whom belonged to Risk Group I. In 23 of 57 children valve resection followed by transurethral drainage was the only therapy. In 22 of 57 children corrective surgery was performed subsequently (neo-implantation, with and without modellage, stenosis of the ureter exit). The article reports on the course in each case.