[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.

[Children and Adolescents with Asthma Differ in Lung Function Parameters and Exhaled NO from Children and Adolescents with Obesity]. / Kinder und Jugendliche mit Asthma unterscheiden sich in ihrer Lungenfunktion und im exhalierten NO von Kindern und Jugendlichen mit Adipositas.

BACKGROUND: The prevalence of asthma and overweight/obesity in children and adolescents is continuously increasing over the last decades. It remains unclear if overweight/obesity raises the risk of developing asthma or if an uncontrolled asthma increases the risk of developing overweight/obesity by restricting physical activity. OBJECTIVES: We aimed to elucidate, if children and adolescents with overweight/obesity differ from normal-weight asthmatics in lung functions parameters (FEV1, FEV1/VC, MEF50 and SRtot) and in exhaled nitric oxide (FeNO). METHODS: Totally, n=142 children and adolescents aged 6-18 years were included in this study: group 1 comprised n=44 with overweight/obesity defined as a Body-Mass-Index (BMI)>90th percentile; group 2 n=44 with a doctors diagnosed bronchial asthma according to the GINA-guidelines, and group 3 with n=36 pulmonary healthy controls. N=18 children with both asthma and overweight/obesity were excluded from further analysis. We collected data about socio-demographic variables from a standardized questionnaire, bodyplethysmography (FEV1, FEV1/VC, MEF50 and SRtot) and FeNO. RESULTS: Normal-weight children and adolescents with asthma had significantly lower FEV1/VC (Tiffenau-Index 90,9±12,8) and MEF50 (84.0% predicted±27.6) than children with overweight/obesity (97,6±12,4 p=0.001 respectively 99.1±20.9 p=0.001) and healthy controls (98±13,5 p=0,003; 96.7±19.3 p=0.011). Normal weight asthmatics had a significantly higher FeNO (38.3 ppb) than children and adolescents with overweight/obesity (14.0 ppb p=0.014). CONCLUSIONS: Normal-weight children and adolescents with asthma differ significantly both in their lung function parameters as well as in their exhaled nitric oxide concentration from children and adolescents with overweight/obesity. For clinical practice it is important to note that children and adolescents with overweight/obesity have no signs of an obstructive airway diseases and are as resilient as healthy children and adolescents with regard to their lung function. The possible late-onset of asthma symptoms and lung function changes in children and adolescents with overweight/obesity requires further detailed longitudinal studies.

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.

[LiLa classification for paediatric long bone fractures. Intraobserver and interobserver reliability]. / LiLa-Klassifikation für Frakturen der langen Röhrenknochen im Wachstumsalter. Intra- und Interobserverreliabilität.

BACKGROUND: There are two child-specific fracture classification systems for long bone fractures: the AO classification of pediatric long-bone fractures (PCCF) and the LiLa classification of pediatric fractures of long bones (LiLa classification). Both are still not widely established in comparison to the adult AO classification for long bone fractures. METHODS: During a period of 12 months all long bone fractures in children were documented and classified according to the LiLa classification by experts and non-experts. Intraobserver and interobserver reliability were calculated according to Cohen (kappa). RESULTS: A total of 408 fractures were classified. The intraobserver reliability for location in the skeletal and bone segment showed an almost perfect agreement (K = 0.91-0.95) and also the morphology (joint/shaft fracture) (K = 0.87-0.93). Due to different judgment of the fracture displacement in the second classification round, the intraobserver reliability of the whole classification revealed moderate agreement (K = 0.53-0.58). Interobserver reliability showed moderate agreement (K = 0.55) often due to the low quality of the X-rays. Further differences occurred due to difficulties in assigning the precise transition from metaphysis to diaphysis. CONCLUSIONS: The LiLa classification is suitable and in most cases user-friendly for classifying long bone fractures in children. Reliability is higher than in established fracture specific classifications and comparable to the AO classification of pediatric long bone fractures. Some mistakes were due to a low quality of the X-rays and some due to difficulties to classify the fractures themselves. Improvements include a more precise definition of the metaphysis and the kind of displacement. Overall the LiLa classification should still be considered as an alternative for classifying pediatric long bone fractures.

Laryngomalacia and complicated, life-threatening mTOR-positive Kaposiform hemangioendothelioma cured by Supraglottoplasty and sirolimus.

The therapy of complicated Kaposiform hemangioendothelioma (KHE) is still difficult. We present the first case of laryngomalacia with simultaneous mammalian target of Rapamycin (mTOR)-positive KHE of the neck and thoracic inlet and concurrent Kasabach-Meritt Phenomenon (KMP) in an 11-month-old boy suffering life-threatening progress despite intravenous vincristine, corticosteroids, propranolol and local interstitial laser-application. The laryngomalacia restored after laser-supraglottoplasty. Successfully treatment of the prior fatal course of the KHE with KMP was initiated not till adding the mTOR inhibitor sirolimus to therapy. After 16 months single therapy of KHE with oral sirolimus the boy presented free of symptoms with minimal residual disease and excellent functional long-term results. Thus we stopped sirolimus therapy. The results are stable for 9 months without therapy. The special features including full report of histopathologic findings of this utmost complicated case are demonstrated in detail underlining the effectiveness of sirolimus for KHE.

Increasing stability by pre-bending the nails in elastic stable intramedullary nailing: a biomechanical analysis of a synthetic femoral spiral fracture model.

Elastic stable intramedullary nailing (ESIN) is generally acknowledged to be the treatment of choice for displaced diaphyseal femoral fractures in children over the age of three years, although complication rates of up to 50% are described. Pre-bending the nails is recommended, but there are no published data to support this. Using synthetic bones and a standardised simulated fracture, we performed biomechanical testing to determine the influence on the stability of the fracture of pre-bending the nails before implantation. Standard ESIN was performed on 24 synthetic femoral models with a spiral fracture. In eight cases the nails were inserted without any pre-bending, in a further eight cases they were pre-bent to 30° and in the last group of eight cases they were pre-bent to 60°. Mechanical testing revealed that pre-bending to 60° produced a significant increase in the stiffness or stability of the fracture. Pre-bending to 60° showed a significant positive influence on the stiffness compared with unbent nails. Pre-bending to 30° improved stiffness only slightly. These findings validate the recommendations for pre-bending, but the degree of pre-bend should exceed 30°. Adopting higher degrees of pre-bending should improve stability in spiral fractures and reduce the complications of varus deformity and shortening.

Biomechanical analysis of a synthetic femur spiral fracture model: Influence of different materials on the stiffness in flexible intramedullary nailing.

BACKGROUND: Flexible intramedullary nail fixation of dislocated diaphyseal femur fractures has gained wide acceptance for children and adolescents with open physes. Studies with a special emphasis on complications reveal frequent problems regarding stability, usually in complex fracture types such as spiral fractures and in older children weighing >40kg. This biomechanical study analyses how much the material of the nails influences the stiffness in a synthetic bone model. METHODS: Twenty-four composite grafts (Sawbones®, 4th generation, medullar canal of 10mm) with an identical spiral fracture were used in three configurations of eight grafts. Elastic stable intramedullary nailing was performed in a retrograde C-shaped manner with two nails of equal size (2×3.5mm). Close contact of the fragments could be achieved. We compared Group A (steel nails) with Group B and C (two types of titanium nails). All specimens underwent 4-point bending, torsion and axial compression in the 0° and 9° positions, and the results were analysed. FINDINGS: Group A (steel nails) revealed a significantly higher stiffness in all directions than Group B. Apart from compression in the 9° position this steel nail fixation showed significant higher stiffness than titanium nails of Group C. Comparing Group B and C did not show an systematic difference. INTERPRETATION: In this biomechanical study with composite artificial bones the use of steel Nails demonstrated the highest stiffness in our model when compared to two different titanium nail configurations. Apart from in cases of known allergy or planned MRI-examinations our results and data from the literature question the use of titanium nails.

[Dislocated midclavicular fractures in children and adolescents: who benefits from operative treatment?]. / Dislozierte Klavikulafrakturen im Kindes- und Jugendalter: Wer profitiert von einer Operation?

BACKGROUND: Displaced midclavicular fractures in children are generally treated non-operatively. But there is a lack of age-related data concerning the functional and cosmetic results following conservative treatment and patients' content with the treatment. PATIENTS AND METHODS: In patients with displaced midclavicular fractures complications and pain was evaluated in relation to treatment option and age. Outcome was measured with the Constant Shoulder Score, a client satisfaction questionnaire (ZUV-8) about the satisfaction with the treatment and the cosmetic result and ultrasound of both clavicles. RESULTS: A review of emergency room and fracture clinic records revealed 101 children and adolescents in whom displaced midclavicular fracture had been treated between 1/1997 and 12/2007. The follow-up included 59 patients with 60 fractures 1-10 years after the accident. Of those, 50 fractures were treated with a sling and 10 by operation. All patients under the age of ten were treated conservatively and reached very good functional and cosmetic results. Only an eight-year-old girl suffered from a painful pseudarthrosis. After resection and stabilisation by flexible intramedullary nailing, the outcome was excellent. Patients over the age of ten received a conservative treatment in 28 cases and ten had an operation (K-wires fixation n=2, elastic stable intramedullary nail n=8 in 7 patients). Functional outcome independent of treatment method was as good as in younger children, but the global and cosmetic satisfaction score was much lower. Older patients with a non-operative treatment suffered from more pain and were dissatisfied with the long immobilisation. CONCLUSION: The method of choice in children under the age of ten with a displaced clavicular fracture is the non-surgical treatment supported by sufficient pain medication. Older children reach good results but suffer from more pain and are dissatisfied by the cosmetic results and immobilisation. Because of this, active older children and adolescents with a displaced clavicular fracture benefit from elastic stable intramedullary nailing.

Early Weight Bearing of Calcaneal Fractures Treated by Intraoperative 3D-Fluoroscopy and Locked-Screw Plate Fixation.

Operative therapy of intraarticular fractures of the calcaneus is an established surgical standard. The aim is an accurate reduction of the fracture with reconstruction of Boehler's angle, length, axis and subtalar joint surface. Intraoperative 3D-fluoroscopy with the Siremobil Iso-C 3D(R) mobile C-arm system is a valuable assistant for accurate reconstruction of these anatomical structures. Remaining incongruities can be recognized and corrected intraoperatively. The achieved reduction can be fixed by the advantages of an internal fixator (locked-screw plate interface). In the period of October 2002 until April 2007 we operated 136 patients with intraarticular fractures of the calcaneus by means of anatomical reduction, and internal plate fixator under intraoperative control of 3D-fluoroscopy. All patients were supplied with an orthesis after the operation which allowed weight bearing of 10 kg for 12 weeks for the patients operated between October 2002 and October 2004 (Group A). Transient local osteoporosis was observed in all X-Rays at follow-up after an average of 8,6 months. Therefore we changed our postoperative treatment plan for the patients operated between November 2004 and April 2007 (Group B). Weight bearing started with 20 KG after 6 weeks, was increased to 40 KG after 8 weeks and full weight bearing was allowed after 10 weeks for these patients. In no case a secondary dislocation of the fracture was seen. No bone graft was used. At follow up the average American Foot and Ankle Society Score (AOFAS) were 81 for Group_A, compared to 84 for Group B, treated with earlier weight bearing. Autologous bone graft was not necessary even if weight bearing was started after a period of six weeks postoperatively. The combination of 3D-fluoroscopy with locked internal fixation showed promising results. If the rate of patients developing subtalar arthrosis will decrease by this management will have to be shown in long term follow up.

[The laparoscopic spleen-preserving approach to splenic cysts: advantages and limitations]. / Laparoskopische organerhaltende operationen bei nicht-parasitären milzzysten: möglichkeiten und grenzen.

INTRODUCTION: Due to the multiple functions of the spleen the preferred management of cystic non-parasitic lesions is nowadays laparoscopic partial splenectomy or decapsulation with preservation of the spleen. We have analysed our patients with non-parasitic cystic lesions and the current literature to weigh the benefits and complications of these methods in children and adults. PATIENTS AND METHODS: Laparoscopic partial splenectomy was performed in three children with dysontogenetic cysts. Laparoscopic marsupialisation was performed in one child and in three adults. RESULTS: Follow-up in the true cysts showed no recurrence in one patient and one residual cyst in the second. In the third patient, splenectomy was performed because there was not enough residual spleen to warrant preservation. In the group with post-traumatic cysts, no complications or recurrences were observed. DISCUSSION: The laparoscopic spleen-preserving approach for the treatment of non-parasitic cysts is feasible, but challenging. The main problem is a recurrence rate of more than 20 %. The reason for recurrence remains uncertain: it is probably due to different operative strategies, the morphology of the cysts or the presence of residual cysts. The recurrence rate in post-traumatic cysts is low on the basis of our own experience and a literature survey. CONCLUSION: The benefit of laparoscopic treatment in true non-parasitic splenic cysts has to be weighed against the rate of recurrence. A complete resection of the cysts should be attempted. In post-traumatic cysts, laparoscopy offers a good minimally invasive treatment option.

[Omphalocele and gastroschisis. Outcome--complications--follow-up--quality of life]. / Omphalocele und Gastroschisis. Ergebnisse--Komplikationen--Verlauf--Lebensqualität.

From 1970 to 1998, 35 children with omphalocele (OC) and 31 with gastroschisis (GS) were treated at the Department of Paediatric Surgery at Lübeck Medical University. Forty of 43 survivors were examined in 1990, the data of 30 patients were renewed in 1999 and 12 new cases added. Total follow-up was 1-28 years. Primary closure was possible in 25 OCs and 20 GSs. Eighteen children with OC and 8 with GS suffered from additional abnormalities, which were treated simultaneously. Twenty percent of the babies with OC died mostly because of severe congenital anomalies and 12.9% of GS because of infectious complications in combination with other diseases. There were no more deaths in the last decade. Accordingly, there was a reduction in consecutive operations. Improvements were due to better operative and perioperative treatment as well as abortions following improved ultrasound examinations. The results of the literature and our own experience show the benefit of primary closure. A two-stage approach with dura/amnion or a silo procedure prevents high intra-abdominal pressure, therefore, indirect measurements of intra-abdominal pressure can be used exceptionally. Umbilical preservation offers better cosmetic results. Long-term follow-up reveals normal growth and development of the children except for those with severe congenital anomalies. All the others are participating without problems in normal activities and education without reduction in their quality of life. Today an isolated OC or GS is not an indication for abortion. If prenatal OC or GS is diagnosed, paediatric surgeons should be involved in the consultations.

[Treatment strategy in inguinal injection abscess and complications]. / Behandlungsstrategie inguinaler Spritzenabscesse und ihrer Komplikationen.

From 1994 to March 1997, 12 patients with 15 drug-related abscesses of the groin were treated at the Surgical Department of Lübeck Medical University. Besides laboratory, serological and microbiological examinations, the standard diagnostic investigation consisted of sonography or duplex sonography. If indicated, the diagnosis was extended to include, for example, clarification of the retroperitoneum by CT. The most common accompanying disease was deep femoral vein thrombosis. Substitution was planned individually. After surgical débridement and perioperative administration of a beta-lactam-protected acylaminopenicillin, open wound treatment was successfully carried out in 13 cases; secondary closure was performed four times in cases of good compliance. One abscess led to necrotising of the femoral artery; saphenous vein was interposed because of erosion bleeding and formation of aneurysm. In a second case, the bifurcation was reconstructed with saphenous vein after external resection of an infected false aneurysm and early occlusion. Both defects were covered by rotation of sartorius muscle and mesh graft. On the basis of the treatment concept, a rapid and successful intervention was possible; complications such as sepsis, amputation or withdrawal delirium did not occur. Resistance against the antibiotic was not observed. In the case of infected aneurysm, we prefer the autogenous saphenous vein graft followed by rotation of sartorius muscle and mesh graft. Ligation or excision leads to high rates of claudication or amputation; extended reconstructions are threatened by insufficient compliance of the patients; the use of synthetic grafts is endangered by further bacteraemia or infections.

[Ischemic colitis after vascular surgery reconstruction of an abdominal aortic aneurysm]. / Ischämische Colitis nach gefässchirurgischer Rekonstruktion des Bauchaortenaneurysmas.

Between 1978 and 1994, a total of 678 patients were operated on for infrarenal (abdominal) aortic aneurysm at the Department of Surgery of Lübeck Medical University. Rupture had occurred in 165 patients, 351 were treated electively, and 162 presented with severe symptoms but no rupture. Only CT, angiography and intraoperative judgement were used for diagnosis. Reconstruction of the inferior mesenteric artery (IMA) was performed only in exceptional cases. Severe ischemic colitis occurred in 1.03% (in no case following elective surgery, in 0.66% of patients presenting with symptoms, and in 3.6% of patients in whom rupture had occurred prior to the operation). Three patients presented with mild ischemia, two with grade B ischemic colitis and three with transmural infarction. One patient had to be operated on for ischemic colitis despite open reconstruction of the IMA. We conclude from our data that there is no need to reconstruct the IMA as a routine procedure; this topic has been a controversial issue in the literature. We do reimplant a patent IMA when there is only oozing from the IMA and/or a borderline perfusion of the sigma following the operation, with at least one open internal iliac artery. When rupture had occurred, reconstruction should be performed if there is the slightest suspicion because of the increased risk, but only if the patient's cardiopulmonary condition allows this to be done. Analysis of our patients with ischemic colitis demonstrates the importance of maintaining stable circulatory conditions to prevent intestinal ischemia. Further diagnostic procedures (Doppler ultrasound, measuring of oxygen saturation or pH) may identify more patients at risk, but at the moment we do not consider these to be routine procedures.

[PTFE prostheses in infrarenal aneurysms of the abdominal aorta]. / PTFE-Prothesen bei infrarenalen Bauchaortenaneurysmata.

Postoperative dilatation of Dacron vascular grafts can lead to aneurysms and rupture of the prosthesis making it necessary to change the graft by operation. Therefore, 15 patients at Lübeck University Hospital underwent replacement of the aorta with PTFE prostheses due to infrarenal aortic aneurysms. Ultrasound measurements 2-12 months postoperatively revealed a dilatation of 11.6% concerning tubular grafts, 11.5% for the shafts and 14.6% for the limbs of bifurcation grafts compared to the higher dilatation rate of Dacron prostheses described in the literature. There was no evidence of anastomotic false aneurysms, thrombosis of the limbs of bifurcation grafts, peripheral embolization or perigraft reaction. In conclusion, PTFE prostheses seem to be a means of preventing patients from having secondary complications as a result of graft dilatation. Based on our early results and the results described in the literature, PTFE prostheses can be regarded as an alternative to dacron prostheses.