Abdominal Cryptorchidism with Complete Dissociation between the Testis and Deferent Duct Mimicking Testicular Regression Syndrome.

Complete separation of the deferent duct from the epididymis in cryptorchid testes residing in the abdomen is an extremely rare variant of developmental disorders of the testis and epididymis. Available sources mention only three clinical cases similar to our observations. The unique anatomic aspects of this disorder hamper the correct diagnosis of an intra-abdominal cryptorchid testis. Two boys with nonpalpable left-sided cryptorchidism underwent diagnostic laparoscopy, revealing an intra-abdominally located testis. The epididymis was completely separated from the deferent duct, and the epididymis and testis were supplied by testicular vessels. Exploration of the inguinal canal revealed blind-ending deferent ducts. The testis was brought down through the inguinal canal and fixed in the scrotum in both boys. The follow-up examination at 6 months revealed no signs of testicular atrophy or malposition of the testis in either patient. With our observations in mind, the exclusive use of a transscrotal or transinguinal approach as the initial surgical exploration in the treatment of patients with nonpalpable forms of cryptorchidism may be inappropriate. Careful laparoscopic examination of the abdominal cavity is indispensable in children with suspected testicular regression syndrome or nonpalpable forms of cryptorchidism.

Transposition and fixation of lower pole crossing vessel in children with ureteropelvic junction obstruction: A STROBE-compliant study.

ABSTRACT: Chapman and Hellstrom techniques are typically employed to transpose renal lower pole crossing vessels (LPCVs). Both procedures have certain limitations. We investigated the midterm outcomes in pediatric patients in whom LPCV-induced ureteropelvic junction obstruction was treated with either dismembered Anderson-Hynes pyeloplasty or upward transposition coupled with a new technique to fix the LPCV.We retrospectively compared Anderson-Hynes pyeloplasty to the new technique in terms of outcome. LPCV transposition was considered feasible in patients in whom the diuretic loading test revealed a decrease in the pelvic volume after correction of vascular compression as well as absence of structural changes in the ureteropelvic junction (UPJ) and hemodynamic compromise of the lower renal pole. The fascial flap was passed below the LPCV to form a "hammock". The free edge of the flap was sutured to its base.Group 1 consisted of 102 (69.9%) patients (median age: 7.9 years) undergoing dismembered Anderson-Hynes pyeloplasty, while group 2 included 44 (30.1%) patients (median age: 8.4 years) treated with upward transposition and the new technique to fix the LPCV. No intra-operative complications or conversions occurred in either group. Redo-pyeloplasty was performed in 3 (2.9%) children of group 1 and 1 (2.3%) child of group 2. Renal ultrasonography conducted 12 months after surgery revealed similar anteroposterior diameters of the renal pelvis in groups 1 (7.9 ±â€Š8.1 mm) and 2 (6.0 ±â€Š2.9 mm). Patients in both groups showed a non-significant median increase in differential renal function at follow-up after at least 1 year after surgery (group 1: 36% [33.3; 40.5] vs 36.5% [35.3; 41.0]; group 2: 41% [37.5; 46.0] vs 43% [39; 46]).In our patients, the new technique for laparoscopic or open fixation of the obstructing vessel after transposition was effective, reproducible, and devoid of limitations typical for the Chapman and Hellstrom techniques. We recommend Anderson-Hynes pyeloplasty in children with a history of hydronephrosis diagnosed antenatally, recurrent abdominal pain, intra-operative absence of peristalsis across the UPJ, high location of the UPJ at the renal pelvis, or intra-operative absence of volume reduction of the renal pelvis upon furosemide testing.

Treatment of Unstable Occipital Condylar Fractures in Children-A STROBE-Compliant Investigation.

Background and objectives: Occipital condyle fractures (OCF) occur rarely in children. The choice of treatment is based on the Anderson-Montesano and Tuli classification systems. We evaluated the outcome of unstable OCF in children and adolescents after halo-vest therapy. Materials and Methods: We treated 6 pediatric patients for OCF, including 3 patients (2 girls, 1 boy) with unstable OCF. Among the 3 patients with unstable OCF, 2 patients presented with an Anderson-Montesano type III and Tuli type IIB injury, while 1 patient had an Anderson-Montesano type I fracture (Tuli type IIB) accompanied by a C1 fracture. On admission, the children underwent computed tomography (CT) of the head and cervical spine as well as magnetic resonance imaging (MRI) of the cervical spine. We treated the children diagnosed with unstable OCF with halo-vest immobilization. Before removing the halo vest at the end of therapy, we applied the CT and MRI to confirm OCF consolidation. At follow-up, we rated functionality of the craniocervical junction (CCJ) based on the Neck Disability Index (NDI) and Questionnaire Short Form 36 Health Survey (SF-36). Results: All children achieved OCF consolidation after halo-vest therapy for a median of 13.0 weeks (range: 12.5-14.0 weeks). CT and MRI at the end of halo-vest therapy showed no signs of C0/C1 subluxation and confirmed the correct consolidation of OCF. The only complication associated with halo-vest therapy was a superficial infection caused by a halo-vest pin. At follow-up, all children exhibited favorable functionality of the CCJ as documented by the NDI score (median: 3 points; range: 3-11 points) and SF-36 score (median: 91 points; range: 64-96 points). Conclusions: In our small case series, halo-vest therapy resulted in good mid-term outcome in terms of OCF consolidation and CCJ functionality. In pediatric patients with suspected cervical spine injuries, we recommend CT and MRI of the CCJ to establish the diagnosis of OCF and confirm stable fracture consolidation before removing the halo vest.

Conservative treatment and outcome of upper cervical spine fractures in young children: A STROBE-compliant case series.

ABSTRACT: Cervical spine (C-spine) fractures in young children are very rare, and little information on treatment modalities and functional, radiographic, and patient-reported outcome exists. In this 2-center, retrospective case series, we assessed subjective and functional mid-term outcomes in children aged ≤5 years whose C-spine fractures were treated nonoperatively.Between 2000 and 2018, 6 children (median age at injury: 23.5 months; range: 16-31 months) with C1 or C2 injuries were treated with Minerva cast/brace or soft collar brace at 1 of the 2 study centers. Two patients suffered C1 fractures, and 4 patients had lysis of the odontoid synchondrosis. Overall, 3 children had sustained polytrauma. One child died due to the consequences of massive head injury.For the primary outcome parameter, we recorded subjective symptoms such as pain and functional restrictions due to the sequelae of C-spine injuries at follow-up.Based on medical records, we also assessed the causes of injury, diagnostic procedures, treatments and complications, and time to fracture consolidation.Median follow-up of the 5 surviving children was 51 months (range: 36-160 months). At the latest follow-up, 4 of 5 children did not complain of any pain. One child who sustained an open head injury in combination with a subluxation of the odontoid and undisplaced fracture of the massa lateralis reported occasional headache. All patients experienced complete fracture healing and normal range of motion of the cervical spine.Median duration of cast/brace treatment was 8.5 weeks. Fracture healing was confirmed by computed tomography in all patients.All C-spine injuries were managed with either Minerva cast/Halo brace or soft collar brace without complications.In our retrospective case series, nonoperative treatment of atlas fractures and dislocations or subluxations of the odontoid in young children using Minerva casts or prefabricated Halo braces resulted in good subjective and functional outcomes at mid-term. We observed no complications of conservative treatment of C1 and C2 injuries in young children.

Risk factors for obstructive complications after endoscopic correction of vesico-ureteral reflux using polyacrylate polyalcohol copolymer.

Use of polyacrylate-polyalcohol copolymer (PPC) after endoscopic correction (EC) of vesico-ureteral reflux (VUR) is highly effective but is associated with a higher risk of obstructive complications (OC) compared with other implants. We undertook a STROBE compliant retrospective investigation and studied the OC risk factors to increase the practical safety of PPC.Overall, 798 patients (464 [58.1%] girls and 334 [41.9%]) boys) from 5 hospitals in whom PPC was routinely used were evaluated retrospectively. The patients were subdivided into 2 groups. Group I consisted of 754 (94.5%) children (449 [59.5%] girls and 305 [40.5%] boys) without OC. Median age was 41 months [Q1: 18.0; Q3: 81.0]. Group II comprised 44 (5.5%) patients (29 [65.9%] boys and 15 [34.1%] girls) experiencing OC, and their median age was 21.5 months [Q1: 12.0; Q3: 43.0]. Clinical and renal ultrasound examinations were carried out 1 day and 1 month after EC, and then every 6 months after EC. At the follow-up examination approximately 6 months after EC, voiding cysto-urethrography (VCUG) was performed. All patients with OC underwent diuretic renography.OC occurred in 44 (5.5%) of 798 children, in some cases as late as 60 months after endoscopic injection of the bulking agent PPC for correction of VUR. Univariate analysis revealed that younger age (P < .001), higher grade of VUR (P < .001), male gender (P < .001), second injection (P = .003), and EC injection using hydrodistension implantation technique (HIT; P < .001) represented significant risk factors. At multivariate analysis, only male gender (P = .0078), younger age (P = .0044), HIT technique (P < .0001), and second injection (P = .04) represented significant risk factors for the occurrence of OC.We identified young age, male gender, high reflux grade, HIT technique, and second endoscopic injections as factors associated with the risk of OC after EC of VUR using PPC as a bulking agent. Thus, patients who have undergone EC with PPC must be monitored sonographically for occurrence of OC for at least 60 months after the intervention.

[Treatment of lateral humeral condyle fractures in children]. / Die Behandlung der Condylus-radialis-humeri-Fraktur im Kindesalter.

OBJECTIVE: Surgical treatment of lateral humeral condyle fractures with reduction and retention in order to prevent lasting malalignment, pseudarthrosis, and joint instability. INDICATIONS: Absolute: fractures with a complete dislocation or those in which plaster-free control X-ray on day 4 shows a gap of > 2 mm. Relative: complete fractures of the lateral humeral condyle which demonstrate a dislocation < or = 2 mm on follow-up. CONTRAINDICATIONS: Incomplete, so-called hanging fractures of the lateral humeral condyle without notable secondary dislocation on follow-up. SURGICAL TECHNIQUE: Open reduction of the lateral humeral condyle via a lateral approach to the elbow joint. In smaller children (< 5 years of age) fixation with Kirschner wires. In older children (> or = 5 years of age) or in cases requiring compression radial screw fixation is recommended. In all cases, suture repair of the periosteum is advisable. POSTOPERATIVE MANAGEMENT: Long upper-arm plaster cast until wound healing is achieved. Subsequently, upper-arm plaster cast for 3-4 weeks postoperatively. Implants are removed following consolidation (confirmed by X-ray) after approximately 2-3 months. Routine physiotherapy is normally not required. RESULTS: From January 1, 1999 to December 31, 2006, 85 children with a median age of 6.1 years had lateral condyle fracture of the humerus treated. 47 patients underwent surgery. Of these, 31 were treated with a combination of screw and Kirschner wire fixation, 13 with a single screw, and in three cases, the fracture was fixed with Kirschner wires only. After a median of 8.6 weeks (range, 5.0-17.1 weeks), implants were removed. Median follow-up time was 6 months (range, 2-50 months). There were no late complications in this series (e.g., lack of consolidation, pseudarthrosis). In five cases, hyposensitivity of the skin above the proximal aspect of the radial bone was noted postoperatively. This problem was solved in all instances within the following 6 months. A telephone survey with a response rate of 87% (74 patients) was undertaken in September 2007. Three children noted a minimal deficiency in strength of the injured arm in comparison to the contralateral extremity. One of these children additionally stated a minor flexion deficit of the elbow already present at the last follow-up in the outpatient clinic, which showed no progress. None of the patients had to be referred back to the outpatient clinic because of persistent problems and/or unacceptable results.

[Treatment of medial epicondylar apophyseal avulsion injury in children].

OBJECTIVE: Surgical reduction and retention of apophyseal avulsion injuries at the medial epicondyle to prevent joint instability, lasting malalignment, or pseudarthrosis. INDICATIONS: Absolute: intraarticular apophyseal dislocation of the medial epicondyle, complete lesion of the ulnar nerve. Relative: dislocation of the apophysis (> 4 mm) in children > 5 years of age; the need for intervention increases in children as the degree of dislocation, age, and athletic activity increase. CONTRAINDICATIONS: Dislocation of the medial epicondyle (< or = 4 mm) in children < 5 years of age, provided the fragment location is not intraarticular. SURGICAL TECHNIQUE: Open reduction of the apophysis through a medial approach. Identification of the ulnar nerve. In young children or with small fragments fixation with Kirschner wire. Screw fixation in older children or for larger fragments. POSTOPERATIVE MANAGEMENT: Long upper-arm plaster cast until wound healing is achieved. Subsequently, upper-arm plaster cast for 3 weeks. Removal of Kirschner wires after 4-6 weeks, screw removal after 8-12 weeks. Physiotherapy only if marked reduction of elbow mobility is found 6 weeks after cast removal. RESULTS: From January 1, 1994 to December 31, 2003, 25 children with an average age of 12 years suffering from medial epicondylar avulsion fractures were operated on using open reduction and Kirschner wire fixation. An average of 3 years after the injury 14 of these children underwent follow-up examination using a procedure that took subjective, clinical and radiologic parameters into account. Two children showed a slight reduction in overall strength of the injured extremity when compared with the contralateral extremity. One child had a flexion deficit of 10 degrees, all other children showed movement limitations of < or = 5 degrees compared to the contralateral extremity. In all the cases available to follow-up, there was a slight increase in valgus alignment of the elbow joint compared with the uninjured side (3 degrees on average). All fractures consolidated within 6 weeks.

Sonoanatomy of the Achilles tendon insertion in children.

PURPOSE: The aim of this study was to describe typical age-related sonographic features of the Achilles tendon and calcaneal apophysis in children, providing a reference for the assessment of heel pathologies during the growth period. METHODS: The calcaneal apophysis and Achilles tendon insertion of 100 children 2 months to 18 years old were examined by high-frequency gray-scale and color Doppler sonography along both the longitudinal and transverse planes. The thicknesses of the apophyseal cartilage at the calcaneal tuberosity and of the Achilles tendon were measured. Also, the sonographic appearance of the bone-cartilage interface was studied. RESULTS: In children 2 months to 3 years old, the cartilage of the calcaneal tuberosity apophysis was anechoic, with small scattered echoes. In 19 of these 25 children (76%), the echogenic areas contained at least 1 small vessel, visualized on color Doppler sonography. In 15 of 25 children (60%) 4-6 years old, a wavy interface was noted at the junction of the calcaneus and the apophyseal cartilage. CONCLUSIONS: High-frequency sonography can yield reliable information about the bone-cartilage interface and the Achilles tendon insertion site at the calcaneal tuberosity in children. The sonographic features of the normal heel described here may contribute to improved assessment of pathologies in this anatomic region.

Causes and consequences of pedestrian injuries in children.

UNLABELLED: Pedestrian-car collisions are in motorised countries one of the leading causes of unintentional-injury-related death and morbidity among children. The objective of this study was to assess correlations between the mode and the severity or post-traumatic sequels of the injury. A 12-year (1989-2001) retrospective study of children aged 0-16 years injured in pedestrian-motor-vehicle collisions was undertaken. An anonymous survey with questionnaires completed by families was conducted. In this time period, 501 children (average age: 7.9 years) were injured. The lack of visibility of the vehicle (45%) and/or the pedestrian (39%) was the leading cause of injury. The mean injury severity score was 6.0 (1-75) and the mortality rate was 0.8% ( n=4, injury severity scores 47, 75, 75, 75). In this study, 217 questionnaires were analysed. When the children were injured, 37% of them were alone, 32.3% were in the presence of accompanying adults, and 24.0% were in the presence of other children. The latter group suffered the highest injury severity score ( P=0.016). Positive correlations were noted between injury severity score and impact speed ( r=0.31, P<0.001) and the distances that the children were thrown off or transported on the vehicle front ( r=0.29, P<0.001). Physical sequels were reported by 27% of the families, and 23% noted psychological disturbances. A positive correlation was noted between impact speed and the occurrence of physical sequels ( P<0.001). The number of deformed parts per vehicle was correlated to the occurrence of behavioural disturbances ( P<0.004). CONCLUSION: The incidence of post-traumatic sequels seems to be associated with higher speed at impact, lack of braking attempts, and higher numbers of vehicle parts deformed.