Trampoline injuries in children: A prospective study.

BACKGROUND: Trampolining is popular and widely practiced among children. A literature review has shown a rise in the incidence of trampoline injuries with a concomitant increase in paediatric emergency department visits. The primary objective of this study was to describe the severity of trampoline injuries in children. The secondary objectives were to assess the epidemiology of the study population and injuries and to describe the treatments. HYPOTHESIS: We hypothesized that over 10% of trampoline injuries were severe. MATERIAL AND METHODS: We prospectively evaluated consecutive patients seen for surgical conditions at our paediatric emergency department over a 10-month period. Among them, 103 (1.2% of visits) aged 4 months to 16 years (mean, 8 years) had trampoline injuries. We classified trampoline injuries as severe if they required general anaesthesia. RESULTS: Severe injuries accounted for 16.5% of all trampoline injuries. The upper limb was predominantly affected (70.6% of cases). Overall, 66.7% of fractures were at the upper limb and 76% of contusions at the lower limb. The predominant fracture sites were the supra-condylar humerus (15.3%) and distal radius (15.3%). Among patients with non-severe injuries, four-fifths left the emergency department with a temporary immobilisation system. DISCUSSION: The proportion of severe injuries was slightly higher in our study than in earlier reports. Trampoline injuries remain uncommon but can be severe. Thus, in our study over one-sixth of patients required surgery under general anaesthesia. LEVEL OF EVIDENCE: IV, prospective descriptive epidemiological study.

Induced membrane maintains its osteogenic properties even when the second stage of Masquelet's technique is performed later.

PURPOSE: Previous clinical studies have shown the effectiveness of bone repair using two-stage surgery called the induced membrane (IM) technique. The optimal wait before the second surgery is said to be 1 month. We have been successfully performing the IM technique while waiting an average of 6 months to carry out the second stage. We hypothesised that the IM maintains its beneficial capabilities, even at a later second stage, and that there is no relation between the speed of bone union and the wait between the first and second stage. We sought to explore the biological properties of 'older' IMs sampled to substantiate our clinical observations. METHODS: Thirty-four patients with a critical size defect were treated with the IM technique. In seven of these patients, pieces of the IM were collected 4.2-14.7 months after the first surgery. IM-derived cell phenotype and osteogenic potential were investigated using in vitro studies (n = 4) while IM nature and function were investigated by histology and immunohistochemistry (n = 3). RESULTS: The median wait before the second surgery was 5.8 months [range 1.2-14.7] and bone healing occurred at 7.6 months [range 2.5-49.9] for 26 patients. IMs aged 4.2-14.7 months contained mesenchymal stromal cells with in vitro osteogenic potential and corresponded to a multipotent tissue with osteogenic and chondrogenic capabilities contributing to osteogenesis over time. CONCLUSION: This preliminary study suggests the IM retains its powerful osteogenic properties over time and that waiting longer between the two surgeries does not delay bone union.

Correction to: Induced membrane maintains its osteogenic properties even when the second stage of Masquelet's technique is performed later.

The original version of this article unfortunately contained a mistake. The presentation and legends of Figs. 4 and 5 were incorrect. The corrected versions are given below. The original article has been corrected.

In vitro osteodifferentiation of intact human amniotic membrane is not beneficial in the context of bone repair.

The human amniotic membrane (hAM) is an attractive biomaterial for regenerative medicine, as it contains amniotic mesenchymal stromal cells (hAMSC), epithelial cells (hAEC) and growth factors. We examined the potential use of hAM in orthopaedic and maxillofacial bone surgery, integrating the requirements of current regulations regarding advanced therapy medicinal products (ATMP) in the European Union. Previous studies have described the potential osteodifferentiation of intact hAM during whole-tissue culture in osteogenic conditions. The present study aims to determine whether in vitro osteodifferentiation of hAM is needed in the context bone repair, and the influence of this process on tissue structure, cell phenotype and cell function. Different conditions (fresh or cultured hAM; intact or hAM-derived cells) were tested. Phenotypic and functional analyses were performed with standard approaches (cell culture and staining, histological and immunolabelling) as well as original approaches (tissue staining, energy dispersive X-ray and X-ray diffraction). In our study, non-osteodifferentiated hAM (i.e., fresh or native hAM) exhibited innate pre-osteoblastic potential. Osteodifferentiation of fresh hAM induced a change in tissue structure, cell phenotype and function. Therefore, we hypothesize that pre-osteodifferentiation may not be necessary, especially if it induces unwanted changes. To our surprise, in these osteogenic conditions, hAEC had a mesenchymal phenotype with osteocyte function, and even native synthesis of hydroxyapatite, focusing osteogenic potential mainly in this epithelial layer. In conclusion, in vitro osteodifferentiation by tissue culture does not appear to be necessary for hAM to be used as an innovative ATMP for bone repair.

Is the Clavicula Pro Humero Technique of Value for Reconstruction After Resection of the Proximal Humerus in Children?

BACKGROUND: There are several options for reconstruction of proximal humerus resections after wide resection for malignant tumors in children. The clavicula pro humero technique is a biologic option that has been used in the past, but there are only scant case reports and small series that comment on the results of the procedure. Because the longevity of children mandates a reconstruction with potential longevity not likely to be achieved by other techniques, the clavicula pro humero technique may be a potential option in selected patients. QUESTIONS/PURPOSES: (1) How successful is the clavicula pro humero procedure in achieving local tumor control? (2) What is the frequency of nonunion? (3) What are the complications of the procedure? (4) What scores do patients achieve (on the Musculoskeletal Tumor Society (MSTS) and the Toronto Extremity Salvage Score (TESS) after this procedure? METHODS: Four university hospitals performed the clavicula pro humero technique in eight children aged 8 to 18 years between June 2006 and February 2014. During that period, general indications for this approach included all reconstructions of the proximal humerus for malignant tumors in children older than 8 years. All patients were followed for a mean of 40 months (range, 25-86 months); one patient was lost to followup before 2 years. The tumor resections removed the rotator cuff muscles in all patients, glenohumeral joint in five, and deltoid muscle in three. The median length of the bone defect after resection was 20 cm (range, 7-25 cm). It was reduced to 9 cm (range, 0-17 cm) or 27% (range, 0%-64%) of the total humerus length after clavicular rotation. Direct osteosynthesis (one patient), induced membrane technique (one patient), or vascularized fibular autograft (six patients) was used to complete the defect after rotation of the clavicle if necessary. Presence of union (defined as bone healing before 10 months, as assessed by disappearance of the osteotomy on AP and lateral view radiographs), and complications were determined by chart review performed by a surgeon not involved in patient care. Function assessed by the MSTS and the TESS scores were determined by the patients with their families. RESULTS: None of the patients had tumor recurrence. One patient died of pulmonary metastases before the 2-year followup. Proximal and distal bone unions were achieved before 10 months without an additional surgical procedure in two and six of seven patients, respectively. Fourteen local complications occurred resulting in nine revision operations. The main complication was aseptic proximal pseudarthrosis (five patients); other complications included one proximal junction fracture, one clavicle fracture complicated by clavicle osteolysis, one distal junction fracture, one necrosis of the skin paddle of the fibular autograft, one glenoclavicular ossification, and one distal pseudarthrosis complicated by a fracture of this distal junction. Function, as assessed by the MSTS score, was a median of 23 of 30 (range, 11-27). The median TESS score was 82% (range, 75%-92%). Shoulder ROM (median; range) in abduction, front elevation, and external and internal rotations were 70°(30°-90°), 75°(30°-85°), 10°(0°-20°), and 80°(80°-100°), respectively. Three of the seven patients reported dissatisfaction with the cosmetic appearance. CONCLUSIONS: The clavicula pro humero technique achieved oncologic local control after resection and reconstruction of proximal humerus tumors in children. Although union times are approximately 2 years and some patients underwent augmentation with other grafts, it eventually provides a solid, painless, biologic, and stable reconstruction and creates a mobile acromioclavicular joint and generally good function. Nonunion of the proximal junction is the main complication of this technique. We cannot directly compare this technique with other reconstruction options, and longer followup is needed, but this may be a useful reconstruction option to consider in select pediatric patients with sarcomas of the proximal humerus. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Similarities between induced membrane and amniotic membrane: Novelty for bone repair.

Previous clinical studies have shown the efficacy of a two-stage surgical procedure - the induced membrane (IM) technique - for reconstruction of large bone defects or bone non-union. The first stage involves radical debridement and insertion of a cement spacer into the bone defect. The second stage, performed weeks to months later, consists of removing the spacer while leaving the foreign body membrane induced by the cement in place, and then filling the cavity with bone autograft. The IM has been shown to (1) act as a protective physical barrier by preventing bone autograft resorption and (2) act as a bioreactor by promoting healing through revascularisation and growth factor secretion, and by concentrating mesenchymal stem cells (MSC) with osteogenic properties. New solutions to reduce this surgical procedure to a single step are being explored, for example by using an IM-like bioactive and protective barrier inserted into the bone defect at the same time as bone graft.

Fresh and in vitro osteodifferentiated human amniotic membrane, alone or associated with an additional scaffold, does not induce ectopic bone formation in Balb/c mice.

The human amniotic membrane (hAM) has been successfully used as a natural carrier containing amniotic mesenchymal stromal cells, epithelial cells and growth factors. It has a little or no immunogenicity, and possesses useful anti-microbial, anti-inflammatory, anti-fibrotic and analgesic properties. It has been used for many years in several indications for soft tissue repair. We previously reported that hAM represents a natural and preformed sheet containing highly potent stem cells, and could thus be used for bone repair. Indeed, native hAM possesses pre-osteoblastic potential that can easily be stimulated, even as far as mineralization, by means of in vitro osteogenic culture. However, cell culture induces damage to the tissue, as well as to cell phenotype and function. The aim of this study was to evaluate new bone formation by fresh and in vitro osteodifferentiated hAM, alone or associated with an additional scaffold presenting osteoinductive properties. Moreover, we also aimed to determine the effect of in vitro hAM pre-osteodifferentiation on its in vivo biocompatibility/tissue degradation. Results showed that neither fresh nor osteodifferentiated hAM induced ectopic bone formation, whether or not it was associated with the osteoinductive scaffold. Secondly, fresh and osteodifferentiated hAM presented similar in vivo tissue degradation, suggesting that in vitro hAM pre-osteodifferentiation did not influence its in vivo biocompatibility.

Complications in pediatric spine surgery using the vertical expandable prosthetic titanium rib: the French experience.

STUDY DESIGN: Multicenter retrospective study of 54 children. OBJECTIVE: To describe the complication rate of the French vertical expandable prosthetic titanium rib (VEPTR) series involving patients treated between August 2005 and January 2012. SUMMARY OF BACKGROUND DATA: Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery. METHODS: Of the 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 mo-14 yr and 2 mo) at primary VEPTR surgery. During the follow-up period, several complications occurred. RESULTS: Mean follow-up was 22.5 months (range, 6-64 mo). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 nonscheduled procedures for different types of complications: mechanical complications (i.e., fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients: a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence. CONCLUSION: The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities.

Intercalary segmental reconstruction of long bones after malignant bone tumor resection using primary methyl methacrylate cement spacer interposition and secondary bone grafting: the induced membrane technique.

BACKGROUND: Bone reconstruction after surgical resection of malignant bone tumor in children remains a difficult challenge and various techniques exist. Induced membrane reconstruction as described by Masquelet et al has been reported in traumatic large bone defects. We have been using this 2-stage technique after primary malignant bone tumors resection in children since 2000. METHODS: We retrospectively studied 12 cases: 6 Ewing sarcomas and 6 osteosarcomas. Mean age of the patients was 9 years old (range, 3 to 15.5 y). Surgical treatment consisted of wide resection and insertion of a cement spacer then secondary bone grafting. All patients had neoadjuvant and adjuvant chemotherapy and 2 patients had adjuvant radiotherapy. RESULTS: Surgical excision was complete in all cases. There was no local recurrence at 6.2 years (range, 4.6 to 9.1 y) follow-up. Three patients had pulmonary metastasis (of whom 1 deceased) and 1 had a metastasis on the contralateral limb. The 11 patients operated on the lower limb achieved weight bearing 4.1 months (range, 0.2 to 14.2 mo) after the second stage of the procedure. Complications were numerous with 7 nonunions (4 unifocal and 3 bifocal), 5 fractures (in 4 patients), 5 protruding wires (in 4 patients), and 2 femoral varus deformities. There was no infection. CONCLUSIONS: Induced membrane reconstruction seems to be a simple and reliable technique in pediatric bone tumors and these results are promising. Extended use of locking nails could reduce the high rate of nonunion though it is not always possible in skeletally immature patients. LEVEL OF EVIDENCE: IV (case series).

Treatment of congenital pseudarthrosis of the fibula by periosteal flap.

Pseudarthroses of the fibula are frequently associated with a pseudarthrosis of the tibia, but they can be isolated. To treat them it is usually necessary to have ankle alignment at skeletal maturity. We report six cases of fibular pseudarthrosis treated with periosteal flap, all having Recklinghausen's neurofibromatosis type 1. The mean age at the time of treatment was 4 years. Four children were diagnosed with isolated congenital pseudarthrosis of the fibula, with a simple curvature of the tibia, and two children had an associated pseudarthrosis of the tibia that was treated earlier. Treatment of the pseudarthrosis of the fibula was indicated to prevent a fracture of a curved tibia or to prevent ankle valgus. The technique of periosteal flap was different: in one case, the periosteum was taken from the fibular diaphysis as a free pedicled flap; in two cases, the flap was taken with its proximal pedicle; and in three cases, the flap was taken from the fibular diaphysis with its distal pedicle and returned to the pseudarthrosis. We analyzed the different operative techniques used for each patient, the complications and the functional result to follow-up. We did not use any osteosynthesis in two cases; a centro-medullary wire and a screwed plate were used in two cases. The pseudarthrosis healed in four cases in a mean period of 10 months. Healing was faster in the cases treated with distal pedicled returned periosteal flaps, a relatively simple technique not requiring vascular sutures. The distal pedicled returned periosteal flap permits good mobility of the periosteum and gives the best healing times. This treatment is indicated for young children to prevent a fracture and a pseudarthrosis of a dysplastic or congenital curvature of the tibia, or after treatment of congenital pseudarthrosis of the leg after healing of the tibia to prevent ankle instability and severe ankle valgus formation.

Interobserver reliability in the interpretation of radiologic signs in Legg-Calvé-Perthes disease.

An accurate interpretation of radiographs is crucial in determining therapeutic choices in Legg-Calvé-Perthes disease. The aim of this study was to measure the interobserver reliability of a group of surgeons in this condition. Twenty-three radiographs were shown to nine pediatric orthopedic surgeons at nine different medical centers. Differences in coding between members of the group was assessed using a two-way random factor analysis of variance. Reliability was excellent for the Catterall classification [intraclass correlation coefficient (ICC) = 0.94], and good for the stage of disease and Head at Risk signs (ICC ranging from 0.74 to 0.85) except for lateral subluxation, whose reliability is fair (ICC = 0.68). Analysis of results shows that lateral subluxation should be expressed in a quantitative measurement rather than a binary answer. The reliability of Gage's sign would be improved if multiple definitions did not exist in the literature. In experienced hands, Catterall's classification can be used with reliability. Difficulties are still noted in separating group II frorm group III.