Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Undergoing Orthopedic and Hand Surgery: A RAND/UCLA Appropriateness Method Consensus Study.

Surgical site infections (SSIs) represent a potential complication in any type of surgery and can occur up to one year after the procedure in the case of implant placement. In the field of orthopedic and hand surgery, the rate of SSIs is a relevant issue, considering the need for the placement of synthesis devices and the type of some interventions (e.g., exposed fractures). This work aims to provide guidance on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing orthopedic and hand surgery in order to standardize the management of patients and to reduce, on the one hand, the risk of SSI and, on the other, the development of antimicrobial resistance. The following scenarios were considered: (1) bloodless fracture reduction; (2) reduction of unexposed fracture and grade I and II exposed fracture; (3) reduction of grade III exposed fracture or traumatic amputation; (4) cruel fracture reduction with percutaneous synthesis; (5) non-traumatic amputation; (6) emergency intact skin trauma surgery and elective surgery without synthetic media placement; (7) elective orthopedic surgery with prosthetic and/or synthetic media placement and spinal surgery; (8) clean elective hand surgery with and without bone involvement, without use of synthetic means; (9) surgery of the hand on an elective basis with bone involvement and/or with use of synthetic means. This manuscript has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies and represents, in our opinion, the most complete and up-to-date collection of recommendations regarding the behavior to be adopted in the peri-operative setting in neonatal and pediatric orthopedic and hand surgery. The specific scenarios developed are aimed at guiding the healthcare professional in practice to ensure the better and standardized management of neonatal and pediatric patients, together with an easy consultation.

Congenital Pseudarthrosis of the Clavicle in Children: A Systematic Review.

(1) Background: Congenital pseudoarthrosis of the clavicle is a rare condition due to the failure of the union process of the ossification nuclei of the clavicle. The aim of this study was to conduct a systematic review of relevant case series about the argument to find an up-to-date base of evidence for treatment choice. (2) Methods: an electronic literature research of Ovid, MEDLINE and the Cochrane Library databases was conducted, and articles were selected based on inclusion criteria. Demographic data, clinical features, treatment options, outcomes and complications were analyzed. (3) Results: 21 articles met the inclusion criteria, showing a poor overall study quality; 231 pediatric patients (240 clavicles) were analyzed. The condition was typically right sided, showed no sex predominance and no clear predisposing factors. 156 patients underwent surgical treatment, mainly open debridement and refresh of bony ends, fixation with pin or plate and bone graft, with a successful union rate of 87.4%. The nonunion rate was significantly higher in the allograft group (44.4%, p = 0.019). (4) Conclusions: this paper presents an updated systematic review about treatment of congenital pseudoarthrosis of the clavicle. We confirm the generally satisfactory results of surgery, demonstrating that successful union is achievable in 87.4% of cases with a prevalence of 15.7% of major complications. Nonetheless our results should be interpreted with caution due to several limitations.

Deformity progression in congenital posteromedial bowing of the tibia: a report of 44 cases.

BACKGROUND: congenital posteromedial bowing of tibia (CPMBT) is a very rare birth defect, characterized by shortened bowed leg and ankle deformity. We described a single institution experience in the management of CPMBT. METHODS: we identified 44 CPMBT in 44 children. The age at presentation was 5.5 ± 5.6 years and the mean age at the final review was 10.1 ± 4.8 years. Radiographic evaluation included the antero-posterior and lateral inter-physeal angle (AP-IPA and L-IPA), the limb length discrepancy (LLD), the morphology of the distal tibia and the lateral distal tibial angle (LDTA). During the study period, 26 children underwent surgical treatment. RESULTS: the estimated curves showed a progressive spontaneous correction of both AP-IPA and L-IPA during growth, but a progressive increase of the LLD. The L-IPA showed a more predictable behaviour while the AP-IPA showed a scattered correction, with a wider variation of the estimated final angle. The final LDTA was 85.3° ± 4.2° and was correlated with the L-IPA (r = 0.5; p = 0.02). Among the 26 children who underwent surgical treatment, 23 cases had limb lengthening, 1 case had contralateral epiphysiodesis, 1 child underwent tibial osteotomy, 1 patient was treated by hemiepiphysiodesis of the distal tibia to correct ankle valgus deformity. CONCLUSIONS: our study described the largest case series of CPMBT. A combination of surgical treatments, in a staged surgical process, should be tailored to the developmental characteristics of this abnormality. An experience-based algorithm of treatment is also proposed. Further studies are needed to understand which is the best strategy to correct this deformity during childhood. LEVEL OF EVIDENCE: level IV prognostic study.

Evolution of clubfoot deformity and muscle abnormality in the Ponseti method: evaluation with the Dimeglio score.

PURPOSE: The modality of progression of the correction along casting sessions of Ponseti method has been poorly investigated and information regarding evolution of muscular abnormalities is missing. The aim of the study was to investigate dynamics of correction of the different components of clubfoot deformity in a clinical setting. METHODS: In a prospective study, 124 clubfeet consecutively treated by a single orthopaedic surgeon were evaluated with the Dimeglio system at each casting session and score progression was determined. RESULTS: For each component a typical pattern was recorded. Cavus and medial crease showed a rapid correction. Rotation, adduction and varus corrected gradually and simultaneously. The posterior crease usually persisted until final cast was discontinued. Equinus improved progressively after each cast and then to a larger extent with Achilles tenotomy. The parameter describing poor muscular condition, reported at presentation in 39 feet (31.5%), was the only item showing extremely different dynamics of correction (from rapid and complete resolution to persistence at last cast removal), which could be explained by the large diversity of entities included (hypertonia, imbalance, fatty infiltration, fibrosis, aplasia). CONCLUSIONS: This study confirmed that dynamics of correction in clinical setting correspond essentially to theoretical principles of Ponseti method. Muscle abnormalities are not uncommon in clubfeet and have great influence on the progression of correction. If abnormalities are recorded, their evolution along the treatment should be monitored. A more objective evaluation would be required.

Tissue engineering for total meniscal substitution: animal study in sheep model--results at 12 months.

The aim of the study was to investigate the use of a hyaluronic acid/polycaprolactone material for meniscal tissue engineering and to evaluate the tissue regeneration after the augmentation of the implant with expanded autologous chondrocytes. Eighteen skeletally mature sheep were treated. The animals were divided into three groups: cell-free scaffold, scaffold seeded with autologous chondrocytes, and meniscectomy alone. The implant was sutured to the capsule and to the meniscal ligament. At a 12-month gross assessment, histology and histomorphometry were used to assess the meniscus implant, knee joint, and osteoarthritis development. All implants showed excellent capsular ingrowth at the periphery. The implant gross assessment showed significant differences between cell-seeded and cell-free groups (p=0.011). The histological analysis indicated a cellular colonization throughout the implanted constructs. Avascular cartilaginous tissue formation was significantly more frequent in the cell-seeded constructs. Joint gross assessment showed that sheep treated with scaffold implantation achieved a significant higher score than those underwent meniscectomy (p<0.0005), and the Osteoarthritis Research Society International score showed that osteoarthritic changes were significantly less in the cell-seeded group than in the meniscectomy group (p=0.047), even though results were not significantly superior to those of the cell-free scaffold. Seeding of the scaffold with autologous chondrocytes increases its tissue regeneration capacity, providing a better fibrocartilaginous tissue formation. The study suggests the potential of the novel hyaluronic acid/polycaprolactone scaffold for total meniscal substitution, although this approach has to be further improved before being applied into clinical practice.

Arthroscopic treatment for symptomatic discoid lateral meniscus during childhood.

PURPOSE: The purpose of this study was to review the operative long-term results of a large cohort of children treated arthroscopically for a symptomatic discoid lateral meniscus. METHODS: We retrospectively reviewed the arthroscopic procedures performed on 104 knees (97 patients) between 1990 and 2006 to treat symptomatic discoid lateral meniscus in children. The median age at the time of surgery was 8 years (range 2.5-13.9 years). RESULTS: The follow-up was 8.5 ± 2.5 (mean ± SD) years (median 9, range 2-18.5 years). In this series, young children (2-7 years) usually presented complete discoid menisci with deficit in extension and little pain. The meniscal tissue was almost degenerated, and subtotal meniscectomy was performed. Children aged from 8 to 14 years referred to our institute typically presented a symptomatic tear (pain and swelling joint with snap) of a complete or incomplete discoid lateral meniscus, usually pursuant to a trauma. The treatment performed in this group was a partial meniscectomy. Clinical results at long-term follow-up show better results for subtotal meniscectomies than for partial ones. CONCLUSION: The results showed the long-term efficacy of arthroscopic treatment of a symptomatic discoid lateral meniscus. On the basis of this study, subtotal meniscectomies in younger patients are preferable when meniscal tissue is degenerated. In older children, we recommend to preserve meniscal tissue as much as possible. In younger patients submitted to subtotal meniscectomies, some adaptation of the knee to stress activity may occur. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

A modified technique for reconstruction of the femoral neck in paediatric patients.

Hip deformities during early childhood following Perthes' disease, congenital dislocation or septic arthritis are not rare, causing limitation of motion and limping. A number of proximal femoral osteotomies to address residual deformities have been described, but the outcome has been variable. We describe a proximal femoral osteotomy aimed at restoring a more anatomic insertion of the gluteus medius. The clinical and radiographic results thus far are promising. We believe that the technique improves both the anatomy and biomechanics of the hip.

Osteochondral allograft in a femoral head chondroblastoma: a case report.

Osteoarthritis of the hip joint secondary to femoral head collapse may develop after curettage of lesions in the femoral head. We report the case of a patient with chondroblastoma of the femoral head who was treated with wide curettage of the lesion and implantation of an osteochondral allograft to prevent femoral head collapse.

Electron microscopy of the remodelling process in hamstring tendon used as ACL graft.

The purpose of the present study was to make a histological analysis of the remodelling process of hamstring tendon graft used as Anterior Cruciate Ligament (ACL). The hamstring graft of eight patients was biopsied at different follow-up times from 1 to 10 years. The specimens were analysed with transmission electron microscopy (TEM) at ultrastructural level comparing them with a native ACL and a native hamstring graft. The hamstring graft was found to undergo ultrastructural changes in terms of number and diameter of fibrils with the major changes occurring in the first 2 years. At longer times after surgery (48 and 120 months) no important further changes were evident and the ultrastructure did not vary substantially from 2 to 10 years. In conclusion, the hamstring tendon used as ACL graft undergoes a transformation process but does not match the ultrastructure pattern of a normal ACL up to 10 years.