Novel Interdisciplinary Enhanced Recovery after Surgery Protocol Implementation in Paediatric Orthopaedics.

The enhanced recovery after surgery (ERAS) protocol is not routine management in paediatric orthopaedics. Cultural differences or assumptions about the financing of medical care in different countries encourage creative adaptation of general assumptions in local communities. The aim of this study was to compare the quality of the perioperative period before and after the introduction of an interdisciplinary protocol adopted to organisational conditions. A group of 4098 children were included in the "before-after" observational study. The data of 1553 patients (BEFORE group) were analysed in terms of compliance with the enhanced recovery after surgery protocol guidelines and the time and cost of hospitalisation over a 20-month period. A novel interdisciplinary protocol was developed, including an education and training app called BackOnFeet (BOF®), standardised hospital management, and the introduction of methods novel to Poland (intraoperative nerve cryoanalgesia in children). A further 2545 patients (AFTER group) were reassessed over a period of 20 months. It was found that the groups differed in hospitalisation time (p < 0.001), type of procedures, and percentage ratio of costs incurred to revenue generated. The usefulness of the BOF® app as an effective educational tool was demonstrated. The optimisation of perioperative management in paediatric orthopaedics based on novel tools and the interdisciplinary ERAS protocol is possible and brings tangible benefits in psychological, organisational, and financial terms.

Intercostal nerve cryoanalgesia in the treatment of pain in patients operated on by the modified Nuss method with the BackOnFeet application-a new strategy to improve outcomes.

Introduction: The surgical Nuss correction of the funnel chest deformity is a painful procedure without an established consensus of pain relief methods. High doses and long duration of opioids requirements impedes the ERAS protocol introduction. The aim of this study was to evaluate the effectiveness of intraoperative intercostal nerve cryolysis in terms of pain management in relation to the routinely used multimodal analgesia in Poland. We also assessed the impact of using the proprietary "BackOnFeet" application on the quality of life of patients after surgery in relation to the ERAS protocol. Methods: The prospective, single-centre, non-randomised, before-after pilot study was conducted. Inclusion criteria were: funnel-shaped chest deformity, age range 11-18 years, first chest wall operation, agreement for the cryolysis and regional analgesia, no history of chronic painkillers use. The results of the "control group" (multimodal analgesia with regional analgesia commonly performed in Poland) were assessed. The interdisciplinary perioperative protocol with the "BackOnFeet" application and intraoperative intercostal nerve cryoanalgesia were introduced to the "intervention group". Results: Eighteen children were treated with standard protocol typical for Polish management and matched to eighteen patients who received cryoanalgesia and the "BackOnFeet" application access "intervention group". We noticed lower NRS points in first 24 h (p = 0.0048), shortening of time of opioid use (p = 0.0002), hospitalisation time (p = 0,01), improved quality of postoperative rehabilitation (p < 0.0001) and quality of life (p < 0.0001) among the "intervention group". Conclusions: Intraoperative intercostal nerves cryolysis performed during the minimally invasive Nuss correction of funnel deformation in combination with bilateral is more effective in terms of acute pain management in relation to the routinely used multimodal analgesia in Poland, allowing for the shortening of time of opioid use, hospitalisation time, improved quality of postoperative rehabilitation and enabled ERAS protocol introduction. The use of the proprietary "BackOnFeet" application has a positive effect on the quality of life of patients after surgery.

A Nonlinear Elastic Model for Compressible Aluminum Alloys with Finite Element Implementation.

In this paper, a three-dimensional model of nonlinear elastic material is proposed. The model is formulated in the framework of Green elasticity, which is based on the specific elastic energy potential. Equivalently, this model can be associated to the deformation theory of plasticity. The constitutive relationship, derived from the assumed specific energy, divides the material's behavior into two stages: the first one starts with an initial almost linear stress-strain relation which, for higher strain, smoothly turns into the second stage of hardening. The proposed relation mimics the experimentally observed response of ductile metals, aluminum alloys in particular. In contrast to the classic deformation theory of plasticity or the plastic flow theory, the presented model can describe metal compressibility in both stages of behavior. The constitutive relationship is non-reversible expressing stress as a function of strain. Special attention is given to the calibration process, in which a one-dimensional analog of the three-dimensional model is used. Various options of calibration based on uniaxial stress test are extensively discussed. A finite element code is written and verified in order to validate the model. Solutions of selected problems, obtained via ABAQUS, confirm the correctness of the model and its usefulness in numerical simulations, especially for buckling.

A Thermodynamically Consistent Model of Quasibrittle Elastic Damaged Materials Based on a Novel Helmholtz Potential and Dissipation Function.

In the paper, a thermodynamically consistent model of elastic damaged material in the framework of small strain theory is formulated, describing the process of deterioration in quasibrittle materials, concrete in particular. The main goal is to appropriately depict the distinction between material responses in tension and compression. A novel Helmholtz energy and a dissipation potential including three damage parameters are introduced. The Helmholtz function has a continuous first derivative with respect to strain tensor. Based on the assumed functions, the strain-stress relationship, the damage condition, the evolution laws, and the tangent stiffness tensor are derived. The model's predictions for uniaxial tension, uniaxial compression, uniaxial cyclic compression-tension, and pure shear tests are calculated using Wolfram Mathematica in order to identify the main features of the model and to grasp the physical meaning of an isotropic damage parameter, a tensile damage parameter, and a compressive damage parameter. Their values can be directly bound to changes of secant stiffness and generalized Poisson's ratio. An interpretation of damage parameters in association with three mechanisms of damage is given. The considered dissipation potential allows a flexible choice of a damage condition. The influence of material parameters included in dissipation function on damage mode interaction is discussed.

Missense splice variant (g.20746A>G, p.Ile183Val) of interferon gamma receptor 1 (IFNGR1) coincidental with mycobacterial osteomyelitis - a screen of osteoarticular lesions.

Previously, dominant partial interferon-gamma receptor 1 (IFN-g-R1) susceptibility to environmental mycobacteria was found with IFNGR1 deletions or premature stop. Our aim was to search for IFNGR1 variants in patients with mycobacterial osteoarticular lesions. Biopsies from the patients were examined for acid-fast bacilli, inflammatory cell infiltration, and mycobacterial niacin. Mycobacterial rRNA was analyzed using a target-amplified rRNA probe test. Peripheral-blood-leukocyte genomic DNA was isolated from 19 patients using the QIAamp DNA Mini Kit, and all IFNGR1 exons were sequenced using an ABIPRISM 3130 device. After the discovery of an exon 5 variant, a Polish newborn population sample (n = 100) was assayed for the discovered variant. Splice sites and putative amino acid interactions were analyzed. All patients tested were positive for mycobacteria; one was heterozygous for the IFNGR1 exon 5 single-nucleotide-missense substitution (g.20746A>G, p.Ile183Val). No other variant was found. The splice analysis indicated the creation of an exonic splicing silencer, and alternatively, molecular graphics indicated that the p.Ile183Val might alter beta-strand packing (loss of van der Waals contacts; Val183/Pro205), possibly altering the IFN-g-R1/IFN-g-R2 interaction. The probability of non-deleterious variant was estimated as <10%. Heterozygous IFNGR1:p.Ile183Val (frequency 0.003%) was found to be coincidental with mycobacterial osteomyelitis. The small amount of variation detected in the patients with osteoarticular lesions indicates that screens should not yet be restricted: Intronic variants should be analyzed as well as the other genes affecting Type 1 T-helper-cell-mediated immunity.

Familial occurrence of Caffey-Silverman syndrome.

Caffey-Silverman syndrome, or infantile hyperostosis, is a rare condition of unclear etiology and pathogenesis affecting the skeletal system and the surrounding soft tissues. It is characterized by indurated swelling of soft tissues and cortical bone hyperostosis. The changes are usually multiple and affect such parts as the mandible, scapulae, ribs, clavicles, and forearm and shank bones. When long bones are affected, the lesions are typically limited to shafts, with the sparing of meta- and epiphyses. The prognosis is usually good and, in most patients, the changes resolve spontaneously after several months to over a year, leaving no permanent sequelae. Caffey-Silverman syndrome needs to be distinguished from osteitis, for which it is most often mistaken. We present a case of an early form of Caffey-Silverman syndrome. The course of disease in this form is usually severe, with multifocal lesions, and the typical self-limiting regression is not complete. In our patient, a systemic musculoskeletal condition was already suspected following the detection of skeletal defects in a prenatal US examination. Physical and radiological work-up in the first weeks of life revealed the typical signs of congenital Caffey-Silverman syndrome. Several years of follow-up showed gradual regression of the bone deformities with persistent lower-extremity bowing. Due to a positive family history for Caffey-Silverman syndrome, the patient's pedigree was prepared. On the basis of the history data, existing radiographs and in- and outpatient medical records, Caffey-Silverman syndrome was confirmed in 10 family members. It was established that the cases of Caffey-Silverman syndrome in the patient's family were characterized by diverse phenotypic expression and different times of onset.

Results of SpineCor dynamic bracing for idiopathic scoliosis.

BACKGROUND: Orthopaedic bracing is used in conservative treatment of spinal curvatures. Apart from rigid braces, SpineCor dynamic braces with a flexible design have recently become available. The idea behind dynamic bracing is that derotational and correcting forces are transmitted via a system of corrective bands. The essence of this technique is maintenance of spine mobility while effecting a position in which all components of the three-plane deformity are corrected. The aim of this study is to evaluate early outcomes of SpineCor dynamic brace treatment for idiopathic scoliosis according to SRS methodology and criteria. MATERIAL AND METHODS: The study group included 50 patients who were using SpineCor braces due to idiopathic scoliosis. The indication for bracing was the finding of a >15(5) spinal curvature in skeletally immature patients (Risser grade 0-3). Correction or stabilization of the scoliosis (Cobb angle change of +/- 5 degrees ) were recognised as positive outcomes, while a negative outcome was defined as progression of the curve of more than 5 degrees or to a value necessitating operative treatment. The study group was divided into subgroups at enrollment, according to gender and degree of scoliosis. RESULTS: In the entire study group, correction was demonstrated in 24 patients (48%), stabilization in 14 (28%) and progression in spite of bracing occurred in 7 patients (14%). Five patients in the entire study group (10%) required operative treatment due to rapid curvature progression. CONCLUSIONS: SpineCor bracing led to stabilization of scoliosis in the majority of the patients. Introducing the SpineCor brace in patients with a scoliosis angle over 20 degrees and Risser grade 0-3 very effectively prevented curve progression.