Epidemiology of trauma-related paediatric limb fracture using a unique classification: A 10-year retrospective, single-centre study.

INTRODUCTION: Research regarding the epidemiology of paediatric trauma is limited. Using our unique classification, we describe paediatric trauma cases in a 10-year single-centre study to improve paediatric care. MATERIALS AND METHODS: Data regarding all paediatric trauma cases were extracted using a computerised medical record system that detected fracture diagnosis and epiphyseal injury. Registry search identified cases from January 2008 to December 2017. Age, sex, type of fracture, and details of injury mechanism were analysed, and we categorised the 'falls/turnover' mechanism using a new trauma energy classification based on speed and height. RESULTS: A total of 1379 cases (953 boys and 426 girls) were included. The highest number of injuries (553 cases, 40%) was seen in school children (aged 6 to 10 years). Forearm fracture occurred most frequently, followed by humeral fracture. The most frequent injury mechanism in falls/turnover (969 cases, 70%) was sports in 272 cases (28%), playground equipment in 179 cases (18%), furniture in 102 cases (11%), and bicycling in 87 cases (9%). We classified 956 cases of falls/turnover using our trauma energy classification scheme. Most cases (29%) were classified into the L2 category (low height and high speed), followed by the L1 category (low height and low speed) (p < 0.01). Subcategory analysis using the classification revealed that younger children were more likely to be injured by falling from high places because of their physique, whereas older children were more likely to be injured by a turnover from lower places and at higher speed. CONCLUSION: We describe the epidemiology of fractures in detail and present a new classification system, which may aid in understanding the injury mechanism independent of children's height. The fact that paediatric fractures occur at relatively low energy levels and are trended by age, activity, and sex, could be of potential universal use for their prevention and parent education.

Independent predictors affecting the reduction of pediatric supracondylar humerus fractures: a retrospective cohort study.

BACKGROUND: Although it is important to understand the risk factors affecting the reduction of pediatric supracondylar humerus fractures (PSHFs), no inclusive study has been conducted so far. We performed a retrospective cohort study to identify the risk factors affecting the quality and difficulty of reduction for PSHFs. METHODS: We reviewed 160 cases with a PSHF that had been surgically treated in our hospital between January 2007 and December 2019. We investigated age, sex, injured side, body mass index (BMI), modified Gartland classification, neurological deficit or an absent radial artery pulse at an initial examination, start time of the operation, waiting time from injury to surgery, operative time, reduction technique, and perioperative radiographic parameters. We calculated independent predictors of unsuccessful closed reduction, prolonged operative time, and malreduction using multivariate analyses. RESULTS: In a logistic regression analysis, modified Gartland type III was a significant predictor of unsuccessful closed reduction (OR 14.50 [95% CI 4.03-51.90]; P < 0.01) and BMI was a significant predictor of malrotation (OR 1.59 [95% CI 1.06-2.39]; P = 0.025). In a multiple linear regression analysis, BMI and open reduction were significant predictors of prolonged operative time (BMI, P = 0.011; open reduction, P < 0.01). CONCLUSIONS: If closed reduction fails, we should not hesitate to immediately switch to other methods. Obesity was an independent predictor of both prolonged operative time and malrotation, a finding that has not been previously reported. Rotational alignment should be carefully checked, especially for obese children, and accurately be reduced. Open reduction also extended operative time.

Timing of Surgery for Pediatric Supracondylar Humerus Fractures and Early Postoperative Results.

Background: Pediatric supracondylar humerus fracture (PSHF) is one of the most common fractures of the elbow seen among boys aged between 5 and 7 years. The timing of surgical treatment for this type of fracture is still controversial. Thus, we aimed to investigate whether the timing of surgery for PSHFs affects the incidence of early postoperative complications and reduction of PSHFs. Methods: We retrospectively reviewed the medical records of PSHF patients who underwent surgery at our hospital between January 2007 and March 2019. We classified patients who underwent surgery within 12 h and more than 12 h after the fracture as the early and delayed groups, respectively. The outcome measures compared between the two groups were the incidence of postoperative early complications such as neurological deficits, including iatrogenic ulnar nerve injury, vascular compromise, compartment syndrome, K-wire migration, and unplanned returns to the operating room. We also examined surgical time, reduction procedure, and perioperative radiographic parameters. Results: There was no significant difference in the incidence of early complications between the early and delayed groups for either modified Gartland type II or type III fractures. There was also no significant difference in surgical time, reduction procedure, or perioperative radiographic parameters between the two groups. Conclusions: Delayed surgery was not associated with an increased rate of postoperative early complications in either type II or type III fractures. The timing of surgery does not affect the difficulty or quality of reduction.

A New Classification for Ankle Arthrodesis When Using an External Fixator.

BACKGROUND: We have classified ankle arthrodesis when using an external fixator into four types based on the deformity and defect. Each of the four types of technique have been evaluated retrospectively. MATERIALS AND METHODS: Thirty-three lower limb segments in 30 patients (average age 49 years) were treated by ankle arthrodesis using an external fixator in our institution. We classified the pre-treatment problems into four types and adjusted the surgical treatment accordingly: type I-no bone defect, no or mild deformity; type II-no bone defect, severe deformity; type III-bone defect with the possibility to shorten acutely after resection of the pathological focus; and type IV-bone defect but without the ability to shorten acutely after resection of the pathological focus. Type I problems were treated with curettage of ankle cartilage and bone graft with external fixation. Type II problems were treated with mobilisation using an external fixation after performing a type I ankle arthrodesis. Type III problems were treated with ankle arthrodesis using acute shortening and distraction. Type IV problems were treated with ankle arthrodesis using bone transport. RESULTS: All patients had secure ankle fusion and were able to bear total weight in walking on completion of treatment. The mean external fixation period was 96 days in type I, 181 days in type II, 231 days with lengthening in type III and IV. The complications included re-fracture in three cases, deformity at the lengthening site in one, delayed union in one, and infection at fusion site in one. CONCLUSION: We have strategized ankle arthrodesis procedures using an external fixator into four groups in order to align the surgical technique with the pre-treatment problem. Our classification can help decide the appropriate operative method when using an external fixator, especially for difficult cases. HOW TO CITE THIS ARTICLE: Matsubara H, Watanabe K, Takata M, et al. A New Classification for Ankle Arthrodesis When Using an External Fixator. Strategies Trauma Limb Reconstr 2019;14(3):148-154.

Reference positions for transosseous elements in femur: A cadaveric study.

INTRODUCTION: During external fixator treatment, displacement of soft tissue at pin sites may cause infection and contracture. Due to surrounding soft tissue thickness, the femur is especially susceptible to severe complications. However, standard textbooks demonstrate only how major neurovascular bundles should be avoided. This study is the first cadaver study investigating which pin sites within safe zones exhibit minimal soft tissue displacement. METHODS: To identify the clear direction of any pin, the femoral shaft was divided into eight levels, from I to VIII. The transverse sections at each level were further divided into 12 radial positions analogous to a clock face, where the anterior direction was assigned twelve o'clock, the medial three, etc. Fifteen adult cadavers were used. Twelve wires were aligned radially on the examined ring, and were dyed at each point toward the soft tissue. Each soft tissue displacement was measured by marking the surface before and after three particular joint motions, namely hip flexion (0-90°), abduction (0-45), and knee flexion (0-90). The same procedures were performed in three layers of soft tissue: skin, fascia, and muscle. RESULTS: The average displacement was determined in 89 directions excluding the groin part, upon three joint motions. The three layers of skin, fascia, and muscle showed similar data curves. Greater displacements were seen at juxta-articular areas than at the mid-diaphyseal. The data curve exhibited a bimodal characteristic, with larger displacements at the extension and flexion directions. The amount of displacement at 6 o'clock was large at the levels near the hip joint, whereas at 12 o'clock, it was large near the knee joint. DISCUSSION: "Reference positions" for transosseous elements were defined within zones absent neurovascular bundles, indicating 30 sites with minimal tissue displacement. Three or four directions at each level were chosen: I.9-11, II.9-11, III.8-11, IV.8-11, V.7-10, VI.3, 7-9, VII.3, 4, 8, 9, and VIII.3, 4, 8, 9. The anterolateral aspect near the hip joint and the posterolateral aspect near the knee tended to be chosen. They may prove useful in perioperative practice.

Foot deformity correction with hexapod external fixator, the Ortho-SUV Frame™.

External fixators enable distraction osteogenesis and gradual foot deformity corrections. Hexapod fixators have become more popular than the Ilizarov apparatus. The Ortho-SUV Frame™ (OSF; Ortho-SUV Ltd, St. Petersburg, Russia), a hexapod that was developed in 2006, allows flexible joint attachment such that multiple assemblies are available. We assessed the reduction capability of several assemblies. An artificial bone model with a 270-mm-long longitudinal foot was used. A 130-mm tibial full ring was attached 60 mm proximal to the ankle joint. A 140-mm, two-third ring forefoot was attached perpendicular to the metatarsal bone axis. A 130-mm, two-third ring hindfoot was attached parallel to the tibial ring. A V-osteotomy, which was combined with 2 oblique osteotomies at the navicular-cuboid bone and the calcaneus, was performed. The middle part of the foot, including the talus, was connected to the tibial ring. We assessed 5 types of forefoot applications and 4 types of hindfoot applications. The range of correction included flexion/extension in the sagittal plane, adduction/abduction in the horizontal plane, and pronation/supination in the coronal plane. Additionally, we reported the short-term results in 9 clinical cases. The forefoot applications in which the axis of the hexapod was parallel to the axis of the metatarsal bones had good results, with 52°/76° for flexion/extension, 48°/53° for adduction/abduction, and 43°/51° for pronation/supination. The hindfoot applications in which the hexapod encircled the ankle joint also had good results, with corresponding values of 47°/58°, 20°/35°, and 28°/31°. Clinically, all deformities were corrected as planned. Thus, multiple assemblies and a wide range of corrections are available with the OSF.

TNF-α and tumor lysate promote the maturation of dendritic cells for immunotherapy for advanced malignant bone and soft tissue tumors.

BACKGROUND: Dendritic cells (DCs) play a pivotal role in the immune system. There are many reports concerning DC-based immunotherapy. The differentiation and maturation of DCs is a critical part of DC-based immunotherapy. We investigated the differentiation and maturation of DCs in response to various stimuli. METHODS: Thirty-one patients with malignant bone and soft tissue tumors were enrolled in this study. All the patients had metastatic tumors and/or recurrent tumors. Peripheral blood mononuclear cells (PBMCs) were suspended in media containing interleukin-4 (IL-4) and granulocyte-macrophage colony stimulating factor (GM-CSF). These cells were then treated with or without 1) tumor lysate (TL), 2) TL + TNF-α, 3) OK-432. The generated DCs were mixed and injected in the inguinal or axillary region. Treatment courses were performed every week and repeated 6 times. A portion of the cells were analyzed by flow cytometry to determine the degree of differentiation and maturation of the DCs. Serum IFN-γ and serum IL-12 were measured in order to determine the immune response following the DC-based immunotherapy. RESULTS: Approximately 50% of PBMCs differentiated into DCs. Maturation of the lysate-pulsed DCs was slightly increased. Maturation of the TL/TNF-α-pulsed DCs was increased, commensurate with OK-432-pulsed DCs. Serum IFN-γ and serum IL-12 showed significant elevation at one and three months after DC-based immunotherapy. CONCLUSIONS: Although TL-pulsed DCs exhibit tumor specific immunity, TL-pulsed cells showed low levels of maturation. Conversely, the TL/TNF-α-pulsed DCs showed remarkable maturation. The combination of IL-4/GM-CSF/TL/TNF-α resulted in the greatest differentiation and maturation for DC-based immunotherapy for patients with bone and soft tissue tumors.

Lengthening of the normal tibia in a patient with hemihypertrophy caused by Klippel- Trenaunay-Weber syndrome: a case report.

We report a case of Klippel-Trenaunay-Weber syndrome in a 31-year-old woman who presented with hypertrophy of the left leg. She had severe osteoarthritic changes in the left hip joint secondary to the lack of acetabular coverage of the femoral head as the result of lateral inclination of the pelvis owing to leg-length discrepancy of 4 cm. The centre-edge angle (coverage ratio of the acetabulum to the femoral head) was improved from 15º to 33º after a foot lift. She underwent osteotomy and lengthening of the normal contralateral tibia using a Taylor spatial frame. Hip arthroplasty could be avoided as osteoarthritic changes of the hip joint had improved.

Activity of bone morphogenetic protein-7 after treatment at various temperatures: freezing vs. pasteurization vs. allograft.

Insufficient bone union is the occasional complication of biomechanical reconstruction after malignant bone tumor resection using temperature treated tumor bearing bone; freezing, pasteurization, and autoclaving. Since bone morphogenetic protein (BMP) plays an important role in bone formation, we assessed the amount and activity of BMP preserved after several temperature treatments, including -196 and -73°C for 20 min, 60 and 100°C for 30 min, 60°C for 10h following -80°C for 12h as an allograft model, and 4°C as the control. The material extracted from the human femoral bone was treated, and the amount of BMP-7 was analyzed using an enzyme-linked immunosorbent assay. Then, the activity of recombinant human BMP-7 after the treatment was assessed using a bioassay with NIH3T3 cells and immunoblotting analysis to measure the amount of phospho-Smad, one of the signaling substrates that reflect the intracellular reaction of BMPs. Both experiments revealed that BMP-7 was significantly better preserved in the hypothermia groups. The percentages of the amount of BMP-7 in which the control group was set at 100% were 114%, 108%, 70%, 49%, and 53% in the -196, -73, 60, 100°C, and the allograft-model group, respectively. The percentages of the amount of phospho-Smad were 89%, 87%, 24%, 4.9%, and 14% in the -196, -73, 60, 100°C, and the allograft-model group, respectively. These results suggested that freezing possibly preserves osteoinductive ability than hyperthermia treatment.