In vivo cartilage regeneration in a multi-layered articular cartilage architecture mimicking scaffold

AIMS

Extracellular matrix (ECM) and its architecture have a vital role in articular cartilage (AC) structure and function. We hypothesized that a multi-layered chitosan-gelatin (CG) scaffold that resembles ECM, as well as native collagen architecture of AC, will achieve superior chondrogenesis and AC regeneration. We also compared its in vitro and in vivo outcomes with randomly aligned CG scaffold.

METHODS

Rabbit bone marrow mesenchymal stem cells (MSCs) were differentiated into the chondrogenic lineage on scaffolds. Quality of in vitro regenerated cartilage was assessed by cell viability, growth, matrix synthesis, and differentiation. Bilateral osteochondral defects were created in 15 four-month-old male New Zealand white rabbits and segregated into three treatment groups with five in each. The groups were: 1) untreated and allogeneic chondrocytes; 2) multi-layered scaffold with and without cells; and 3) randomly aligned scaffold with and without cells. After four months of follow-up, the outcome was assessed using histology and immunostaining.

RESULTS

In vitro testing showed that the secreted ECM oriented itself along the fibre in multi-layered scaffolds. Both types of CG scaffolds supported cell viability, growth, and matrix synthesis. In vitro chondrogenesis on scaffold showed an around 400-fold increase in collagen type 2 (COL2A1) expression in both CG scaffolds, but the total glycosaminoglycan (GAG)/DNA deposition was 1.39-fold higher in the multi-layered scaffold than the randomly aligned scaffold. In vivo cartilage formation occurred in both multi-layered and randomly aligned scaffolds treated with and without cells, and was shown to be of hyaline phenotype on immunostaining. The defects treated with multi-layered + cells, however, showed significantly thicker cartilage formation than the randomly aligned scaffold.

CONCLUSION

We demonstrated that MSCs loaded CG scaffold with multi-layered zonal architecture promoted superior hyaline AC regeneration.Cite this article: Bone Joint Res 2020;9(9):601-612.

Osteogenesis imperfecta: Novel genetic variants and clinical observations from a clinical exome study of 54 Indian patients

Osteogenesis imperfecta (OI) is a group of inherited disorders with increased bone fragility and wide genetic heterogeneity. We report the outcome of clinical exome sequencing validated by Sanger sequencing in clinically diagnosed 54 OI patients in Indian population. In 52 patients, we report 20 new variants involving both dominant and recessive OI-specific genes and correlate these with phenotypes. COL1A1 and COL1A2 gene variants were identified in 44.23%, of which 28.84% were glycine substitution abnormalities. Two novel compound heterozygous variants in the FKBP10 gene were seen in two unrelated probands. A novel heterogeneous duplication of chromosomal region chr17: 48268168-48278884 from exons 1-33 of the COL1A1 gene was found in one proband. In five probands, there were additional variants in association with OI. These were ANO5 in association with CRTAP in two probands of the same family causing gnathodiaphyseal dysplasia, COL5A2 with LEPRE1 causing Ehlers Danlos syndrome, COL11A1 in addition to COL1A1 causing Stickler syndrome, and a previously unreported combination of SLC34A1 gene variant with FKBP10 leading to Fanconi renal tubular syndrome type II. Our findings demonstrate the efficacy of clinical exome sequencing in screening OI patients, classifying its subtypes, and identifying associated disorders in consanguineous populations.

First Report of a Tissue-Engineered Graft for Proximal Humerus Gap Non-union After Chronic Pyogenic Osteomyelitis in a Child: A Case Report

CASE

An 11-year-old child who presented with a postseptic gap nonunion of 4 cm in the proximal humerus was treated with a customized hydroxyapatite-tricalcium phosphate-tricalcium silicate composite (HASi) scaffold loaded with culture-expanded autologous bone marrow-derived mesenchymal stem cells (MSCs) primed into osteogenic lineage. Union occurred at 3 months, and at 3 years, the child had improved joint mobility, with radiographic and computed tomographic imaging evidence of incorporation of the graft.

CONCLUSIONS

This case demonstrated the feasibility of MSC directed into osteogenic lineage on HASi to repair a long bone defect owing to postseptic osteomyelitis, a condition notorious for a high failure rate.

Radial Extracorporeal Shock Wave Treatment Promotes Bone Growth and Chondrogenesis in Cultured Fetal Rat Metatarsal Bones

BACKGROUND

Substantial evidence exists to show the positive effects of radialextracorporeal shock wave therapy (ESWT) on bone formation. However, it is unknown whether rESWT can act locally at the growth plate level to stimulate linear bone growth. One way to achieve this is to stimulate chondrogenesis in the growth plate without depending on circulating systemic growth factors. We wished to see whether rESWT would stimulate metatarsal rat growth plates in the absence of vascularity and associated systemic growth factors.

QUESTIONS/PURPOSES

To study the direct effects of rESWT on growth plate chondrogenesis, we asked: (1) Does rESWT stimulate longitudinal bone growth of ex vivo cultured bones? (2) Does rESWT cause any morphological changes in the growth plate? (3) Does rESWT locally activate proteins specific to growth plate chondrogenesis?

METHODS

Metatarsal bones from rat fetuses were untreated (controls: n = 15) or exposed to a single application of rESWT at a low dose (500 impulses, 5 Hz, 90 mJ; n = 15), mid-dose (500 impulses, 5 Hz, 120 mJ; n = 14) or high dose (500 impulses, 10 Hz, 180 mJ; n = 34) and cultured for 14 days. Bone lengths were measured on Days 0, 4, 7, and 14. After 14 days of culturing, growth plate morphology was assessed with a histomorphometric analysis in which hypertrophic cell size (> 7 µm) and hypertrophic zone height were measured (n = 6 bones each). Immunostaining for specific regulatory proteins involved in chondrogenesis and corresponding staining were quantitated digitally by a single observer using the automated threshold method in ImageJ software (n = 6 bones per group). A p value < 0.05 indicated a significant difference.

RESULTS

The bone length in the high-dose rESWT group was increased compared with that in untreated controls (4.46 mm ± 0.75 mm; 95% confidence interval, 3.28-3.71 and control: 3.50 mm ± 0.38 mm; 95% CI, 4.19-4.72; p = 0.01). Mechanistic studies of the growth plate's cartilage revealed that high-dose rESWT increased the number of proliferative chondrocytes compared with untreated control bones (1363 ± 393 immunopositive cells per bone and 500 ± 413 immunopositive cells per bone, respectively; p = 0.04) and increased the diameter of hypertrophic chondrocytes (18 ± 3 µm and 13 ± 3 µm, respectively; p < 0.001). This was accompanied by activation of insulin-like growth factor-1 (1015 ± 322 immunopositive cells per bone and 270 ± 121 immunopositive cells per bone, respectively; p = 0.043) and nuclear factor-kappa beta signaling (1029 ± 262 immunopositive cells per bone and 350 ± 60 immunopositive cells per bone, respectively; p = 0.01) and increased levels of the anti-apoptotic proteins B-cell lymphoma 2 (718 ± 86 immunopositive cells per bone and 35 ± 11 immunopositive cells per bone, respectively; p < 0.001) and B-cell lymphoma-extra-large (107 ± 7 immunopositive cells per bone and 34 ± 6 immunopositive cells per bone, respectively; p < 0.001).

CONCLUSION

In a model of cultured fetal rat metatarsals, rESWT increased longitudinal bone growth by locally inducing chondrogenesis. To verify whether rESWT can also stimulate bone growth in the presence of systemic circulatory factors, further studies are needed.

CLINICAL RELEVANCE

This preclinical proof-of-concept study shows that high-dose rESWT can stimulate longitudinal bone growth and growth plate chondrogenesis in cultured fetal rat metatarsal bones. A confirmatory in vivo study in skeletally immature animals must be performed before any clinical studies.

Radiology of Acquired Constriction Band Syndrome: An Unusual Cast Complication: A Case Report

CASE

A severe acquired constriction band in the proximal calf in an infant treated with a below-knee cast, which was protected with a waterproof sheet secured with a rubber band, is described. The radiological and computed tomography features of an elastic band causing the acquired constriction are presented for their novelty and uniqueness in the complication of cast treatment.

CONCLUSIONS

The waterproof covering of plaster casts in children secured with a rubber band to prevent soiling can cause an acquired constriction band, which mimics osteomyelitis. The imaging modalities showed the elastic band shadow cutting through the bone and soft tissues as demonstrated in this case. We recommend that the complication can be prevented by avoiding the use of elastic bands to hold the waterproofing covers for the cast.

An Assessment of the Applicability of Shriners Hospital Upper Extremity Evaluation as a Decision-making Tool and Outcome Measure in Upper Limb Cerebral Palsy in Indian Children

BACKGROUND

The aim of this study was to assess the applicability and performance of the Shriners Hospital Upper Extremity Evaluation (SHUEE) and to determine its usefulness in clinical decision-making and as an outcome measure with reference to Indian children suffering from cerebral palsy.

MATERIALS AND METHODS

The SHUEE videos of 40 children with cerebral palsy with spastic hemiplegia or asymmetrical diplegia were analyzed and scored. Seven children had undergone upper extremity surgery based on a preoperative evaluation. All seven had a postoperative evaluation. Pre- and postoperative scores were compared. Intra- and interobserver reliability was assessed. The level of familiarity and comfort of the children with the assigned tasks was gauged.

RESULTS

Analysis of the scores revealed that patients could be categorized into three discrete groups based on the modified House scores and Spontaneous Functional Analysis (SFA) scores, which helps in identifying the patients who would benefit from surgical intervention. In the seven children who were operated, there was a mean increase in the postoperative SFA (2.97, P = 0.259), Dynamic Positional Analysis (3.15, P = 0.229) and Grasp/Release Analysis (4.96, P = 0.334) scores, though the differences were not statistically significant. There was excellent intraobserver (r - 0.98) and interobserver reliability (r - 0.97, 0.96) based on the intraclass correlation coefficient. The children were familiar with the assigned tasks and were not duly uncomfortable while attempting to perform them.

CONCLUSIONS

SHUEE is a useful modality to assess upper limb function in Indian children with cerebral palsy, and can be used as a decision-making tool and mode of documentation.

Bone marrow extract as a growth supplement for human iliac apophyseal chondrocyte culture

Background & objectives:

Human bone marrow is rich in various growth factors which may support the chondrocyte growth. This study was conducted to compare the culture characteristics of human growth plate chondrocyte in foetal bovine serum (FBS) and human autologous bone marrow extract (BME) in monolayer culture.

Methods:

Iliac crest apophyseal cartilage was harvested from four donors, aged between two and nine years, undergoing hip surgery. Chondrocytes were propagated under two culture conditions, with 10 per cent FBS and 10 per cent autologous BME harvested from the same donors. Cells were harvested at 7, 14 and 21 days to assess viability, morphology, cell count and immunocytochemistry.

Results:

With an initial seeding density of 2500 cells/cm², the average yield in monolayer cultured with FBS was 3.35 × 10⁵, 5.9 × 10⁵, 14.1 × 10⁵ and BME was 0.66 × 10⁵, 1.57 × 10⁵ and 3.48 × 10⁵ at 7, 14 and 21 days, respectively. Viability was 98.21 per cent with FBS and 97.45 per cent with BME at 21 days. In BME supplemented cultures, hyaline phenotype was maintained up to 21 days. The yield was higher in the FBS supplemented group; however, the phenotype could not be maintained by the FBS group as long as BME group.

Interpretation & conclusions:

Autologous BME was found to be a safer alternative to FBS for human studies. BME could maintain the hyaline phenotype for a longer time. Ways to enhance the cell yield needs to be explored in future studies.

Can Pixel Value Ratio be Used in the Assessment of Ceramic Bone Substitute Incorporation? Observations from a Pilot Study

Background

Assessment of bone graft substitute incorporation is critical in the clinical decision making process and requires special investigations. We examined if the pixel value ratio (PVR) obtained in routine follow-up digital radiographs could be used for such assessment.

Material/Methods

Radiographic images were acquired using either computed radiography or flat panel digital radiography systems. The PVR from radiographs of thirty children with ceramic bone substitute grafting were analyzed using the software from the picture archival and communication system (PACS) workstation. Graft incorporation was also assessed using the van Hemert scale. Three independent observers (A, B, C) measured PVRs at two different time points during the first and the last follow-up visits. PVR was compared with the van Hemert scale scores and analyzed using Spearman's rank correlation.

Results

The mean intra-observer reliability was 0.8996, and inter-observer reliabilities were 0.69 (A vs. C), 0.78 (A vs. B), and 0.85 (B vs. C) for the first follow-up visit and 0.74 (A vs. C), 0.82 (A vs. B), and 0.70 (B vs. C) for the last follow-up measurements. Spearman's correlation showed a strong negative association between PVR values and van Hemert scale scores, as the healing process advanced on serial measurements at each follow-up (r=-0.94, n=60, z=-7.24, p≤0.0001). The reliability of the PVR measurements was assessed using an aluminum step wedge and ceramic graft.

Conclusions

PVR is potentially a reliable indicator of bone graft incorporation and can aid in clinical decision making provided standard radiographic techniques are used.

Radiofrequency Ablation of Osteoid Osteoma in Common and Technically Challenging Locations in Pediatric Population

Context:

Percutaneous radiofrequency ablation (RFA) of osteoid osteoma has a high technical and clinical success rate. However, there is limited data on its use in the pediatric population, especially in technically challenging locations.

Objective:

The objective of this study was to assess the safety and efficacy of CT-guided percutaneous RFA of osteoid osteoma in pediatric population.

Subjects and Methods:

From June 2009 to May 2014, thirty patients with osteoid osteoma were treated with CT-guided RFA in common (25 cases) and technically challenging (five cases: four near articular surface and one in sacrum) locations. Therapy was performed under general anesthesia with a three-array expandable RF probe for 6 min at 90°C and power of 60–100 W. The patients were discharged next day under instruction. The treatment success was evaluated in terms of pain relief before and after (1 day, 1 month, and 6 months) treatment.

Results:

Technical success was achieved in all patients (100%). Primary clinical success was 96.66% (29 of total 30 patients) despite the pediatric population and atypical location. One patient had persistent pain after 1 month duration and were treated successfully with a second procedure (secondary success rate was 100%). One patient had immediate complication of weakness of right hand and fingers extension. No delayed complications were observed.

Conclusions:

CT-guided RFA is relatively safe and highly effective for treatment of osteoid osteoma in pediatric population, even in technically difficult locations.

Advance in Knowledge:

Our study showed that if technical success is 100% and if strict desired temperature (90°C) can be maintained for desired time (6 min) using controlled power (wattage) delivery (60–100 W), then high clinical success can be achieved even in pediatric population similar to adult population.

Accuracy of Various MRI Sequences in Determining the Tumour Margin in Musculoskeletal Tumours

Background

It is imperative that bone tumour margin and extent of tumour involvement are accurately assessed pre-operatively in order for the surgeon to attain a safe surgical margin. In this study, we comprehensively assessed each of the findings that influence surgical planning, on various MRI sequences and compared them with the gold standard – pathology.

Material/Methods

In this prospective study including 21 patients with extremity bone tumours, margins as seen on various MRI sequences (T1, T2, STIR, DWI, post-gadolinium T1 FS) were measured and biopsies were obtained from each of these sites during the surgical resection. The resected tumour specimen and individual biopsy samples were studied to assess the true tumour margin. Margins on each of the MRI sequences were then compared with the gold standard – pathology. In addition to the intramedullary tumour margin, we also assessed the extent of soft tissue component, neurovascular bundle involvement, epiphyseal and joint involvement, and the presence or absence of skip lesions.

Results

T1-weighted imaging was the best sequence to measure tumour margin without resulting in clinically significant underestimation or overestimation of the tumour extent (mean difference of 0.8 mm; 95% confidence interval between −0.9 mm to 2.5 mm; inter-class correlation coefficient of 0.998). STIR and T1 FS post-gadolinium imaging grossly overestimated tumour extent by an average of 16.7 mm and 16.8 mm, respectively (P values <0.05). Post-gadolinium imaging was better to assess joint involvement while T1 and STIR were the best to assess epiphyseal involvement.

Conclusions

T1-weighted imaging was the best sequence to assess longitudinal intramedullary tumour extent. We suggest that osteotomy plane 1.5 cm beyond the T1 tumour margin is safe and also limits unwarranted surgical bone loss. However, this needs to be prospectively proven with a larger sample size.

Does pamidronate enhance the osteogenesis in mesenchymal stem cells derived from fibrous hamartoma in congenital pseudarthrosis of the tibia?

Neurofibromatosis type 1 (NF1) is a commonly occurring genetic disorder in children. Mutation in the NF1 gene has its implication in poor osteoblastic capabilities. We hypothesised that pamidronate will enhance the osteoblastic potential of the mesenchymal stem cells (MSCs) derived from lipofibromatosis tissue of children with congenital pseudarthrosis tibia (CPT) associated with NF1. In this study, bone marrow MSCs (BM MSCs) and CPT MSCs were obtained from three patients undergoing salvage surgeries/bone grafting (healthy controls) and those undergoing excision of the hamartoma and corrective surgeries respectively. The effects of pamidronate (0, 10 nM, 100 nM and 1 μM) on cell proliferation, toxicity and differentiation potential were assessed and the outcome was measured by staining and gene expression. Our outcome showed that CPT MSCs had more proliferation rate as compared to BM MSCs. All 3 doses of pamidronate did not cause any toxicity to the cells in both the groups. The CPT MSCs showed less differentiation with pamidronate compared to the healthy control MSCs. This was quantitated by staining and gene expression analysis. Therefore, supplementation with pamidronate alone will not aid in bone formation in patients diagnosed with CPT. An additional stimulus is required to enhance bone formation.

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First study demonstrating the differentiation potential of MSCs derived from the hamartoma using pamidronate

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The CPT MSCs have lower osteogenic potential as compared to BM MSCs.

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The osteoblastic response does not improve with the addition of pamidronate (1 μM) in CPT MSCs.

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Pamidronate enhances osteogenic differentiation in normal BM MSCs.

Retrospective cohort study comparing the efficacy of prednisolone and deflazacort in children with muscular dystrophy: A 6 years' experience in a South Indian teaching hospital

BACKGROUND

Muscular dystrophies are inherited myogenic disorders characterized by progressive muscle wasting and weakness of variable distribution and severity. They are a heterogeneous group characterized by variable degree of skeletal and cardiac muscle involvement. The most common and the most severe form of muscular dystrophy is DMD. Currently, there is no curative treatment for muscular dystrophies. Several drugs have been studied to retard the progression of the muscle weakness. There is much controversy about steroid usage in muscular dystrophy with respect to regimen, adverse effects, and whether long term benefits outweigh side effects. This study is to assess steroid efficacy in children with muscular dystrophy.

MATERIALS AND METHODS

All children with diagnosed muscular dystrophy by muscle biopsy, immunohistochemistry and/or genetic test were enrolled in the study. They were started on either prednisolone (0.75 mg/kg/day) or deflazacort 0.9 mg/kg/day based on affordability. All were followed up every 6 months with clinical assessment, quality of life questionnaire and clinical and laboratory assessment of side effects. Outcome measures of children on deflazacort and prednisolone at 1 year followup were summarized as numbers and percentages and were compared using Fisher's exact test.

RESULTS

Twenty two children with muscular dystrophy were included (prednisolone group: 10 and deflazacort group: 12). The mean age was 7.7 years at an average followup of 26.4 months. Twenty children were diagnosed to have Duchenne's; one had Becker's muscular dystrophy while one had sarcoglycanopathy by Type 2C. All children from prednisolone group maintained their ambulatory status at 2 and 4 years followups while three on deflazacort lost their ability to walk at an average age of 11.3 years. All activities of daily living were found to be better in prednisolone group. Muscle function and time taken to walk improved in prednisolone group. Weight gain in children on prednisolone was three times more.

CONCLUSIONS

Prednisolone is more beneficial than deflazacort at doses of 0.75 mg/kg/day and 0.9 mg/kg/day, respectively, however it is associated with adverse effects.

WISP3 mutational analysis in Indian patients diagnosed with progressive pseudorheumatoid dysplasia and report of a novel mutation at p.Y198

Objectives

To determine the pattern of mutations of the WISP3 gene in clinically identified progressive pseudorheumatoid dysplasia (PPD) in an Indian population.

Patients and Methods

A total of 15 patients with clinical features of PPD were enrolled in this study. Genomic DNA was isolated and polymerase chain reaction performed to amplify the WISP3 gene. Screening for mutations was done by conformation-sensitive gel electrophoresis, beginning with the fifth exon and subsequently proceeding to the remaining exons. Sanger sequencing was performed for both forward and reverse strands to confirm the mutations.

Results

In all, two of the 15 patients had compound heterozygous mutations: one a nonsense mutation c.156C>A (p.C52*) in exon 2, and the other a missense mutation c.677G>T (p.G226V) in exon 4. All others were homozygous, with three bearing a nonsense mutation c.156C>A (p.C52*) in exon 2, three a missense mutation c.233G>A (p.C78Y) in exon 2, five a missense mutation c.1010G>A (p.C337Y) in exon 5, one a nonsense mutation c.348C>A (p.Y116*) in exon 3, and one with a novel deletion mutation c.593_597delATAGA (p.Y198*) in exon 4.

Conclusion

We identified a novel mutation c.593_597delATAGA (p.Y198*) in the fourth exon of the WISP3 gene. We also confirmed c.1010G>A as one of the common mutations in an Indian population with progressive pseudorheumatoid dysplasia.

Cite this article: V. Madhuri, M. Santhanam, K. Rajagopal, L. K. Sugumar, V. Balaji. WISP3 mutational analysis in Indian patients diagnosed with progressive pseudorheumatoid dysplasia and report of a novel mutation at p.Y198* Bone Joint Res 2016;5:301–306. DOI: 10.1302/2046-3758.57.2000520.

Limb lengthening in achondroplasia

BACKGROUND

Stature lengthening in skeletal dysplasia is a contentious issue. Specific guidelines regarding the age and sequence of surgery, methods and extent of lengthening at each stage are not uniform around the world. Despite the need for multiple surgeries, with their attendant complications, parents demanding stature lengthening are not rare, due to the social bias and psychological effects experienced by these patients. This study describes the outcome and complications of extensive stature lengthening performed at our center.

MATERIALS AND METHODS

Eight achondroplasic and one hypochondroplasic patient underwent bilateral transverse lengthening for tibiae, humeri and femora. Tibia lengthening was carried out using a ring fixator and bifocal corticotomy, while a monolateral pediatric limb reconstruction system with unifocal corticotomy was used for the femur and humerus. Lengthening of each bone segment, height gain, healing index and complications were assessed. Subgroup analysis was carried out to assess the effect of age and bone segment on the healing index.

RESULTS

Nine patients aged five to 25 years (mean age 10.2 years) underwent limb lengthening procedures for 18 tibiae, 10 femora and 8 humeri. Four patients underwent bilateral lengthening of all three segments. The mean length gain for the tibia, femur and humerus was 15.4 cm (100.7%), 9.9 cm (52.8%) and 9.6 cm (77.9%), respectively. Healing index was 25.7, 25.6 and 20.6 days/cm, respectively, for the tibia, femur and humerus. An average of 33.3% height gain was attained. Lengthening of both tibia and femur added to projected height achieved as the 3(rd) percentile of standard height in three out of four patients. In all, 33 complications were encountered (0.9 complications per segment). Healing index was not affected by age or bone segment.

CONCLUSION

Extensive limb lengthening (more than 50% over initial length) carries significant risk and should be undertaken only after due consideration.

Use of a vascular sheath for introduction of radiofrequency ablation probe during radiofrequency ablation of osteoid osteoma

Radiofrequency ablation (RFA) has now become a preferred treatment option for osteoid osteoma. Accurate placement of RFA probe into the nidus of osteoid osteoma is important for good clinical outcome. Various methods and techniques have been described in the literature available. We describe the technique of using a vascular access sheath for introduction of RFA probe after bone drilling, which prevents loss of access to drill track and also serves as a pathway for accurate placement of RFA probe, thereby reducing the risk of damage to the RFA probe tip itself and the surrounding soft tissue.

Multiple Unerupted Permanent Teeth Associated with Noonan Syndrome

The present report describes a case of Noonan's syndrome from a dental viewpoint. Noonan syndrome is an autosomal dominant multisystem disorder. Congenital heart deformities, short stature, thoracic deformities, short neck with webbing, hypertelorism, and malocclusions are some of the frequently observed clinical features. Atypical dental anomalies such as multiple unerupted permanent teeth, multiple submerged and retained deciduous teeth, and supernumerary teeth were found in the present case. Oral prophylaxis and preventive resin restorations were done following which the supernumerary teeth were extracted. 54, 55, 64, 65, 74, 75 and 84 were extracted after orthodontic consultation to facilitate the eruption of permanent teeth. The patient is undergoing fixed orthodontic therapy for forced eruption of unerupted permanent teeth. General dentists should correlate dental anomalies with other systemic features in the diagnosis of such syndromes because of the variability in presentation and the need for multidisciplinary care.

Interventions for treating femoral shaft fractures in children and adolescents

BACKGROUND

Fractures of the femoral shaft in children are relatively uncommon but serious injuries that disrupt the lives of children and their carers and can result in significant long-term disability. Treatment involves either surgical fixation, such as intramedullary nailing or external fixation, or conservative treatment involving prolonged immobilisation, often in hospital.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating femoral shaft fractures in children and adolescents.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (accessed 16 August 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013 Issue 7), MEDLINE (1946 to August Week 1 2013), EMBASE (1980 to 2012 week 9), CINAHL (16 August 2013), clinical trials registries, conference proceedings and reference lists; and contacted trial authors and experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing conservative and surgical interventions for diaphyseal fractures of the femur in children under 18 years of age. Our primary outcomes were functional outcome measures, unacceptable malunion, and serious adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected trials, assessed risk of bias and extracted data. We assessed the overall quality of the evidence for each outcome for each comparison using the GRADE approach. We pooled data using a fixed-effect model.

MAIN RESULTS

We included 10 trials (six randomised and four quasi-randomised) involving a total of 527 children (531 fractures). All trials were at some risk of bias, including performance bias as care provider blinding was not practical, but to a differing extent. Just one trial was at low risk of selection bias. Reflecting both the risk of bias and the imprecision of findings, we judged the quality of evidence to be 'low' for most outcomes, meaning that we are unsure about the estimates of effect. Most trials failed to report on self-assessed function or when children resumed their usual activities. The trials evaluated 10 different comparisons, belonging to three main categories. Surgical versus conservative treatment. Four trials presenting data for 264 children aged 4 to 12 years made this comparison. Low quality evidence (one trial, 101 children) showed children had very similar function assessed using the RAND health status score at two years after surgery (external fixation) compared with conservative treatment (spica cast): mean 69 versus 68. The other three trials did not report on function. There was moderate quality evidence (four trials, 264 children, aged 4 to 12 years, followed up 3 to 24 months) that surgery reduced the risk of malunion (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.15 to 0.59, 4 trials). Assuming an illustrative baseline risk of 115 malunions per 1000 in children treated conservatively, these data equate to 81 fewer (95% CI 47 to 97 fewer) malunions per 1000 in surgically-treated children. Conversely, low quality evidence indicated that there were more serious adverse events such as infections after surgery (RR 2.39, 95% CI 1.10 to 5.17, 4 trials). Assuming an illustrative baseline risk of 40 serious adverse events per 1000 for conservative treatment, these data equate to 56 more (95% CI 4 to 167 more) serious adverse events per 1000 children treated surgically. There was low quality evidence (one trial, 101 children) of similar satisfaction levels in children and parents with surgery involving external fixation and plaster cast only. However, there was low quality evidence (one trial, 46 children) that more parents were satisfied with intramedullary nailing than with traction followed by a cast, and that surgery reduced the time taken off from school. Comparisons of different methods of conservative treatment. The three trials in this category made three different comparisons. We are very unsure if unacceptable malunion rates differ between immediate hip spica versus skeletal traction followed by spica in children aged 3 to 10 years followed up for six to eight weeks (RR 4.0, 95% CI 0.5 to 32.9; one trial, 42 children; very low quality evidence). Malunion rates at 5 to 10 years may not differ between traction followed by functional orthosis versus traction followed by spica cast in children aged 5 to 13 years (RR 0.98, 95% CI 0.46 to 2.12; one trial, 43 children; low quality evidence). We are very unsure (very low quality evidence) if either function or serious adverse events (zero events reported) differ between single-leg versus double-leg spica casts (one trial, 52 young children aged two to seven years). Low quality evidence on the same comparison indicates that single-leg casts are less awkward to manage by parents, more comfortable for the child and may require less time off work by the caregiver. Comparisons of different methods of surgical treatment. The three trials in this category made three different comparisons. Very low quality evidence means that we are very unsure if the rates of malunion, serious adverse events, time to return to school or parental satisfaction actually differ in children whose fractures were fixed using elastic stable intramedullary nailing or external fixation (one trial, 19 children). The same applies to the rates of serious adverse events and time to resume full weight-bearing in children treated with dynamic versus static external fixation (one trial, 52 children). Very low quality evidence (one trial, 47 children) means that we do not know if malunion, serious adverse events and time to resume weight-bearing actually differ between intramedullary nailing versus submuscular plating. However, there could be more difficulties in plate removal subsequently.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine if long-term function differs between surgical and conservative treatment. Surgery results in lower rates of malunion in children aged 4 to 12 years, but may increase the risk of serious adverse events. Elastic stable intramedullary nailing may reduce recovery time. There is insufficient evidence from comparisons of different methods of conservative treatment or of different methods of surgical treatment to draw conclusions on the relative effects of the treatments compared in the included trials.

PLAIN LANGUAGE SUMMARY

Different methods of treating fractures of the shaft of the thigh bone in children and adolescents Although uncommon, fractures of the femoral shaft (thigh bone) in children may require prolonged treatment in hospital and sometimes surgery. This can cause significant discomfort and can disrupt the lives of the children and their familles. This review compared different methods of treating these fractures. Surgical treatment comprises different methods of fixing the broken bones, such as internally-placed nails, or pins incorporated into an external frame (external fixation). Non-surgical or conservative treatment usually involves different types of plaster casts with or without traction (where a pulling force is applied to the leg). We searched for studies in the medical literature until August 2013. The review includes 10 randomised or quasi-randomised controlled trials that recruited 527 children. Four trials compared different surgical versus non-surgical treatments; three compared different methods of non-surgical treatment and three compared different methods of surgical treatment. Generally we are unsure about the results of these trials because some were at risk of bias, some results were contradictory and usually there was too little evidence to rule out chance findings. Most trials failed to report on self-assessed function or when children resumed their usual activities. Comparing surgical versus non-surgical treatment. Low quality evidence (one trial, 101 children) showed children had similar function at two years after having surgery, involving external fixation, compared with those treated with a plaster cast. The other three trials did not report this outcome. There was moderate quality evidence (four trials, 264 children, aged 4 to 12 years, followed up for 3 to 24 months) that surgery reduced the risk of malunion (the leg is deformed) compared with non-surgical treatment. However, low quality evidence (four trials) indicated that there were more serious adverse events such as infections after surgery. There was low quality evidence (one trial, 101 children) of similar satisfaction levels in children and parents with surgery involving external fixation and plaster cast only. However, there was low quality evidence (one trial, 46 children) that more parents were satisfied with surgery involving an internal nail than with traction followed by a cast and that surgery reduced the time taken off from school. Comparing various non-surgical treatments. Very low quality evidence means that we are very unsure if the rates of malunion differ or not between children treated with immediate plaster casts versus with traction followed by plaster cast (one trial, 42 children), or between children treated with traction followed by either a functional orthosis (a brace or cast that allows some movement) or a cast (one trial, 43 children). We are very unsure if either function or serious adverse events differ between young children (aged two to seven years) immobilised in single-leg versus double-leg casts (one trial, 52 children). However, single-leg casts appear to be easier to manage by parents and more comfortable for the child. Comparing various surgical treatments Very low quality evidence means that we are very unsure if the rates of malunion, serious adverse events, time to return to school or parental satisfaction actually differ in children whose fractures were fixed using internal nails or external fixation (one trial, 19 children). (ABSTRACT TRUNCATED)

Interferon-Induced Transmembrane Protein 5 Mutation Causing Type-V Osteogenesis Imperfecta: A Case Report

CASE

We report a case of heterozygous mutation of c.-14C>T in the 5'-untranslated region of the interferon-induced transmembrane protein 5 in a nine-year-old girl. She was diagnosed with type-V osteogenesis imperfecta based on the classic features of bone fragility, radial head dislocation, forearm interosseous membrane calcification, limited forearm rotation, hyperplastic callus formation, and radiodense metaphyseal bands, as well as absent blue sclerae, absence of hearing loss, and absence of dentinogenesis imperfecta.

CONCLUSION

Although the differential diagnosis may include infantile cortical hypertrophy, child abuse, or a malignant tumor (e.g., osteosarcoma), the presence of typical clinical and radiographic features and characteristic gene mutation helps confirm the diagnosis of type-V osteogenesis imperfecta.

Interventions for treating femoral shaft fractures in children and adolescents

BACKGROUND

Fractures of the femoral shaft in children are relatively uncommon but serious injuries that disrupt the lives of children and their carers and can result in significant long-term disability. Treatment involves either surgical fixation, such as intramedullary nailing or external fixation, or conservative treatment involving prolonged immobilisation, often in hospital.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating femoral shaft fractures in children and adolescents.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (accessed 16 August 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013 Issue 7), MEDLINE (1946 to August Week 1 2013), EMBASE (1980 to 2012 week 9), CINAHL (16 August 2013), clinical trials registries, conference proceedings and reference lists; and contacted trial authors and experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing conservative and surgical interventions for diaphyseal fractures of the femur in children under 18 years of age. Our primary outcomes were functional outcome measures, unacceptable malunion, and serious adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected trials, assessed risk of bias and extracted data. We assessed the overall quality of the evidence for each outcome for each comparison using the GRADE approach. We pooled data using a fixed-effect model.

MAIN RESULTS

We included 10 trials (six randomised and four quasi-randomised) involving a total of 527 children (531 fractures). All trials were at some risk of bias, including performance bias as care provider blinding was not practical, but to a differing extent. Just one trial was at low risk of selection bias. Reflecting both the risk of bias and the imprecision of findings, we judged the quality of evidence to be 'low' for most outcomes, meaning that we are unsure about the estimates of effect. Most trials failed to report on self-assessed function or when children resumed their usual activities. The trials evaluated 10 different comparisons, belonging to three main categories. Surgical versus conservative treatment Four trials presenting data for 264 children aged 4 to 12 years made this comparison. Low quality evidence (one trial, 101 children) showed children had very similar function assessed using the RAND health status score at two years after surgery (external fixation) compared with conservative treatment (spica cast): mean 69 versus 68. The other three trials did not report on function. There was moderate quality evidence (four trials, 264 children, aged 4 to 12 years, followed up 3 to 24 months) that surgery reduced the risk of malunion (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.15 to 0.59, 4 trials). Assuming an illustrative baseline risk of 115 malunions per 1000 in children treated conservatively, these data equate to 81 fewer (95% CI 47 to 97 fewer) malunions per 1000 in surgically-treated children. Conversely, low quality evidence indicated that there were more serious adverse events such as infections after surgery (RR 2.39, 95% CI 1.10 to 5.17, 4 trials). Assuming an illustrative baseline risk of 40 serious adverse events per 1000 for conservative treatment, these data equate to 56 more (95% CI 4 to 167 more) serious adverse events per 1000 children treated surgically. There was low quality evidence (one trial, 101 children) of similar satisfaction levels in children and parents with surgery involving external fixation and plaster cast only. However, there was low quality evidence (one trial, 46 children) that more parents were satisfied with intramedullary nailing than with traction followed by a cast, and that surgery reduced the time taken off from school. Comparisons of different methods of conservative treatmentThe three trials in this category made three different comparisons. We are very unsure if unacceptable malunion rates differ between immediate hip spica versus skeletal traction followed by spica in children aged 3 to 10 years followed up for six to eight weeks (RR 4.0, 95% CI 0.5 to 32.9; one trial, 42 children; very low quality evidence). Malunion rates at 5 to 10 years may not differ between traction followed by functional orthosis versus traction followed by spica cast in children aged 5 to 13 years (RR 0.98, 95% CI 0.46 to 2.12; one trial, 43 children; low quality evidence). We are very unsure (very low quality evidence) if either function or serious adverse events (zero events reported) differ between single-leg versus double-leg spica casts (one trial, 52 young children aged two to seven years). Low quality evidence on the same comparison indicates that single-leg casts are less awkward to manage by parents, more comfortable for the child and may require less time off work by the caregiver. Comparisons of different methods of surgical treatmentThe three trials in this category made three different comparisons. Very low quality evidence means that we are very unsure if the rates of malunion, serious adverse events, time to return to school or parental satisfaction actually differ in children whose fractures were fixed using elastic stable intramedullary nailing or external fixation (one trial, 19 children). The same applies to the rates of serious adverse events and time to resume full weight-bearing in children treated with dynamic versus static external fixation (one trial, 52 children). Very low quality evidence (one trial, 47 children) means that we do not know if malunion, serious adverse events and time to resume weight-bearing actually differ between intramedullary nailing versus submuscular plating. However, there could be more difficulties in plate removal subsequently.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine if long-term function differs between surgical and conservative treatment. Surgery results in lower rates of malunion in children aged 4 to 12 years, but may increase the risk of serious adverse events. Elastic stable intramedullary nailing may reduce recovery time.There is insufficient evidence from comparisons of different methods of conservative treatment or of different methods of surgical treatment to draw conclusions on the relative effects of the treatments compared in the included trials.

Triphasic ceramic scaffold in paediatric and adolescent bone defects

We evaluated novel triphasic hydroxyapatite tricalcium phosphate calcium silicate scaffold (HASi) in the management of paediatric bone defects. Their main advantage is considered to be adequate strength and stimulation of bone formation without resorting to autograft. A total of 42 children younger than 16 years of age were recruited over a period of 1 year and were treated with this synthetic bone substitute as a stand-alone graft for pelvic, femur, calcaneal and ulnar osteotomies, cystic bone lesions, subtalar arthrodesis and segmental bone defects. Forty children, 22 boys and 18 girls, mean age 8.3 years and a mean follow-up of 18.51 months, were available for evaluation. Analysis showed that younger age, cancellous defects and no internal fixation were associated with significantly faster healing. Partial incorporation was observed in 22.5% and complete incorporation in 77.5% of cases at 18 months of follow-up. Sex, type of defect, BMI and the shape of the ceramic graft did not significantly affect the rate of healing. Complications attributable to HASi included four nonunions, three of which were diaphyseal. HASi was found to be safe in children with cancellous or benign cavitatory defects. It is not suitable for diaphyseal and segmental bone defects as a stand-alone graft.