Cost-utility analysis of teduglutide compared to standard care in weaning parenteral nutrition support in children with short bowel syndrome

BACKGROUND & AIMS

A growing proportion of children with short bowel syndrome (SBS) remain dependent on long-term parenteral nutrition (PN). Teduglutide offers the potential for more children to decrease PN support and achieve enteral autonomy (EA), but at a significant expense. This study aims to assess the incremental costs of teduglutide plus standard of care compared to standard of care alone in weaning PN support per quality-adjusted life year (QALY) gained in children with SBS.

METHODS

This is a cost-utility analysis comparing teduglutide with standard of care alone in children with SBS. A microsimulation model of children with SBS on PN aged 1-17 years was constructed over a time horizon of six years, with a cycle length of one month. The study adopted the healthcare system and societal payer perspectives in Ontario, Canada. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Scenario analyses were performed to examine the effects of different time horizons, timing of teduglutide initiation, and modeling cost of teduglutide based on pediatric weight-dosing.

RESULTS

Incremental healthcare system costs for teduglutide compared to standard of care were CAD$441,314 (95% CI, 414,006 to 441,314) and incremental QALYs were 1.80 (95% CI, 1.70 to 1.89) resulting in an incremental cost-effectiveness ratio (ICER) of CAD$285,334 (95% CI, 178,209 to 392,459) per QALY gained. Incremental societal costs were CAD$418,504 (95% CI, 409,487 to 427,522) and incremental societal QALYs were 1.91 (95% CI, 1.85 to 1.98) resulting in an ICER of CAD$261,880 (95% CI, 136,887 to 386,874) per QALY gained. Scenario analysis showed that teduglutide was cost-effective when it was started two years after intestinal resection (ICER CAD$48,741, 95% CI, 17,317 to 80,165) and when its monthly cost was adjusted using weight-based dosing, avoiding wastage of the remaining 5 mg dose vial (Teduglutide dominated over SOC as the less costly and most effective strategy).

CONCLUSIONS

Although teduglutide was not cost-effective in weaning PN support in children with SBS, starting teduglutide once natural intestinal adaptation is reduced and adjusting its monthly cost to reflect cost by volume as dictated by weight-based dosing rendered the intervention cost-effective relative to standard of care. These results indicate the potential for clinicians to re-assess optimal time for initiation of teduglutide after intestinal resection, drug manufacturers to consider the use of multi-dose or paediatric-dose vials, and the opportunity for decision-makers to re-evaluate teduglutide funding.

[Investigation of the reduction in the disability after fractures in children and adolescents]

The student accident insurance has been part of the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV) for 50 years. In order to assess the reduction in working capacity (Minderung der Erwerbsfähigkeit, MdE) in the event of permanent consequences of accidents and injuries, the recommendation to treat the affected child or adolescent "as an average adult" is currently still valid. The present work deals with the everyday practice of the MdE assessment in children and adolescents and their weaknesses through the transfer of the principles from adulthood. In addition, proposals for the adaptation of the assessment principles for the growth age are drawn up.

Multicentre phase II trial of near-infrared imaging in elective colorectal surgery

BACKGROUND

Decreasing anastomotic leak rates remain a major goal in colorectal surgery. Assessing intraoperative perfusion by indocyanine green (ICG) with near-infrared (NIR) visualization may assist in selection of intestinal transection level and subsequent anastomotic vascular sufficiency. This study examined the use of NIR-ICG imaging in colorectal surgery.

METHODS

This was a prospective phase II study (NCT02459405) of non-selected patients undergoing any elective colorectal operation with anastomosis over a 3-year interval in three tertiary hospitals. A standard protocol was followed to assess NIR-ICG perfusion before and after anastomosis construction in comparison with standard operator visual assessment alone.

RESULTS

Five hundred and four patients (median age 64 years, 279 men) having surgery for neoplastic (330) and benign (174) pathology were studied. Some 425 operations (85·3 per cent) were started laparoscopically, with a conversion rate of 5·9 per cent. In all, 220 patients (43·7 per cent) underwent high anterior resection or reversal of Hartmann's operation, and 90 (17·9 per cent) low anterior resection. ICG angiography was achieved in every patient, with a median interval of 29 s to visualization of the signal after injection. NIR-ICG assessment resulted in a change in the site of bowel division in 29 patients (5·8 per cent) with no subsequent leaks in these patients. Leak rates were 2·4 per cent overall (12 of 504), 2·6 per cent for colorectal anastomoses and 3 per cent for low anterior resection. When NIR-ICG imaging was used, the anastomotic leak rates were lower than those in the participating centres from over 1000 similar operations performed with identical technique but without NIR-ICG technology.

CONCLUSION

Routine NIR-ICG assessment in patients undergoing elective colorectal surgery is feasible. NIR-ICG use may change intraoperative decisions, which may lead to a reduction in anastomotic leak rates.

Double-barrelled wet colostomy formation after pelvic exenteration for locally advanced or recurrent rectal cancer

AIM

In advanced pelvic cancer it may be necessary to perform a total pelvic exenteration. In such cases urinary tract reconstruction is usually achieved with the creation of an ileal conduit with a urinary stoma on the right side of the patient's abdomen and an end colostomy separately on the left. The potential morbidity from a second stoma may be avoided by the use of a double-barrelled wet colostomy (DBWC), as a single stoma. Another advantage is the possibility of using a vertical rectus abdominis muscle flap for perineal reconstruction.

METHOD

All patients undergoing formation of a DBWC were included.

RESULT

A DBWC was formed in 10 patients. One patient underwent formation of a double-barrelled wet ileostomy.

CONCLUSIONS

In this technical note we present our early experience in 11 cases and a video of DBWC formation in a male patient.

Measurement of Attitude Change in Nursing Aides

The results of a year's group discussion between 12 aides and 3 professional persons suggest the value of group techniques for increasing understanding between nursing aides and other persons and the effectiveness of Employee Supervisor Statement Study and the Patient Attitude Scale as pre-employment selective measures and for reflecting attitude changes following group educational experience.

A report of three cases and review of the literature on rectal disruption following abdominal seatbelt trauma

Seatbelt associated blunt trauma to the rectum is a rare but well recognised injury. The exact mechanism of hollow visceral injury in blunt trauma is unclear. Stress and shear waves generated by abdominal compression may in part account for injury to gas containing structures. A 'seatbelt sign' (linear ecchymosis across the abdomen in the distribution of the lap belt) should raise the suspicion of hollow visceral injuries and can be more severe with disruption of the abdominal wall musculature. Three consecutive cases of rectal injury following blunt abdominal trauma, requiring emergency laparotomy and resection, are described. Lumbar spine injury occurred in one case and in the other two cases, there was injury to the iliac wing of the pelvis; all three cases sustained significant abdominal wall contusion or muscle disruption. Abdominal wall reconstruction and closure posed a particular challenge, requiring a multidisciplinary approach. The literature on this topic is reviewed and potential mechanisms of injury are discussed.

Endoscopically assisted extralevator abdominoperineal excision

AIM

Extralevator abdominoperineal excision (ELAPE) has been advocated to optimize clearance of lower third rectal cancers with an involved or threatened circumferential resection margin. ELAPE could reduce positive margins and specimen perforation compared with standard abdominoperineal excision. However, there can be difficulties with ELAPE, particularly in identifying the anterior plane in male patients. Usually, the dissection is performed in the prone position, which can be hazardous, particularly in obese patients in whom wound problems are commonly encountered. We describe an endoscopically assisted approach for ELAPE in the lithotomy position.

METHOD

Three male patients with a rectal tumour located at the anorectal junction underwent an endoscopically assisted ELAPE in the lithotomy position after preoperative radiotherapy.

RESULTS

All the procedures were performed successfully with operation times of 180, 390 and 420 mins. There were no instances of intra-operative perforation or other complications. One patient developed postoperative intestinal obstruction which resolved on conservative management. There were no wound complications. Histopathological examination demonstrated clear margins and intact mesorectal planes in each patient.

CONCLUSION

We report a good outcome in three patients after endoscopically assisted ELAPE. This approach allows the patient to be operated on in the lithotomy position giving excellent views of the anterior dissection.

Fluorescence angiography in laparoscopic low rectal and anorectal anastomoses with pinpoint perfusion imaging--a critical appraisal with specific focus on leak risk reduction

BACKGROUND AND AIMS

Anastomotic dehiscence is one of the most feared complications in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. One of the key factors is the perfusion of the bowel to be joined. Presently, surgeons rely on a variety subjective measures to determine anastomotic perfusion and mechanical integrity however these have shortcomings. The aim of this paper is to appraise the literature on the use of fluorescence angiography (FA) in laparoscopic rectal surgery.

MATERIALS AND METHODS

A Pubmed search was undertaken using terms 'fluorescence angiography' and 'rectal surgery'. The search was expanded using the related articles function. Studies were included if they used FA specifically for rectal surgery. Outcomes of interest including anastomotic leak rate, change of operative strategy and time taken for FA were recorded.

RESULTS

Eleven papers detailing the use of FA in rectal surgery are outlined demonstrating that this technique may change operative strategy and lead to a reduction in anastomotic leak rate.

CONCLUSION

In this paper, we discuss assessment of colorectal blood supply using FA and how this technique holds great potential to detect insufficiently perfused bowel. In so doing, the operator can adjust their operative strategy to mitigate these affects with the aim of reducing the complications of anastomotic leak and stenosis. However, it is highlighted that there is a clear need for randomised controlled trials in order to determine this definitively.

Magnetic moments and exchange coupling in nitride clusterfullerenes Gd(x)Sc(3-x)N@C80 (x = 1-3)

The magnetic properties of nitride clusterfullerenes GdxSc3-xN@C80 (x = 1-3) are studied as a function of the number of Gd atoms in the cluster. The intracluster interaction of the Gd ions in Gd2ScN@C80 and Gd3N@C80 is ferromagnetic with exchange constants of -1.2 K ± 0.1 K and -0.6 K ± 0.1 K, respectively. At 2 K, the magnetization curves exhibit noticeable deviations from the Heisenberg model pointing to a non-negligible anisotropy.

[Fractures of the thoracic and lumbar spine in children and adolescents]

BACKGROUND

Only 1.5-2% of all fractures in children and adolescents are fractures of the thoracic and lumbar spine. Treatment is most often conservative. This study compares the own experience with the recent literature.

MATERIAL AND METHODS

Over a 48 month period all patients with fractures of the thoracic and lumbar spine, younger than 16 years were included prospectively. Of the patients 67 underwent follow-up investigations after 3-36 months.

RESULTS

The average age of the patients was 11.9 years. Sports (53%) and traffic (28%) accidents were most frequent. Fractures most often appeared in the mid-thoracic (47%) and thoracolumbar spine (41%). Operative treatment was performed in 9 cases (10.4%). Secondary loss of alignment was not observed neither after conservative nor operative treatment. Neurological deficits (n=2) did not completely improve.

CONCLUSIONS

Most fractures of the thoracic and lumbar spine heal fast and without any sequelae. Unstable fractures of type B and C (exclusively occurring as a result of traffic accidents) need operative stabilization as in adults.

Triplane fractures: do we need cross-sectional imaging?

INTRODUCTION

Diagnosis of Triplane fractures remains difficult in common practice. Aim of the study was the evaluation of the fracture pattern and the benefit of cross-sectional imaging in classification of Triplane-fractures.

MATERIAL AND METHODS

A total of 27 pediatric patients treated for ankle fractures were identified from patient charts. Radiographic images of epiphyseal fractures (X-rays and additional cross-sectional imaging) were blinded evaluated by 13 observers to answer a specific questionnaire regarding type or fracture and treatment suggestion.

RESULTS

There were seven Triplane-I and eight Triplane-II fractures. The other physeal ankle fracture group consisted of four patients with a Twoplane-fracture, five Salter-and-Harris (SH) II, one SH-III, and two SH-IV fracture. Accuracy of classification improved considerably depending on the experience of the observer in pediatric trauma care. Surgeons specialized in pediatric trauma care classified correctly with conventional X-rays in 48.1 % of all cases presented versus 31.5 % appropriate diagnosis by younger fellows. Accuracy in exact specification of Triplane-fractures was comparable lesser in younger fellows (31.1 vs. 22 %). Cross-sectional imaging improved classification of all fractures in both groups (75.6 % specialized vs. 47.3 % non specialized). Whereas availability of cross-sectional imaging improved treatment recommendation in specialized surgeons this benefit was not detectable for the doctors without specialization. Evaluation of fracture pattern showed a relatively stereotypical fracture pattern in Triplane-II fractures, whereas Triplane-I fractures were more variable.

CONCLUSION

The additional information of cross-sectional imaging seems helpful for any physician in finding the right classification of a pediatric ankle fracture. However, the additive information appears especially viable for experienced surgeons to suggest the appropriate treatment.

The pediatric vs. the adolescent elbow. Some insight into age-specific treatment

Almost 20 % of all long bone fractures in childhood and adolescents involve the elbow region. Physicians dealing with pediatric trauma cases on a regular basis must be familiar with the specific radiologic features of the elbow at every developmental stage. This includes the shape and the appearance of elbow ossification centers, and knowledge of age-specific injury patterns. In young children, lateral condyle and supracondylar fractures of the distal humerus are most common. Radial neck fractures, Monteggia's lesion and olecranon fractures appear in every age during growth. Bicondylar fractures of the distal humerus, capitellar fractures and radial head fractures almost solely occur after the tenth year. Treatment options depend on fracture type, age and demands and vary from immobilization to closed reduction and open reduction including internal fixation with different types of materials. Special circumstances to influence the treatment regimen in every single injury entity are discussed. Additionally, the most common malformations and nontraumatic diseases of the elbow region are mentioned.

[Informed consent consultation as a part of patient safety in pediatric traumatology]

In pediatric traumatology as in any other surgical specialty, every treatment measure has to be protected by an adequate clarification. A legally effective clarification has to cover various aspects, such as diagnosis, treatment, risk and safety clarification and leads to an informed consent consultation. The contents of this informed consent discussion must be documented. The nature and extent of clarification, among other things depend on the urgency of the procedure and in an emergency it can be dispensed with in pediatric traumatology. In the case of minors the conversation must be conducted basically in the presence of both parents as they alone are legally entitled to give approval. General treatment proxies are not allowed. If it is not possible to talk to both parents the physician is allowed to trust that the parent present represents the will of the absent parent. Intervention cannot be carried out against the will of adolescents capable of self-determination even with the consent of the parents. The application of these rules is illustrated by means of practical examples.

[Treatment-related damage to the radial nerve in paediatric traumatology]

BACKGROUND

Iatrogenic damage of the N. ulnaris is a known complication of treatment of supracondylar humeral fractures in children. But damage to the N. radialis can also occur in the treatment of many typical fractures of the upper extremity during growth. There are no differentiated investigations on their incidence.

PATIENTS AND METHODS

This paper presents a prospective case collection and describes the personal experience with the occurrence and treatment of iatrogenic damage to the radial nerve during growth.

RESULTS

In all 9 out of 20 cases occurred in the primary care setting, a further 9 under the metal removal and 2 on the occasion of corrective surgery. 50 % occurred after treatment of forearm shaft fractures, 39 % after distal-metaphyseal radius fractures, 11 % after radial neck fractures. In 80 % of the cases the sensory terminal branch was affected, in another 15 % the motor branch and in 5 % the main trunk of the nerve.

CONCLUSIONS

The treatment of iatrogenic nerve damage should be cautious and restrained, spontaneous remissions, especially of pure sensory deficits, are common.

[Dupuytren's disease in children - case report and literature review]

Dupuytren's disease in childhood and adolescence is extremely rare. As in adults most patients are male. We report on a girl at the age of 7 years with a cord in the palm.

Unoccupied electronic structure of TiOCl studied using x-ray absorption near-edge spectroscopy

We study the unoccupied electronic structure of the spin-1/2 quantum magnet TiOCl using x-ray absorption near-edge spectroscopy (XANES) at the Ti L and O K edges. We acquire data both in total electron and fluorescence yield modes (TEY and FY, respectively). While only the latter allows us to access the unconventional low-temperature spin-Peierls (SP) phase of TiOCl, the signal is found to suffer from significant self-absorption in this case. Nevertheless, we conclude from FY data that effects of the SP distortion on the electronic structure are absent in the incommensurate intermediate phase within experimental accuracy. The similarity of room-temperature FY and TEY data, the latter not being obscured by self-absorption, allows us to use TEY spectra for comparison with simulations. These are performed by means of cluster calculations in D(4h) and D(2h) symmetries using two different codes. We extract values of the crystal-field splitting and parameterize our results using the commonly seen notation of Slater, Racah and Butler. In all cases, good agreement with published values from other studies is found.

[Reconstruction of the heel in a two-year-old boy after lawn mower injury]

INTRODUCTION

Lawn mower injuries in children usually involve the lower extremities and can lead to serious amputation injuries. Treatment should look not only at the acute reconstruction, but also on maintaining the ability to grow. We report the case of a two-year-old boy with amputation of the heel.

CASE REPORT

The boy was run over by a lawn mower. He suffered a complete loss of heel soft tissue, 30 % of the os calcis and the Achilles tendon. The one-stage reconstruction was performed by transplantation of an iliac crest graft, fascia lata to reconstruct the Achilles tendon and a microvascular latissimus dorsi flap. After one year, the functional and cosmetic result is excellent, the bone graft is healed completely and shows growth trends.

DISCUSSION

The successful treatment of such a severe amputation injury requires the interdisciplinary cooperation between paediatric traumatologists, plastic surgeons, physical therapists and orthopaedic shoemaker. The result justifies the great effort.

[Adhesive strength of a β-tricalcium phosphate-enriched bone adhesive]

BACKGROUND

This investigation describes experimental tests of the biomechanical features of a new resorbable bone adhesive based on methacrylate-terminated oligolactides enhanced with osteoconductive β-tricalcium phosphate.

MATERIAL AND METHODS

51 New Zealand white rabbits were randomised to an adhesive group (n = 29) and a control group (n = 22). An extra-articular bone cylinder was taken from the proximal tibia, two stripes of adhesive were applied and the cylinders were replanted. After 10 and 21 days, 3 and 12 months tibial specimens were harvested and the cylinder pull-out test was performed with a servo-hydraulic machine. Additionally the pull-out force was evaluated with the bone-equivalent Ebazell® after 5, 10 and 360 minutes in 14 specimens each.

RESULTS

Average pull-out forces in the adhesive group were 28 N after 10 days (control: 57 N), 155 N after 21 days (216 N), 184 N after 3 months (197 N) and 205 N after 12 months (185 N). Investigations with Ebazell® showed almost identical pull-out forces after 5 min, 15 min and 360 min. Adhesive forces were as high as 125 N/cm (2) of adhesive surface and more than 1200 N/g of adhesive mass.

CONCLUSIONS

The adhesive investigated here has a very good primary adhesive power, compared to the literature data, achieved after only 5 minutes. Even in moist surroundings the adhesive capacity remains sufficient. The adhesive has to prove its resorptive properties in further investigations and in first line its medium-term and long-lasting biocompatibility. Furthermore, biomechanical features will have to be compared to those of conventional fixation techniques.

[The operative treatment of the dorsal distal phalanx near to the base (osseous pull out of the extensor tendon) with extreme exposure of the hand by athletic activities - is the hook plate a option for treatment?]

AIM

Aim of the presented investigation was to work out the short- and mid-term outcomes after operative treatment of distal phalanx fractures near to the base of type Doyle IVb and IVc (osseous pull out of the extensor tendon) by means of a hook plate in patients with extreme exposure of the hand by athletic activities.

PATIENTS AND METHODS

Between February 2002 and September 2009 77 patients were treated by operation in our hospital by means of a hook plate due to a traumatic fracture of the dorsal distal phalanx near to the base of type Doyle IVb and IVc (osseous pull out of the extensor tendon) by means of a hook plate (Aerni plate/S2-Prong-Plate) of Stryker Leibinger. 64 of these 77 patients incur the fracture while exercising sport. 46 of these 64 patients were clinically and radiologically followed up within a retrospective study. To assess the therapy's outcome a specific scoring scheme containing subjective and objective parameters was elaborated in order to gain a transparent result of the treatment.

RESULTS

According to this scoring scheme 84.79 % of the patients reached a very good or good result. Nail growth defects by an intraoperative injury of nail matrix represents an essential complication of the presented surgical method.

CONCLUSION

By means of the presented method in the majority of the cases good or very good results could be achieved. That method represents a simple, safe and less complicate possibility to treat the distal phalanx fractures near to the base type IVb and IVc according to Doyle and it is considered as a useful alternative to other procedures.

[Do paediatric and adult surgeons follow different approaches to physeal fractures?]

INTRODUCTION

The treatment of paediatric fractures is the concern of several different surgical specialties. There has been no scientific investigation on the different concepts of paediatric (PS) and adult surgeons (AS).

METHODS

62 paediatric traumatologists were asked concerning their experience with physeal fractures of the leg, including ten cases.

RESULTS

Growth disturbances was estimated to be more rare by PS. On evaluation of the examples there were no significant differences in the judgement of degree and direction of the displacement. For displaced fractures, PS rather preferred closed reduction and immobilisation, whereas AS favoured osteosynthesis.

DISCUSSION

There were no basic differences between PS and AS in the treatment of lower limb fractures. AS tend to act more invasively. At the same time they are more concerned about growth disturbances.

Children and adolescents with posttraumatic shoulder instability benefit from arthroscopic stabilization

INTRODUCTION

Traumatic dislocation of the shoulder in childhood is rare, accounting for only 0.01% of all injuries in this age class. However, literature does contain indications that post-traumatic instabilities and re-dislocations occur with more than average frequency in children and adolescents.

MATERIAL AND METHODS

This study describes the technique and results of arthroscopic stabilization of the shoulder joint before the completion of growth. Over a period of four years, seven patients were treated prior to reaching skeletal maturity. Five patients were treated by means of arthroscopically assisted labral refixation using suture anchor systems.

RESULTS

Arthroscopic labral refixation for post-traumatic shoulder instability could be carried out using the same surgical procedure as in adults. Clinical follow-up was undertaken after 12 to 48 (average 26) months using modified Constant-Murley and Rowe scores. Instability, re-dislocations and postoperative impairment of mobility did not occur after arthroscopic treatment, with an average Constant score of 92 points (Rowe score >95 points).

CONCLUSION

This study demonstrated that this technique can be used successfully in children and young people prior to skeletal maturity. Considerable experience in adult shoulder reconstruction promises excellent results in children and adolescents, too. There was no evidence of growth disturbance or biodegradation-associated problems in this group of children and adolescents. Delay of labral refixation until adulthood is therefore not indicated.

Magnetic Resonance Relaxometry at Low and Ultra low Fields

Nuclear magnetic resonance (NMR) and magnetic resonance imaging (MRI) are ubiquitous tools in science and medicine. NMR provides powerful probes of local and macromolecular chemical structure and dynamics. Recently it has become possible and practical to perform MR at very low fields (from 1 μT to 1 mT), the so-called ultra-low field (ULF) regime. Pulsed pre-polarizing fields greatly enhance the signal strength and allow flexibility in signal acquisition sequences. Improvements in SQUID sensor technology allow ultra-sensitive detection in a pulsed field environment.In this regime the proton Larmor frequencies (1 Hz - 100 kHz) of ULF MR overlap (on a time scale of 10 μs to 100 ms) with "slow" molecular dynamic processes such as diffusion, intra-molecular motion, chemical reactions, and biological processes such as protein folding, catalysis and ligand binding. The frequency dependence of relaxation at ultra-low fields may provide a probe for biomolecular dynamics on the millisecond timescale (protein folding and aggregation, conformational motions of enzymes, binding and structural fluctuations of coupled domains in allosteric mechanisms) relevant to host-pathogen interactions, biofuels, and biomediation. Also this resonance-enhanced coupling at ULF can greatly enhance contrast in medical applications of ULF-MRI resulting in better diagnostic techniques.We have developed a number of instruments and techniques to study relaxation vs. frequency at the ULF regime. Details of the techniques and results are presented.Ultra-low field methods are already being applied at LANL in brain imaging, and detection of liquid explosives at airports. However, the potential power of ultra-low field MR remains to be fully exploited.

Consecutive bilateral proximal tibial fractures after minor sports trauma

INTRODUCTION

Fractures of the proximal tibia are infrequent during childhood and adolescence. However, intra-articular fractures, growth plate separations and metaphyseal fractures do appear.

CASE REPORT

An obese adolescent male suffered from consecutive bilateral fractures of the tibia within 6 months of each after minor sports trauma. On the left side, the injury presented as a epiphyseal separation of the Salter-Harris I type; on the right side, as a transitional two-plane fracture. Both injuries were treated by percutaneous screwing and healed without any signs of posttraumatic growth disorder.

DISCUSSION

Although proximal tibial injuries are rare, they frequently seem to appear bilaterally after inadequate trauma. A causal connection to morphological changes prior to physeal closure can be assumed.

Growth disturbances of the distal tibia after physeal separation--what do we know, what do we believe we know? A review of current literature

PURPOSE

Although they are the most frequent physeal separations of the lower limb, epiphyseal separations (Salter I and II) of the distal tibia are rare injuries, peaking in adolescence. Generally they are considered lobe benign fractures with a low rate of complications. However, in the literature, concrete statements on the incidence of fracture-associated growth disturbances are infrequent and inconsistent, even contradictory.

MATERIALS AND METHODS

A review of textbooks, classical references and recent literature was performed to identify the available evidence on distal tibia physeal separations.

RESULTS

A review of the literature showed that most authors agree that conservative, nonoperative treatment is the preferred treatment. But opinions differ on almost all essential fundamentals of treatment. Neither the potential for growth-associated spontaneous correction of posttraumatic axis deviations nor the tolerable degree of axial deviations are evaluated homogenously. Opinions also vary greatly concerning the frequency of posttraumatic growth disturbances, the influence of the mechanism of injury and the amount of primary axial deviation. The most consistent statement in the literature is that poor results of both closed and open reduction lead to an increasing number of growth disturbances, which may include the assumption that not only trauma but operative procedures, too, can be the reason for restrictive physeal plate disturbances.

CONCLUSIONS

There are two major deficiencies in most of the reviewed literature. The first is that the numbers of cases reported in each article are low due to the rarity of the injury. The second deficiency is that many studies report "physeal injuries" but do not clearly distinguish physeal separations (Salter I and II) from epiphyseal fractures (Salter III and IV) and transitional fractures, all involving the physeal plate, but in completely different ways with completely different prognoses. A prospective multicenter study is taking place.

[Conservative treatment of fractures of the long bones during the growth phase]

In the treatment of fractures of the long bones in children and adolescents, surgical and conservative methods are not mutually exclusive alternatives; rather, each can complement the other in the overall treatment strategy. Many operative procedures, such as fixation of juxtaarticular, metaphyseal fractures, need to be supplemented by conservative procedures, such as immobilization by means of casts. We refer to methods that are performed without anaesthesia and do not involve the implantation of osteosynthetic foreign material as conservative. These are: immobilization with no further treatment, plaster wedging, and functional treatment options. The indications for purely conservative treatment strategies are basically different for articular and nonarticular fractures. Whereas in the case of articular fractures only the nondisplaced fractures are treated by conservative methods, in the case of nonarticular (shaft) fractures those involving a degree of displacement, as long as it is not too pronounced to allow the integration of spontaneous corrections, can also be treated conservatively.

Enhanced alpha 1(I) mRNA expression in frozen shoulder and dupuytren tissue

The purpose of this study has been to investigate collagen I and III synthesis during the fibrosing stage of frozen shoulder and Dupuytren samples in comparison to normal capsule tissue. - By using the quantitative PCR significantly increased levels of alpha 1(I) mRNA transcription in samples of frozen shoulder (p = 0.016) and Duypuytren (p = 0.041) could be demonstrated, whereas alpha 2(I) and alpha 1(III) chains have shown the same mRNA levels as in normal capsule tissue. - Despite an enhancement of alpha 1(I) mRNA transcription in frozen shoulder and Dupuytren samples the intracellular precursor procollagen I and extracellular mature collagen I was detected immunohistochemically in reduced levels. - The structural alteration of collagen I assembly might be caused by disturbed post-translation from the polypeptide chains into the triple helices procollagen I though alpha 1(I) mRNA transcription was significantly increased and alpha 2(I) mRNA transcription was in normal range. Fibroblasts might release high quantities of free alpha 1(I) polypeptide chains or (alpha 1(I)) 3 homotrimer into the extracellular space during the fibrosing stage of frozen shoulder and Dupuytren disease. - In all samples neither differences of alpha 1(III) mRNA transcription nor differences of immunohistochemical staining intensity of collagen III could be seen. This might result from apoptosis of myofibroblasts in the final phase of the fibrosing processes. - The stimulating effect of insulin-like growth factor type I (IGF-I) to induce fibrosis in connective tissue such as scarlet is known. In all patients suffering from frozen shoulder and Dupuytren disease the serum IGF-I level was in a normal range and the IGF-I receptor - (IGFR-I) mRNA transcription in the samples was also in the same level compared with normal capsule tissue.

[Intraoperative radiation exposure in elastic stable intramedullary nailing (ESIN) during the growth period. Observations in 162 long bone shaft fractures]

BACKGROUND

The increase of intraoperative radiation exposure in intramedullary techniques of osteosynthesis is recognised and accepted in adults especially in interlocked nailing. In contrast data about fluoroscopy times in elastic stable intramedullary nailing (ESIN) in children and adolescents are hardly available.

MATERIAL AND METHOD

Operation records of 162 surgical procedures (8.6% humerus, 43.8% forearm, 32.7% femur, 14.8% lower leg) of a 3-year period were evaluated retrospectively. The mean age was 6.1 years in femoral shaft fractures, nearly similar in forearm and lower leg fractures (8.7 and 7.9 years, respectively) and 12.4 years in patients with humeral shaft fractures.

RESULTS

Mean operation (OP) and fluoroscopy times (FL) were increased in humeral fractures (58.1 min OP, 1.62 min FL), at a medium level in forearm fractures (35.2 min OP, 1.06 min FL) and femoral fractures (42.3 min OP, 1.27 min FL) and shortest in lower leg fractures (29.6 min OP, 0.69 min FL).

CONCLUSION

Our results and literature analysis show that optimal technical conditions, especially the use of a pulsed image intensifier and well-trained theatre staff, are able to reduce intraoperative radiation load.

[Distraction osteogenesis for adjusting humeral length difference due to premature closure of the proximal growth plate in a simple bone cyst]

Complications after pathological fractures of simple bone cysts of the humerus are refracture, cyst recurrence, and in rare cases premature closure of the physeal plate with resulting shortening of the arm. Length discrepancies of the lower limbs beyond physiological limits need early compensation in children as well as adults to avoid interference with the pelvis and spine. However, surgical treatment of length differences of the humerus is usually cosmetic, because even considerable discrepancies do not lead to functional deficits. We report the long-term course of a complicated bone cyst of the proximal humerus and resolving a severe length difference of 7 cm by distraction osteogenesis in a young adult. The cause of the premature physeal closure and the primary therapeutical concept are discussed.