Osteochondral Fractures in Acute Patellar Dislocations in Adolescents: Midterm Results of Surgical Treatment

Background:

Osteochondral fractures (OCFs) are common injuries during acute patellar dislocation (APD), carrying a high risk of early joint deterioration if left untreated. The recommended approach is reduction and stable fixation; however, data on the results of such treatment are limited.

Purpose:

To evaluate midterm results of fixation of APD-related OCFs in adolescents and to identify predictive factors for poor outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

This was a retrospective analysis of adolescent patients who underwent internal fixation of APD-related OCFs between 2004 and 2015 at a single tertiary pediatric trauma center. The primary outcome variables included Knee injury and Osteoarthritis Outcome Score (KOOS), patient satisfaction (0-10 scale), and sports participation compared with preoperative level. Secondary outcome variables included relationship between final results and OCF location (patellofemoral vs tibiofemoral), surgical delay (>6 weeks), and patellar instability after OCF fixation. OCF healing was evaluated using magnetic resonance imaging (MRI).

Results:

Included were 40 patients (19 female, 21 male) with 42 OCFs (29 patellar OCFs, 13 lateral femoral condyle OCFs). The median patient age at surgery was 14.5 years (interquartile range [IQR], 13-15.5 years), and median follow-up was 76 months (IQR, 52.5-95 months). Recurrence of patellar instability occurred in 27.5% of patients. Median overall KOOS was 93.8 (IQR, 90.8-97.6); KOOS–Symptoms, 92.9 (IQR, 85.7-96.4); KOOS–Pain, 97.2 (IQR, 91.7-100); KOOS–Activities of Daily Living, 100 (IQR, 97.1-100); KOOS–Sports, 90 (IQR, 80-100); and KOOS–Quality of Life, 78.1 (IQR, 56.2-87.5). Median satisfaction score was 8 (IQR, 8-9), and 16 patients (40%) returned to sports participation at their preinjury level. MRI scans revealed a 100% rate of bone healing. Abnormalities exceeding the fracture area were evident on MRI scans in 86.5% of patients. Recurrence of patellar instability (even after surgical fixation) and unstable patella at final follow-up were independent predictors of worse results after OCF fixation.

Conclusion:

In the current study, reduction and internal fixation for APD-related OCF in adolescents yielded favorable midterm outcomes. Recurrence of dislocation and persistent patellar instability jeopardized clinical results.

Genetic Profile and Clinical Implications of Hepatoblastoma and Neuroblastoma Coexistence in a Child

The aim of the following case report is to provide a description of the coexistence of two independent tumors in a child. A 9-month-old male was referred to Department of Pediatric Oncology and Hematology with hepatic tumor present on ultrasound imaging and symptoms of enlarged abdominal circumference. Physical examination revealed a palpable epigastric mass and the imaging techniques showed a tumor of the left hepatic lobe measuring 11 × 6.5 × 8.9 cm with pancreas infiltration, distant metastases in both lungs and abnormal lesion in the left adrenal gland. Basing on histopathological examination, after a core-needle biopsy, hepatoblastoma (HBL) (mixed epithelial-mesenchymal subtype) was diagnosed. The α-fetoprotein level was 112 993 ng/ml. Elevated values of normetanephrine, 3-methoxytyramine as well as neuron-specific enolase were observed. Due to the clinical picture and diagnosis, the patient was qualified to preoperative chemotherapy according to the SIOPEL-3 protocol, followed by SIOPEL-4 protocol for the high-risk patients. After undergoing preoperative chemotherapy, imaging tests revealed regression of hepatic tumor and no focal pulmonary masses, while regression of adrenal gland mass was not completed. The patient was qualified for left hemihepatectomy with left adrenalectomy. Histopathological examination of liver specimen confirmed the HBL diagnosis. However, in left adrenal gland and paraaortic lymph nodes the residual neuroblastoma (NBL) cells were detected. Whole exome sequencing (WES) was utilized to identify disease-associated germline mutations. WES revealed a novel germline insertion variant in TWIST1 (p.Gly86dup), along with the potentially pathogenic non-synonymous variants in NF1 (p.Val2511Ile), RAF1 (p.Leu445Arg), and WHSC1 (p.Ser4Asn) genes. Currently, 6 months after completion of treatment according to the SIOPEL-4 protocol, the patient is in good general condition, without any signs, and symptoms of relapse of both neoplasms. The coexistence of two different primary childhood malignancies is rarely seen. So far, only one case of synchronous HBL and NBL has been reported. However, for the first time therapeutic process was successful. A specific signature of rare germline mutations can be proposed as a predisposing factor to synchronous HBL and NBL occurrence.

Novel insights in ultrasound evaluation of thyroid gland in children with papillary thyroid carcinoma

BACKGROUND

The coincidence of autoimmune thyroiditis (AIT) in patients with papillary thyroid carcinoma (PTC) is ranging between 10 and 58% in the general population.

MATERIAL AND METHODS

In the present study retrospective ultrasound, clinical and autoimmune assessment of 24 patients diagnosed with papillary thyroid carcinoma between 2000-2016 was performed.

RESULTS

The coexistence of PTC and AIT was found in 50% of patients with PTC. Patients were divided into two groups. PTC AIT (+) group involved 12 children at the mean age 14.9 years (range 11-20 years, 9 girls) and PTC AIT (-) 12 children at the mean age 12.9 years (range 7-18 years, 5 girls). Papillary thyroid microcarcinoma (PTMC) was diagnosed in 6 patients (in 5 with AIT). US characteristics of PTC was heterogenous: hypoechogenic with/without increased vascularisation, normoechogenic with halo, with/without microcalcifications. In 70% PTC AIT (+) and in all PTC AIT (-) patients ultrasound analysis revealed that the thyroid tissue of the whole gland was normoechogenic. Local metastases in lymph nodes were found in 40% of PTMC AIT (+).

CONCLUSION

Lack of increased vascularization and microcalcifications and presence of``halo`in the nodule does not exclude malignancy. Due to the presence of lymph node involvement in PTMC in all children with PTC total thyroidectomy should be performed with lymph nodes verification.

Thyroid developmental anomalies among first-degree relatives of children with thyroid dysgenesis and congenital hypothyroidism

BACKGROUND

Thyroid dysgenesis (TD) is usually sporadic. In approximately 2%-8% of TD cases, familial TD has been identified.

AIMS

The aim of this study is to define the prevalence of thyroid developmental anomalies in first-degree relatives of children with TD-caused congenital hypothyroidism (CH).

METHODS

The investigation included 102 relatives of 33 children with CH and TD (study group) and 27 relatives of 12 normal children (comparative group). All the individuals were subjected to thyroid ultrasound and serum thyroid stimulating hormone (TSH) and free T4 (FT4) determinations. Statistical analysis was based on Fisher's exact test.

RESULTS

TD-caused familial CH was noted in 2 of 33 (6%) children with CH. Asymptomatic thyroid developmental anomaly was seen in 1 of 102 (1%) relatives - left thyroid lobe hypoplasia in the mother of a girl with CH and thyroid severe hypoplasia. Familial prevalence of asymptomatic TD in the study group was observed in 1 of 32 families (3.13%). None of the comparative group members demonstrated any thyroid developmental anomalies.

CONCLUSIONS

The prevalence rate of thyroid developmental anomalies in the study group is slightly higher than in the comparative group. These disturbances are asymptomatic.

[Gastrografin challenge test for the management of subileus in children]

BACKGROUND

The appearance of gastrografin in colon within 6 hours after gastric administration rules out the need of surgery in abdominal subileus. This diagnostic management is not routinely applied in children. We present a one-year experience from the department of pediatric surgery.

MATERIAL AND METHODS

Between April 2006 and September 2007 children with symptoms of ileus without clear indications for surgery were subjected to the study. Naso-gastric tube was inserted and 20-100 cc of gastrografin was administered. Abdominal radiograph was taken within 4-6 hours. The presence of contrast in colon allowed for conservative management. All remaining children were subjected to surgery. Newborns and children with intussusception or incarcerated hernia were ruled out of the study.

RESULTS

The study was implemented in 8 girls and 7 boys ranking in the age between 1 and 17 (mean 11) years. Thirteen children had postoperative obstruction (8 after appendectomy, 5 after other laparotomy). Two children (with Crohn disease and Schoenlein-Henoch purpura) were not operated before. Four children without appearance of contrast in colon were operated. None of the remaining eleven children required surgical intervention.

CONCLUSIONS

This management is safe and effective. It brings forward decision for surgery and shortens observation in children who don't require surgical intervention.