Federico Solla

Composite tissue allotransplantation in newborns: A swine model

BACKGROUND Management of congenital limb aplasia or facial malformations could be improved by composite tissue allotransplantation (CTA), a technique that has never been performed in newborns. For this, however, the induction of donor-specific tolerance would be mandatory, as long-term immunosuppression is not acceptable in this non-lifesaving procedure. Induction of tolerance has been shown to be possible in a newborn CTA rat model but has never been tested in large-animal models. Our goals were to establish a model of CTA in newborn swine to see if tolerance could be obtained without immunosuppression and to assess rejection or tolerance properties via clinical and histologic examinations. MATERIALS AND METHODS We applied a CTA heterotopic knee swine model. We performed two series of surgical procedures: Series 1 was 20 autografts in 6-day-old (1-10) 2,544 kg (1,140-4,060 kg) piglets; Series 2 was 10 allografts without immunosuppression between outbred animals aged 7.8 d (6-10) and weighing 2,770 kg (2,200-3,550 kg). RESULTS In Series 1, six early deaths and two cases of vascular failure were observed. In Series 2, no spontaneous deaths were observed and all piglets presented clinical and histologic rejection. CONCLUSIONS Our findings strongly suggest that newborn immunologic status is not sufficient for the development of tolerance in large animals without immunologic intervention. Complications and animal death after transplantation correlate with age and weight. Low rates for both vascular failure and postoperative death permit the use of this model in piglets weighing over 2 kg and aged more than 6 d for research on newborn CTA.

Terrorist attack in Nice: the central role of a children's hospital

www.thelancet.com Vol 389 March 11, 2017 1007 2 Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents. Lancet 2006; 368: 2219–25. 3 Gregory TM, Bihel T, Guigui P, et al. Terrorist attacks in Paris: surgical trauma experience in a referral center. Injury 2016; 47: 2122–26. 4 Tobert D, von Keudell A, Rodriguez EK. Lessons from the Boston Marathon bombing: an orthopaedic perspective on preparing for high-volume trauma in an urban academic center. J Orthop Trauma 2015; 29 (suppl 10): S7–10. 5 Weil YA, Peleg K, Givon A, Israeli Trauma Group, Mosheiff R. Musculoskeletal injuries in terrorist attacks—a comparison between the injuries sustained and those related to motor vehicle accidents, based on a national registry database. Injury 2008; 39: 1359–64. order to keep reserve staff at home was given, resulting in strong feelings of frustration among those people. 44 patients were admitted in 2 h (appendix). Of these, 12 were adults: five were in critical condition, of whom four died quickly. The remaining 32 patients were children: eight were in critical condition, of whom two died later. The trauma leader assigned the patients to the operating room, resuscitation room, or for a CT scan. The CT scanner was made immediately available, performing 15 scans during the night. Six patients needed surgery during the first 24 h. All elective surgeries scheduled for July 15, 2016, were postponed, and team rotations were reorganised to allow rest. Injuries were typical of road crashes, differing from those caused by bomb or bullets, but similar to injuries observed in Israel. Cause of death was mainly haemorrhagic shock after multiple traumas including pelvic disjunction, head trauma, and trunk crush. During the night, child psychiatrists took care of victims, parents, witnesses, and staff. Stress disorder and dissociative symptomatology were observed—more prominently in adults than in children— and resulted in two transfers to the psychiatric emergency department at Pasteur Hospital and in disorganisation and sick leave for affected hospital staff. Multiple debriefing meetings, both technical and psychological, were necessary and profitable for all hospital staff. Our experience confirms that every hospital, regardless of level and specialty, should be prepared to receive patients of all ages, with all types of severities and lesions.

Oral cyclosporine A in neonatal swines for transplantation studies

Abstract The purpose of this study is to define the optimal dose of oral cyclosporine A (CsA) microemulsion in newborn swine for transplantation studies and to describe its pharmacokinetics and acute renal effects in short-term administration. Thirteen neonatal pigs were randomized into four groups: one control and three groups with CsA administration at 4, 8 and 12 mg/kg/d for 15 days (D). Blood samples were collected on D 0, 2, 4, 9 and 14 to determine the changes of the CsA trough concentrations, the creatinine (Cr) and blood urea nitrogen (BUN) serum concentrations. On D 14, blood samples were collected every hour from 1 h to 10 h after CsA administration to determine the area under the curve (AUC). On D 15, kidneys were removed for histological analysis. We observed a stabilization of CsA trough concentrations from D 4 to D 14. On D 14, in the three treated groups, CsA trough concentrations were 687 ± 7, 1200 ± 77 and 2211 ± 1030 ng/ml, respectively; AUC (0–10 h) were 6721 ± 51 ng·h/ml in group 4 mg/kg/d, 13431 ± 988 ng·h/ml in group 8 mg/kg/d and 28264 ± 9430 ng·h/ml in group 12 mg/kg/d. Cr concentrations were not significantly different among the four groups; but compared to control group, BUN concentrations of the three treated groups increased significantly. CsA was well tolerated; neither acute, severe adverse event nor renal histological abnormality was observed. In conclusion, a 15-d course of oral CsA treatment ranged from 4 to 12 mg/kg/d is safe for newborn pigs, which need much lower CsA dose than adult pigs to reach comparable trough level and AUC. As immunosuppressive therapy in newborn pigs, we recommend a CsA dose of 4 mg/kg/d to achieve a trough blood concentration between 400 and 800 ng/ml.

Risk Factors for Developing Scoliosis in Cerebral Palsy: A Cross-Sectional Descriptive Study

This study aims to identify the risk factors leading to the development of severe scoliosis among children with cerebral palsy. A cross-sectional descriptive study of 70 children (aged 12-18 years) with severe spastic and/or dystonic cerebral palsy treated in a single specialist unit is described. Statistical analysis included Fisher exact test and logistic regression analysis to identify risk factors. Severe scoliosis is more likely to occur in patients with intractable epilepsy (P = .008), poor gross motor functional assessment scores (P = .018), limb spasticity (P = .045), a history of previous hip surgery (P = .048), and nonambulatory patients (P = .013). Logistic regression model confirms the major risk factors are previous hip surgery (P = .001), moderate to severe epilepsy (P = .007), and female gender (P = .03). History of previous hip surgery, intractable epilepsy, and female gender are predictors of developing severe scoliosis in children with cerebral palsy. This knowledge should aid in the early diagnosis of scoliosis and timely referral to specialist services.

Can Gartland II and III supracondylar humerus fractures be treated using Blount's method in the emergency room?

BACKGROUND Studies have established that Blounts method is reliable for treating extension supracondylar fractures (SCFs) in paediatric patients. Reduction in the emergency room (ER) under procedural sedation followed by orthopaedic treatment is increasingly used for many fracture types. The primary objective of this study was to determine whether SCF reduction in the ER was feasible, by determining the failure rate. The secondary objective was to identify causes of failure with the goal of improving patient selection to reduction in the ER. HYPOTHESIS Gartland II and III SCFs (Lagrange-Rigault grades 2-4) can be treated in the emergency room under fluoroscopic guidance and with procedural sedation. MATERIAL AND METHODS A retrospective study was conducted in 128 paediatric patients who underwent ER reduction of an SCF in 2014-2015. Mean age was 5.6 years. Reduction was performed either by an orthopaedic surgery resident or by a specially trained emergency physician. RESULTS Of the 128 SCFs, 101 (79%) were Gartland II and 27 Gartland III. In the Lagrange-Rigault classification, 55 (43%) fractures were grade 2, 59 (46%) were grade 3, and 14 (11%) were grade 4. The arm was immobilised using the cuff-and-collar method described by Blount for 4 weeks. All 128 fractures healed without delay. Blounts method alone was effective in 112 (87.5%) patients. Of the 16 other patients, 15 (Lagrange-Rigault 3, n=14; and 4, n=1) had an unstable fracture after ER reduction and were managed by reduction and internal fixation in the operating room. The remaining patient (0.5%) experienced secondary displacement requiring revision surgery in the operating room. CONCLUSION SCFs grades 2 to 4 in the Lagrange-Rigault classification (Gartland II and III) can be treated in the ER by specially trained physicians. Lagrange-Rigault grade 3/Gartland III SCFs are more likely to require subsequent internal fixation but do not contraindicate reduction in the ER. LEVEL OF EVIDENCE IV, retrospective study.

Cobalt-chrome and titanium alloy rods provide similar coronal and sagittal correction in adolescent idiopathic scoliosis

BACKGROUND Cobalt-chrome (CoCr) and the titanium alloy TA6V (Ti) are the materials most widely used for spinal instrumentations in patients with adolescent idiopathic scoliosis (AIS). The objective of this work was to compare the effectiveness of CoCr and Ti rods in terms of coronal and sagittal correction by pedicle screw constructs in patients with AIS. HYPOTHESIS Correction is similar with CoCr and Ti rods in patients with AIS. MATERIAL AND METHOD A retrospective single surgeon study was conducted in patients with AIS managed using pedicle screw posterior spinal fusion with high implant density and reduction by postero-medial translation. Follow-up was more than 2 years in all patients. Patients were divided into two groups based on whether the rods used were made of CoCr (n=30) or Ti (n=33). The groups were identical for age, Risser classification, follow-up duration, type of curve, and implant density. Coronal and sagittal parameters on standing full-spine radiographs were analysed using graphics software before surgery then 1 month after surgery and at last follow-up. Quantitative data were compared by applying Students t test. RESULTS The percentage of main curve correction at last follow-up was the same in the two groups (76%/75%) (p=0.7). Gains in thoracic kyphosis (12°/13°) and lumbar lordosis (8°/10°) were not significantly different between groups. At last follow-up, 3 patients had proximal junctional kyphosis, 1 in the CoCr group and 2 in the Ti group (p=0.6). CONCLUSION For posterior spinal fusion to treat AIS, with a high density of pedicle screws, correction by translation, and 6 mm rods, CoCr rods and Ti rods produce the same amount of coronal and sagittal correction. LEVEL OF EVIDENCE IV, comparative retrospective study with no control group.

Advanced containment methods for Legg-Calvé-Perthes disease: triple pelvic osteotomy versus Chiari osteotomy

Introduction: The goal of intervention in Legg-Calvé-Perthes disease (LCPD) is to prevent femoral head deformation by containing the head within the acetabulum. Currently, surgical containment methods are the mainstay of treatment, and pelvic osteotomies have been shown to be successful. They include triple pelvic osteotomy (TPO), Salter osteotomy, Chiari osteotomy and shelf procedure. The purpose of this study was to compare clinical and radiologic results for Chiari osteotomy and TPO in LCPD. Methods: 29 children treated between 1980 and 2010 for LCPD in 2 centres were reviewed. 19 underwent TPO, and 10, Chiari osteotomy. Two independent observers assessed sequential radiographs and medical data. Each hip was preoperatively classed by clinical data, Catteral, Herring and Salter-Thompson classification, centre-edge angle (CE), and acetabular index (AI). The 2 groups were first tested for their comparability. After surgery the hips were classified by Stulberg classification, CE, AI, Harris Hip Score (HHS) and performance of further surgery. Chiari osteotomy and TPO have been secondary compared on these data by Wilcoxon test. Results: Average follow-up was 4.2 years. The 2 groups were comparable before surgery. At first and last follow-up examination, statistically significantly superior results in patients with TPO regarding Stulberg classification (p = 0.01), AI (p = 0.002), pain (p = 0.02) and function (p = 0.01) in the HHS score were found. No differences were noticed concerning CE angle. Conclusions: In our series, TPO provided better radiologic and clinical outcomes compared to Chiari osteotomy, specially concerning the final Stulberg classification. We concluded that TPO should be preferred when indicated.

Minimally Invasive Far Lateral Lumbar Interbody Fusion: A Prospective Cohort Study:

Study Design: Prospective cohort study. Objectives: To assess rate and degree of interbody bone fusion and evolution in Oswestry Disability index (ODI) and visual analog scale (VAS) of pain after minimally invasive far lateral lumbar interbody fusion. Methods: Twenty-three patients with single-level lumbar instability or degenerative disc were treated by this method and prospectively included. VAS of pain and ODI were evaluated preoperatively and at last follow-up. Computed tomography scan was performed 6 months after surgery to assess interbody fusion. Results: Between preoperative and 2 years postoperative follow-up, mean VAS decreased by 2.4 points (P < .001); mean ODI improved by 21.8% (P < .001). Computed tomography scan showed fusion in all patients but one. No severe complications were observed. Conclusions: Minimally invasive far lateral lumbar interbody fusion resulted in satisfactory clinical and radiological results.

Severe casualties from Bastille Day Attack in Nice, France

PurposeTo describe the most severe casualties from the July 14th, 2016 terror attack in Nice that were treated at the Lenval University Children’s Hospital (LUCH) of Nice (France).MethodsRetrospective study about casualties treated at LUCH from Bastille Day Attack with injuries resulting in the need for surgery, resuscitation, or death. The type of lesions and surgery, duration of hospitalizations, complications, psychological status, and outcome at discharge were collected.ResultsEleven patients presented severe traumas including three adults. They were triaged and managed first by the Critical Care Physician on duty and by emergency room nurses with no additional staff. Six pediatric casualties needed surgery; seven patients were hospitalized in Pediatric Intensive Care Unit (PICU). Five deaths were reported. The most relevant injuries were: pelvic disjunction, lower limb fracture, vascular injuries, and head or trunk crush. As soon as it was possible, two surgeons attended the emergency room (ER) to help carry out the triage. Overall we performed twenty-eight surgeries, including two neurological, one vascular, and five orthopedic. We performed closed reduction and internal fixation (CRIF) in three cases of limb fractures. A compartment syndrome was observed. Stress disorders were observed in three patients, which merited psychiatric support and treatment.ConclusionWe faced uncommon situations with severe casualties without pre-hospital management. The presence of adult patients and unusual lesions increased the complexity. The presence of surgeons in the ER seemed useful for effective clinical decision-making. CRIF has been a valid option for damage control. Competence in vascular, neurological, major trauma surgery and psychic trauma should be available in any pediatric trauma center.

July 14, 2016, Terror Attack in Nice, France

On July 14, 2016, a terrorist attack by truck occurred in Nice, France, during the traditional fireworks for Bastille Day. The authors present the point of view of the doctors from Lenval University Childrens Hospital, which is located near the attack place and which had to manage 47 casualties, including 12 adults.