Grafts In Children Research Articles

The Use of Fish Skin Grafts in Children as a New Treatment of Deep Dermal Burns-Case Series with Follow-Up after 2 Years and Measurement of Elasticity as an Objective Scar Evaluation.

Background: Wound healing in deep dermal burn injuries continues to be a challenge in paediatrics. In the absence quick and spontaneous wound closure, split-thickness skin grafting is often necessary. Since the development of a new type of acellular fish matrix, which is very similar to the human skin matrix, skin closure and wound conditioning can be achieved without split-thickness skin grafting. Methods: The following study shows a case series of 20 children in whom a fish skin graft was used. The aim was to develop an algorithm for selecting and using fish skin and its long-term results after one and two years. Acellular fish skin worked as a granulation base for wound healing and also as a substitute for split-thickness skin grafts. Results: There was no evidence of infection. Skin transplants and, thus, additional operations could be avoided. The follow-up examinations showed an excellent result, both objectively by means of elasticity measurements (DermalabCombo®) and in the subjective assessment of the skin as part of the Patient and Observer Scar Assessment Scale (POSAS). Conclusion: Fish skin grafts are a good alternative to split-thickness skin grafts for deep dermal wounds. These results should be further analysed with a larger number of patients in future publications.

Duraplasty with autologous cervical fascia in pediatric posterior fossa tumor surgery: a single-center experience with 214 cases.

Posterior fossa surgeries for pediatric tumors pose challenges in achieving optimal dural repair and duraplasty is usually required. Autografts, allografts, xenografts, and synthetic substitutes can be used for duraplasty. Autologous cervical fascia can be a safe and reliable graft option for duraplasty after posterior fossa surgeries. This study aims to investigate the outcomes of duraplasty with autologous cervical fascial graft in children after posterior fossa surgery for pediatric brain tumors. Pediatric patients with posterior fossa tumor who underwent surgery between March 2001 and August 2022 were retrospectively reviewed. Data on demographics, preoperative symptoms, diagnosis, tumor characteristics, hydrocephalus history, and postoperative complications, including cerebrospinal fluid (CSF) leakage, pseudomeningocele, and meningitis were collected. Logistic regression analysis was performed to explore risk factors for postoperative complications. Patient cohort included 214 patients. Autologous cervical fascia was used in all patients for duraplasty. Mean age was 7.9 ± 5.3years. Fifty-seven patients (26.6%) had preoperative hydrocephalus and 14 patients (6.5%) received VPS or EVD perioperatively. Postoperative hydrocephalus was present in 31 patients (14.5%). Rates of CSF leak, pseudomeningocele, and meningitis were 4.2%, 2.8%, and 4.2% respectively. Logistic regression analysis revealed that postoperative EVD and VPS placement were the factors associated with postoperative complications. Autologous cervical fascia is a safe and reliable option for duraplasty with minimal risk of postoperative complications. The straightforward surgical technique and with no additional cost for harvesting the graft renders autologous cervical fascia a favorable alternative for resource-limited countries or surgical settings.

Alemtuzumab, Dual Graft-versus-Host Disease Prophylaxis, and Lower CD3+ T Cell Doses Equalize Rates of Acute and Chronic Graft-versus-Host Disease in Pediatric Patients Receiving Allogeneic Hematopoietic Stem Cell Transplantation with Matched Unrelated Donor Peripheral Blood Stem Cells or Bone Marrow Grafts

Data comparing hematopoietic stem cell transplantation (HSCT) using bone marrow (BM) or peripheral blood stem cell (PBSC) grafts in children after alemtuzumab-based conditioning are lacking. We investigated whether in vivo T cell depletion using alemtuzumab could reduce the risk of severe acute graft-versus-host disease (aGVHD) and chronic GVHD (cGVHD) after HSCT with matched unrelated donor (MUD) BM or PBSCs. This retrospective multicenter study included 397 children (BM group, n = 202; PBSC group, n = 195) who underwent first MUD HSCT at 9 pediatric centers in the United Kingdom between 2015 and 2019. The median age at transplantation was 7.0 years (range, .1 to 19.3 years), and the median duration of follow-up was 3.1 years (range, .3 to 7.5 years). The 3-year overall survival was 81% for the entire cohort (BM group, 80%; PBSC group, 81%). The incidence of grade II-IV aGVHD was significantly higher in the PBSC group (31%) compared to the BM group (31% versus 19%; P = .003), with no difference in the incidence of grade III-IV aGVHD (BM, 7%; PBSC, 12%; P = .17). CD3+ T cell dose >5 × 108/kg and the use of PBSCs were independent predictors of grade II-IV aGVHD. When considering CD3+ T cell dose and GVHD prophylaxis, PBSC transplantation with a calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) and a CD3+ T cell dose ≤5 × 108/kg had a comparable grade II-IV aGVHD to BM transplantation plus a CNI (20% versus 18%; P = .52). PBSC transplantation was associated with a lower incidence of cGVHD compared to BM transplantation (6% versus 11%; P = .03). Within the limits of this study, we identified a potential strategy to reduce the risk of severe GVHD in pediatric PBSC recipients that includes a combination of in vivo T cell depletion using alemtuzumab and dual GVHD prophylaxis (with a CNI and MMF) and limiting the CD3+ T cell dose to ≤5 × 108/kg.

Cone Beam-CT-Based Bone Volume Assessments of Alveolar Synthetic Bone Graft GlassBONE™ in Cleft Lip and Palate Patients: A Retrospective Study.

Clefts of the lip and palate(CLP) are facial deformities that require multiple surgical procedures during childhood. One of these steps consists of filling the alveolar space with bone graft, traditionally removed from the iliac crest. However, this procedure could be invasive in children. Here, we aimed to evaluate the outcomes of GlassBONE™ graft, a bioactive glass used as a bone substitute, as an alternative to the deleterious autologous bone graft in children. Retrospective monocentric study with 17children aged 7.5 ± 2.2yo[3.8-13.3yo] carrying CLP. This technique has been established at La Timone Children hospital (Assistance Publique - Hôpitaux de Marseille)since 2011. Clinical(scar, graft rejection and periodontal status) and radiological(both panoramic radiographs and cone beam-CT) follow-up was conducted oneyear after the graft. The primary outcome was the reduction of the cleft volume, and secondary was the eruption of the adjacent tooth through the graft. GlassBONE™ permitted a significant reduction in the cleft volume by 42.4 ± 27.7%[0.6-81.1%](p < 0.0001), corresponding to a filling of 57.6 ± 27.7% of the alveolar cleft. GlassBONE™ is well tolerated, ensuring satifactory clinical results(improvement in both scar and periodontal coverage), as well as the physiological evolution of the germs through the biomaterial. GlassBONE™ appears particularly suitable for small volumes, and we were able to determine a minimum volume of approximtely 0.259 + / - 0.155cc required for a successful bone fusion. The bioactive glass GlassBONE™ could be safely used in children with small CLP cases, providing satisfactory clinical and radiological results.

Emerged donor limb growth morbidity and malalignment after combined ipsilateral tibial and fibular cortical harvest graft in children. Early follow-up report.

The quantity of bone grafts required in certain pediatric conditions is sometimes substantial. This retrospective study details the radiological changes occurring in the donor leg and ankle following the simultaneous harvest of large diaphyseal cortical grafts from the tibia and fibula in 14 children (16 legs). The following preoperative and follow-up radiological parameters were measured and compared for donor legs: the longitudinal continuous regeneration of fibula, distal fibular station, medial proximal tibial angle, lateral distal tibial angle, posterior proximal tibial angle (PPTA), anterior distal tibial angle and interphyseal angle (tibia diaphyseal angulation) in both coronal and sagittal planes. Additionally, the impact of fibular regeneration in combined harvests was separately analyzed. Children were operated at the mean age of 52 months. Mean follow-up of 25.2 months was available. At follow-up, the donor tibia healed completely in all legs whereas fibular regeneration was complete only in 10 legs (62.5%). At follow-up, ankle valgus was present in 6 out of 16 legs (37%) and tibia valga increased in all legs except one (94%). Procurvatum was present in 7 legs. The fibular nonregeneration group was prone to ankle valgus deformity ( P = 0.014), valgus angulation of tibial diaphysis ( P = 0.0076) and lower mean PPTA ( P = 0.026) when compared to the regenerate group. There was a complication of stress fracture in one donor tibia. Combined tibial and fibular harvest is a major surgical undertaking in children. The donor limbs have their share of complications postharvest, more so when the fibula remains nonregenerated. Serial monitoring of donor sites is emphasized.

First Results of Clinical Application of Ultraviolet Corneal Collagen Crosslinking in the Treatment of Corneal and Graft Ulcers in Children

Ulcerative lesions of the cornea and graft in children are a serious problem in pediatric ophthalmology, leading to serious consequences, up to the anatomical death of the eye. The problem of effective treatment of this pathology and corneal tissue regeneration in children remains relevant, despite the large arsenal of drugs. Recently, ultraviolet (UVA) corneal collagen crosslinking has been proposed as an alternative treatment for corneal ulcers in adults. RASK-CXL is the official name used exclusively for crosslinking in cornea inflammatory diseases. In children, corneal collagen crosslinking is still used only for the treatment of keratoconus. We were the first to use this method to treat corneal ulcers and graft ulcers in children.Purpose: to analyze the results of treatment of ulcerative corneal lesions and graft in children using a new device for local UVA crosslinking.Material and methods. For dynamic observation of patients, biomicroscopy with a fluorescein test, photo registration and optical coherence tomography of the eye anterior part were used. The procedure of local UVA crosslinking for the treatment cornea ulcerative lesions was carried out using a new device on the basis of the permission of the Ethics Committee of the National Medical Reseach Center of eye deseases named after Helmholtz of the Ministry of Health of Russia (protocol No. 56 of 21.10.2021).Results. The use of 3–5 procedures of local UVA exposure (against the background of instillations of 0.1 % riboflavin solution) lasting 5–7 minutes with an interval of 1-3 days ensured epithelization of the cornea and the graft and increased visual acuity in children.Conclusion. The first treatment results of corneal ulcers and graft in children using a new portable device for local UVA crosslinking have shown its high therapeutic efficiency and prospects for further use in clinical practice.

Dimensions of the anterior cruciate ligament and thickness of the distal femoral growth plate in children: a MRI-based study.

When determining the dimensions of an anterior cruciate ligament (ACL) graft in children, bone age should be considered in addition to the patient's age, gender, and body height. We aimed to determine the relationship between age, gender, and ACL dimensions as well as thickness of growth plate cartilage of the distal femur during puberty. We retrospectively analyzed MRI scans of the knee in 131 children (82 girls, 49 boys) aged 6-18years (mean age: 14.9 ± 2.6years). ACL length and width as well as thickness of the growth plate cartilage at the distal femoral epiphysis were measured. Mean ACL length increased linearly up to the age of 12years in females and 14years in males; thereafter, mean ACL length remained constant. Mean ACL length was largest at the age of 12 to < 13years (38.18mm) in females and at 15 to < 16years (39.38mm) in males. Mean ACL width increased up to the age of 12years in girls and 13years in boys. After the age of 12years, both the ACL length and width were significantly larger in boys than girls (p = 0.002 and p = 0.045, respectively). Mean thickness of the growth plate cartilage of the distal femur remained stable up to the age of 12years in girls and 14years in boys. Thickness of the growth plate cartilage changed most markedly between the age intervals of 11 to < 12years and 12 to < 13years in girls and between the age intervals of 13 to < 14years and 14 to < 15years in boys. ACL dimensions depended on both age and gender during the growth period. Measurement of cartilage thickness of the femoral distal growth plate proved to be an objective parameter to assess the maturation stage of local bone. This may be useful for the planning and timing of orthopedic ACL procedures. III-retrospective cohort study.

Native T1 mapping detects both acute clinical rejection and graft dysfunction in pediatric heart transplant patients

BackgroundCardiovascular magnetic resonance (CMR) is emerging as an important tool for cardiac allograft assessment. Native T1 mapping may add value in identifying rejection and in assessing graft dysfunction and myocardial fibrosis burden. We hypothesized that CMR native T1 values and features of textural analysis of T1 maps would identify acute rejection, and in a secondary analysis, correlate with markers of graft dysfunction, and with fibrosis percentage from endomyocardial biopsy (EMB).MethodsFifty cases with simultaneous EMB, right heart catheterization, and 1.5 T CMR with breath-held T1 mapping via modified Look-Locker inversion recovery (MOLLI) in 8 short-axis slices and subsequent quantification of mean and peak native T1 values, were performed on 24 pediatric subjects. A single mid-ventricular slice was used for image texture analysis using nine gray-level co-occurrence matrix features. Digital quantification of Masson trichrome stained EMB samples established degree of fibrosis. Markers of graft dysfunction, including serum brain natriuretic peptide levels and hemodynamic measurements from echocardiography, catheterization, and CMR were collated. Subjects were divided into three groups based on degree of rejection: acute rejection requiring new therapy, mild rejection requiring increased ongoing therapy, and no rejection with no change in treatment. Statistical analysis included student’s t-test and linear regression.ResultsPeak and mean T1 values were significantly associated with acute rejection, with a monotonic trend observed with increased grade of rejection. Texture analysis demonstrated greater spatial heterogeneity in T1 values, as demonstrated by energy, entropy, and variance, in cases requiring treatment. Interestingly, 2 subjects who required increased therapy despite low grade EMB results had abnormal peak T1 values. Peak T1 values also correlated with increased BNP, right-sided filling pressures, and capillary wedge pressures. There was no difference in histopathological fibrosis percentage among the 3 groups; histopathological fibrosis did not correlate with T1 values or markers of graft dysfunction.ConclusionIn pediatric heart transplant patients, native T1 values identify acute rejection requiring treatment and may identify graft dysfunction. CMR shows promise as an important tool for evaluation of cardiac grafts in children, with T1 imaging outperforming biopsy findings in the assessment of rejection.

Wide Resection of Primary Malignant Bone Tumors of the Hand in Children and Reconstruction Using Nonvascularized Fibular Bone Graft: Case Series and Literature Review

Primary malignant bone tumors of the hand are rare in children. Resection and reconstruction of the digit are challenging and have been described in case reports. This retrospective study describes the functional and oncologic outcomes of resection and reconstruction using a nonvascularized fibular bone graft in a cohort of children. A total of 5 children were included. The mean age at diagnosis was 7.6 years (range, 1.6-12 years). Histologic diagnosis showed Ewing sarcoma in 3 and osteosarcoma in 2 patients. Four tumors were located in the metacarpal bones of the fingers, and 1 was located in the thumb. Four patients were treated with chemotherapy. All the patients were treated with wide resection and a cement spacer. This was followed by second stage reconstruction using a nonvascularized fibular bone graft. In tumors of the fingers, carpometacarpal joint fusion with a neighboring carpal bone was performed, whereas a pseudoarthrosis was created between the graft and the base of the proximal phalanx. In the thumb's case, the opposite was done, with fusion at the metacarpophalangeal joint and a pseudoarthrosis at the carpometacarpal joint. The mean follow-up duration was 5.5 years (range, 2-9 years). Surgical margins were negative in all the patients. At their latest follow-up visit, none of the patients developed systemic or local recurrence. Two complications required a revision surgery, one due to graft subluxation and the other due to nonunion. At their final follow-up examination, the mean total arc of movement was 80° (range, 60°-100°), and all the patients were able to resume their grasping and writing capabilities. The resection and reconstruction of primary malignant bone tumors of the metacarpals using a nonvascularized fibular bone graft in children can preserve the cosmesis and function of the digit without jeopardizing oncologic outcomes. Therapeutic V.

The Influence of Ciprofloxacin-Dexamethasone Ear Drops on Perforation Closure Rates After Endoscopic Tympanoplasty.

Topical ciprofloxacin and dexamethasone have both been shown to disrupt healing of tympanic membrane perforations in animal models. There have been no clinical studies evaluating the effect of ciprofloxacin-dexamethasone (CD) ear drops on success of tympanoplasty. We compare perforation closure rates in pediatric endoscopic tympanoplasty with and without use of postoperative CD. Retrospective comparative cohort study. Tertiary referral centre. One hundred sixty-two totally endoscopic tympanoplasties with porcine-derived collagen graft in children, mean age 12.0 years (range 2.3-17.9 yrs). Prescription of CD versus no ear drops in the immediate postoperative period. Perforation closure rate 2 months after totally endoscopic tympanoplasty. Postoperative CD was given to 65 (40%) ears and no drops given to the remainder. Overall, successful closure of tympanic membrane perforation was achieved in 140 (86%) of ears. The closure rate was not significantly different in those ears given CD postoperatively than those not given CD (54/65 [83%] vs 86/97 [89%], Fisher's p = 0.35). Multiple logistical regression revealed no confounding effect of other variables on outcome including age, revision surgery, graft position, or type of postoperative packing material. Our results reveal no harm or benefit with prescription of drops containing ciprofloxacin and dexamethasone on success of perforation closure after tympanoplasty. Allocation to treatment in this retrospective study was nonrandomized and was predominantly based on a change in practice. No other variables are known to have influenced this finding but a randomized prospective study could be justified for more reliable evidence.

Using fibrin sealant for skin graft fixation to avoid sedation in children with burns: a prospective study.

To investigate whether a fibrin sealant, Fitrix (Sanquin Blood Supply Foundation, The Netherlands), for fixation of skin grafts in children with burn wounds is less invasive and equally effective in comparison with skin staples. A single-centre prospective observational cohort study was conducted. Children requiring skin grafting after burns were included and received the fibrin sealant. This group was compared with a retrospective control group of children whose skin grafts were fixed with skin staples. Study outcomes were graft take, graft dislocation, other wound complications, healing and need for sedation. In the fibrin sealant and the control groups, 17 and 27 patients were included, respectively. The percentage of total body surface area (%TBSA) grafted was smaller (p=0.028) in the fibrin sealant group (median 1.0, interquartile range (IQR) 1.5 versus 2.0, IQR 2.5). There was no significant difference in graft take or wound healing. There were two graft dislocations in the fibrin sealant group and none in the control group. Other complications included a patient with graft failure in the fibrin sealant group, and another patient with a vanishing graft and wound infection in the control group. There were fewer sedations in the fibrin sealant group compared with the control group (one versus 20, p<0.0001). The fibrin sealant used in this study was non-inferior for the fixation of skin grafts in comparison with skin staples, and avoided sedation procedures.

Functional and aesthetic reconstruction of digital flexion contractures with full-thickness plantar skin grafts in children.

Hand burns are frequently seen in children, often resulting in digital flexion contractures. Traditional split-thickness or full-thickness skin grafts leave notably different skin texture and hyperpigmentation. The purpose of this study was to describe our operation for treating digital flexion contractures with full-thickness plantar skin grafts, and to evaluate the appearance and function outcomes. Hematoxylin and eosin staining, Masson trichrome staining and Melan A (marker of melanocyte) staining were used to evaluate palmar skin, plantar skin, groin skin and burn scars. Full-thickness plantar skin grafts were performed between 2008 and 2015 in 24 hand burn patients with digital flexion contracture. The average age at the time of surgery was 39.3 months and the average follow-up period was 5.5 years. The functional and cosmetic results were assessed. Plantar skin shared similar attributes with palmar skin histologically. Both plantar skin and palmar skin did not express melan A. All of the skin grafts survived well without hematoma, infection and necrosis. The grafts resembled the adjacent normal skin in regards to appearance and texture. The average TAM (total active movement) degree for the fingers was improved from 152.3° to 238.5°. The average VSS (Vancouver Scar Scale) score decreased dramatically from 10.4 to 1.1. Twenty one of twenty four patients (21/24, 87.5%) were very satisfied with function and appearance, and three in twenty four (3/24, 12.5%) were somewhat satisfied. This study indicates that full-thickness plantar skin grafts can achieve a satisfactory appearance and good function for hand burn child patients with digital flexion contractures.

Public health service increased risk donor kidney grafts for transplant into children, a survey of pediatric nephrologists.

Kidney transplant is the best treatment for end-stage renal disease (ESRD); however, access is limited by severe organ shortage. Public Health Service increased risk donors (PHS-IRD) represent a significant portion of available organs which are discarded at disproportional rates. Pediatric nephrologists were surveyed regarding PHS-IRD kidneys to understand attitudes and perceived barriers to the use of these grafts in children. We sought to elucidate what methods may help increase the likelihood of PHS-IRD acceptance. Twenty-two responses were received from United States pediatric nephrologists representing 11 UNOS regions (response rate 5.9%). Of respondents, 50% had been practicing for 20+ years, 77% in academic hospitals, and 63% in cities with over 1000000 people. All respondents worked in an institution with a kidney transplant program. 41% reported that they would not accept PHS-IRD kidneys under any circumstance, 45% would accept depending on the candidate's medical status, and 14% routinely accepted PHS-IRD kidneys. Infectious transmission was the biggest disincentive reported (59%), with only 55% of respondents feeling comfortable counseling families on the associated risks. 82% of respondents did not perceive all PHS-IRD as the same, and 90% supported stratifying PHS-IRD into tiers based on risk, which would increase the likelihood of organ acceptance (82%) and assist in counseling families (91%). With improved utilization, PHS-IRD kidneys offer a step toward decreasing the organ shortage. These findings suggest hesitance in use of PHS-IRD kidneys for pediatric recipients. Further stratification of risk could aid in provider organ acceptance and counseling patients.

Plastic lengthening amputation with vascularized bone grafts in children with bone sarcoma: a preliminary report

BackgroundAt present, amputation was widely adopted for young patients when limb salvage was deemed risky with several surgical strategy such as rotationplasty. However, leg length discrepancies and unfavorable cosmetic results were indispensable complication of this strategy. The purpose of this study was to propose a novel reconstruction strategy and evaluate the early clinical and functional outcomes of the strategy.MethodsPlastic lengthening amputation (PLA) has been developed by lengthening the stump to preserve one additional distal joint for fixing the artificial limb well. The surgical technique and postoperative management were documented, and the functional outcomes were compared with those of traditional amputation (TA). Six pairs of patients matched for age, sex, location, pathological type, and final prosthesis underwent individually designed plastic lengthening amputation with vascularized autografts or traditional amputation between January 2005 and December 2007. All patients were followed, and the locomotor index and the musculoskeletal tumor society score (MSTS) were used to describe and quantitatively grade limb functional outcomes after amputation. The complications and functional outcomes of the patients taken two kinds of procedures were compared.ResultsTwelve patients with osteosarcoma or Ewing’s sarcoma of either the femur or tibia were included in the study. Six patients underwent plastic lengthening amputations, three of whom also underwent vascular anastomosis. Patients were followed for an average of 48.17 months; bone healing required an average of 3.3 months. No local recurrence was found. The average postoperative locomotor index functional score of the affected limb was 32.67 ± 5.89 in the plastic lengthening amputation group while was 19.50 ± 7.87 in the traditional amputation group. The MSTS functional scores were 22.67 ± 1.33 and 24.17 ± 1.45 at 6 and 12 months for patients in PLA group while 17.00 ± 1.549 and 17.83 ± 1.64 at 6 and 12 months for patients in TA group.ConclusionsPlastic lengthening amputations with vascularized autografts could preserve the knee joint to improve the function of the amputated limb in selected bone sarcoma patients.

Comparison of early and conventional autogenous secondary alveolar bone graft in children with cleft lip and palate: A systematic review.

The literature is scarce on studies comparing secondary alveolar bone graft (SABG) performed early at approximately 5-6years and at the conventional time at 9-11years.This systematic literature review(SLR) aimed to compare clinical outcomes after two different timings of SABG in children with unilateral and bilateral cleft lip and palate. The inclusion criteria wereautogenous iliac graftsand the following study designs:case control, cohort, clinical controlled trial (CCT), randomized CCT (RCCT), and previous SLRs. Ovid MEDLINE, Ovid EMBASE, Web of Science, Scopus, Cochrane, ProQuest and Google Scholar were the primary databases. Two calibrated examiners worked independently to select the articles. The MINORS evaluation method for surgical non-RCTs was used to assess for quality. 1,111 articles were retrieved and 19 qualified. Different clinical and radiographic outcomes such as bone level, periodontal status, canine eruption and cleft-side tooth survival were evaluated by different assessment methods such as CBCT volume, computed tomography, periodontal evaluation, panoramic, intraoral radiographs, and Bergland scale. No RCCT or meta-analysis was found. None of the studies received the ideal score, which is 16 for non-comparison studies and 24 for comparison studies. Methodological variation, lack of standardization for initial cleft dimension and low-quality level rendered a fair comparison unfeasible. Although further studies are necessary, it can be assumed that early SABG also can be an acceptable option, but this was based on a single study with a reasonable level of evidence.

Pediatric Corneal Transplant Surgery: Challenges for Successful Outcome.

Visual rehabilitation of pediatric corneal blinds is a major challenge to corneal transplant surgeons. Penetrating keratoplasty (PKP) is the only way to restore vision and prevent irreversible blindness due to amblyopia in children. Performing penetrating corneal grafts in children poses difficulty in evaluation, technical difficulties during surgery and problems during follow-up. Younger children do not cooperate for proper slit-lamp examination and need to be examined under general anaesthesia. In addition, the complications encountered post PKP, including allograft rejection, post PKP astigmatism and post PKP glaucoma are more frequent in pediatric group as compared to adult recipients. Even after a successful graft, the child requires rigorous treatment for amblyopia. Parents need to be counselled before surgery and possible visual outcome and chances of obtaining clear graft should be discussed.

Pediatric living donor liver transplantation with large-for-size left lateral segment grafts.

Usage of "large-for-size" left lateral segment (LLS) liver grafts in children with high graft to recipient weight ratio (GRWR) is controversial due to concerns about increased recipient complications. During the study period, 77 pediatric living donor liver transplantations (LDLTs) with LLS grafts were performed. We compared recipients with GRWR≥2.5% (GR-High=50) vs GRWR<2.5% (GR-Low=27). Median age was higher in the GR-Low group (40 vs 8months, P>.0001). Graft (GR-High: 98%, 98%, 98% vs GR-Low: 96%, 93%, 93%) and patient (GR-High: 98%, 98%, 98% vs GR-Low: 100%, 96%, 96%) survival at 1, 3, and 5years was similar between groups (P=NS). Overall complications were also similar (34% vs 30%; P=.8). Hepatic artery and portal vein thrombosis following transplantation was not different (P=NS). Delayed abdominal fascia closure was more common in GR-High patients (17 vs 1; P=.002). Subgroup analysis comparing recipients with GRWR≥4% (GR-XL=20) to GRWR<2.5% (GRWR-Low=27) revealed that delayed abdominal fascia closure was more common in the GR-XL group, but postoperative complications and graft and patient survival were similar. We conclude that pediatric LDLT with large-for-size LLS grafts is associated with excellent clinical outcomes. There is an increased need for delayed abdominal closure with no compromise of long-term outcomes. The use of high GRWR expands the donor pool and improves timely access to the benefits of transplantation without extra risks.

Proposal of a New Type of Innominate Osteotomy without the Use of Bone Graft in Children: A Preliminary Study.

Background:Good long-term outcomes have been reported for the Salter innominate osteotomy (SIO), which is widely used to correct developmental dysplasia of the hip (DDH) in children. In this study, we describe the procedure and early outcomes of a new pelvic osteotomy termed “angulated innominate osteotomy” (AIO).Methods:Twenty-one patients (22 hips) underwent AIO. We evaluated age at the time of surgery, operative time, blood loss, and time to bone union. Several radiographic parameters were assessed preoperatively, immediately postoperatively, and at the time of the latest examination. Measurements were compared with those of 20 previous patients who underwent SIO. The AIO is made to form an isosceles triangle. This enables 2 points of contact between the proximal and distal bone fragments, eliminating the need for a bone graft.Results:Mean age at the time of surgery was 5.9 years, and the mean duration of follow-up was 30.8 months. The mean operative time was 103 minutes, mean blood loss was 33 mL, and mean time to bone union was 9.8 weeks. Immediately postoperatively, the mean “distance d” (lateral displacement of the distal fragment), mean ratio of the obturator heights (ROH), and mean lateral rotation angle (LRA) were 7.2 mm, 70.4%, and 19.3°, respectively. At the latest examination, the mean acetabular index (AI), center-edge angle (CEA), and acetabular head index (AHI) were 16.4°, 23.7°, and 85.5%, respectively, each of which were significantly improved compared with the preoperative values. Moreover, the mean postoperative iliac length difference (ILD) between the operative and contralateral sides was only 0.1 mm. Those treated with AIO had a significantly shorter operative time and time to bone union, and less blood loss, than those treated with SIO. The mean distance d, ROH, and LRA did not differ significantly from SIO results, while the mean ILD was significantly less.Conclusions:AIO is a less-invasive procedure that does not require a bone graft, and the short-term outcomes were favorable. Sufficient coverage of the acetabulum with displacement of the distal bone fragment to an extent similar to SIO can be achieved; we consider AIO a worthy surgical procedure that has the potential to provide good long-term outcomes similar to those seen with SIO.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

MRI study of the ligamentization of ACL grafts in children with open growth plates

IntroductionThere is little published information on the ligamentization of pediatric anterior cruciate ligament (ACL) grafts. The aims of our study were to compare the MRI appearance of ACL grafts performed in a population with open growth plates to normal ACLs in adolescents and to determine whether the MRI signal in the grafts at 6 months could predict a retear. We hypothesized that ligamentization was a slow, gradual process. Material and methodsThis was a prospective multicenter study of 100 ACL grafts (quadriceps tendon, hamstring tendon, fascia lata) in children 7 to 16 years of age. Of these, 65 intact grafts underwent one or more MRI examinations between 6 months and 2 years postoperative. MRI images were also analyzed in 7 patients who suffered a retear and in the intact ACL of 20 adolescents (15 to 18 years of age). The other 28 patients did not undergo an MRI during the postoperative phase. For each MRI, the signal-to-noise quotient (SNQ) was calculated in three different areas in the ACL (proximal, middle, distal) along with the Howell intra-articular and intra-tibial grades from I to IV. The Mantel-Haenszel Chi-square, Wilcoxon signed-rank test and Student's t-test were used to compare groups. The Lin concordance correlation coefficients were calculated for inter-rater consistency. ResultsThere was a difference in the SNQ between the three zones of a normal ACL. Most were Howell grade III (55% Howell III, 25% Howell II and 20% Howell I). For intact grafts, the SNQ improved significantly between 6 and 12 months and between 6 and 24 months. There was no difference in the SNQ between the three zones independent of the postoperative time point. The intra-articular Howell grade improved significantly between 6 and 24 months and between 12 and 24 months. The intra-tibial Howell grade improved significantly between 12 and 24 months. There were no significant differences between patients with intact grafts and those who suffered a retear. There were no differences between the various types of grafts used. ConclusionNormal ACLs in adolescents have inhomogeneous SNQ and Howell grades. The SNQ and Howell grades in ACL grafts are more homogeneous and continue to improve out to 2 years, but do not reach that of a normal ACL. The signal and appearance of an ACL graft and normal ACL are very different, and the MRI signal at 6 months postoperative is not predictive of retear. Level of evidenceIII, prospective study.

Bone Marrow versus Peripheral Blood from Unrelated Donors for Children and Adolescents with Acute Leukemia

Graft-versus-host disease (GVHD) rates are higher after unrelated donor transplantation; thus, we examined whether there would be differences in transplant outcomes by graft type in children and adolescents with acute leukemia. The primary endpoint was overall survival. We studied 872 patients <18 years old who were transplanted with bone marrow (n = 650) or peripheral blood (n = 222) from unrelated donors. The characteristics of the 2 groups were comparable, except recipients of bone marrow were younger than recipients of peripheral blood (median age, 10 versus 12 years). Grades 2 to 4 (hazard ratio [HR], 1.48; P < .001) and grades 3 and 4 acute (HR, 1.69; P < .001) and chronic GVHD (HR, 1.92; P < .001) were higher with transplantation of peripheral blood than with bone marrow. Although relapse risks were lower after peripheral blood transplants (HR, 0.76; P = .05), transplant-related mortality (HR, 1.91; P = .003) and overall mortality (HR, 1.34; P = .032) were higher than with bone marrow transplants. The 8-year probability of overall survival after transplantation of bone marrow was 47% compared with 42% after peripheral blood. The 8-year probability of leukemia-free survival was 40% after transplantation of bone marrow and peripheral blood. Lower relapse after transplantation of peripheral blood negated the survival advantage after transplantation of bone marrow. The observed higher acute and chronic GVHD seen with peripheral blood suggest cautious use of this graft in children and adolescents with acute leukemia.