Prosthesis In Children Research Articles

When Do Orthopaedic Oncologists Consider the Implantation of Expandable Prostheses in Bone Sarcoma Patients?

Introduction Indications discussed for the implantation of expandable prostheses in bone sarcoma patients are unclear. This survey aimed to analyse common practice with this implant type in orthopaedic oncology. Methods A web-based survey was sent to 98 orthopaedic oncology surgeons. Factors reported in literature to influence the decision on the implantation of a growing prosthesis were covered in individual questions and three case scenarios. Results The completion rate of the survey was 45% (n = 44). Twenty-seven of 44 surgeons (61%) had implanted between 1 and 15 expandable prostheses within three years. The minimum median patient age was 6.5 years, and 3–5 cm of predicted growth deficit was the minimum before implanting a growing prosthesis. One-third of surgeons do not use growth calculation methods. Two out of three surgeons would rather not implant a growing prosthesis in children with metastatic disease. Conclusions Our survey confirmed the literature with 3-4 cm as the minimum estimated growth deficit. The minimum age for the implantation of a growing prosthesis is approx. 6.6 years, and therefore the patients are younger than those reported in previous publications. One-quarter of orthopaedic surgeons do not use growing prostheses at all. It remains unclear whether growing prostheses are indicated in patients with metastatic disease.

Design of powered upper limb prosthesis for children using small diameter McKibben type artificial muscle

Design of powered upper limb prosthesis for children using small diameter McKibben type artificial muscle

Functional changes through the usage of 3D-printed transitional prostheses in children

Introduction: There is limited knowledge on the use of 3 D-printed transitional prostheses, as they relate to changes in function and strength. Therefore, the purpose of this study was to identify functional and strength changes after usage of 3 D-printed transitional prostheses for multiple weeks for children with upper-limb differences.Materials and methods: Gross manual dexterity was assessed using the Box and Block Test and wrist strength was measured using a dynamometer. This testing was conducted before and after a period of 24 ± 2.61 weeks of using a 3 D-printed transitional prosthesis. The 11 children (five girls and six boys; 3–15 years of age) who participated in the study, were fitted with a 3 D-printed transitional partial hand (n = 9) or an arm (n = 2) prosthesis.Results: Separate two-way repeated measures ANOVAs were performed to analyze function and strength data. There was a significant hand by time interaction for function, but not for strength.Conclusion and relevance to the study of disability and rehabilitation: The increase in manual gross dexterity suggests that the Cyborg Beast 2 3 D-printed prosthesis can be used as a transitional device to improve function in children with traumatic or congenital upper-limb differences.Implications for RehabilitationChildren’s prosthetic needs are complex due to their small size, rapid growth, and psychosocial development.Advancements in computer-aided design and additive manufacturing offer the possibility of designing and printing transitional prostheses at a very low cost, but there is limited knowledge on the function of this type of devices.The use of 3D printed transitional prostheses may improve manual gross dexterity in children after several weeks of using it.

Long-term results of early myoelectric prosthesis fittings: A prospective case-control study.

Different recommendations exist regarding what age is best for first-time fitting of myoelectric hand prostheses in children. To compare prosthetic skill, prosthetic use and risk for rejection over time between children fitted with myoelectric hand prostheses before or after 2½ years of age. Prospective case-control design. The cases were nine children fitted with myoelectric hand prostheses before the age of 2½ years, whereas the controls were 27 children who were fitted with myoelectric hand prostheses after the age of 2½ years. The Skills Index Ranking Scale was used to classify prosthetic skill, and prosthetic use was categorised based on wearing time and pattern. Independent samples tests were used to compare data between groups. To estimate and compare the risk of prosthesis rejection between groups and over time, survival analysis was used. Cases showed prosthetic skill early, but controls had caught up by the age of 3½ years. Cases had a significant ( p = 0.046) decrease in prosthetic use at the age of 9 years. In the long term, cases had a higher percentage of prosthesis rejection. Considering young children's development of prosthetic skill and prosthetic use over time, this study shows no additional advantages from fitting a myoelectric hand prosthesis before 2½ years of age. Clinical relevance Children may be fitted with myoelectric hand prostheses to assist in daily tasks and to prevent future over-use problems. Most children fitted with myoelectric hand prostheses before 4 years of age become regular users. No advantages of fitting myoelectric hand prostheses before 2½ years of age were observed.

Evaluation of important factors in accepts or reject of upper limb prosthesis in children


 
 
 Abstract
 Introduction: upper limb amputee Children usually uses prosthesis for better function. But studies show a high percentage of rejection of the prosthesis in this group. In clinical studies, there are not very different in function of children who use of prosthesis and those who do not. Answer to why children accept and use their prosthesis or reject it could help and improve the future design of the prosthesis and rehabilitation. The aim of this study was finding important criteria for children with below elbow amputation, their parents and therapists for acceptance and use of prosthetics or rejects it in children group. Method: This study was conducted by literature search of Science direct, Google Scholar, Cochran Library, MEDLINE and PubMed between 1966 and 2014 ,that investigated effective factors in accept or reject of below elbow prosthesis in below elbow amputee children.For quality assessment of articles we rated each paper using the Downs and Black score ranges and Pedro scale . The two reviewers independently read and classified the articles by population, type of study and results. Results After initial evaluation and reviews, 14 articles were included in this study. Most studies were reported form and questionnaire and clinical observations.The general characteristics of the prosthesis, prosthesis control method, quality of life, family and the rehabilitation procedures were important factors were explored in these literature. Conclusion According to the studies, it is necessary to optimize the prosthesis according to the real children expectations and needs to improve their quality of life.There are controversial studies about performance and first time prosthesis in children but studies confirmed that Group therapy can increase the acceptance rate of prosthesis. Training and finding ways for function without prosthesis along using it to communicate with the environment, increase motor control and sensory perception that could increase accept of prosthesis in children.
 
 
 
 Keywords: upper limb prosthesis, children, amputation
 
 
 
 
 

Testicular prostheses in children: Is earlier better?

The absence of a testis occurs for various reasons in children, but testicular prosthesis implantation in children is uncommon. The optimal time for prosthesis placement is still unclear, and its complication rate has been poorly studied in children. The aim of this study was to determine the risk factors of complications in cases of testicular prosthesis implantation in children. A monocentric, retrospective review was performed of children implanted with a testicular prosthesis between 2008 and 2014. All implantations were performed through an inguinal incision with a standardized procedure. Children were divided into two groups depending on the interval after orchiectomy: (A) early implantation (delay between surgeries <1 year); and (B) delayed surgeries (delay ≥1 year). Statistical analysis was performed with Student and Fisher tests. Twenty-six patients (A, 15; B, 11) had a total of 38 testicular prostheses placements. Mean follow-up was 36.2 months. First surgery was performed at the mean age of 11.8 years (range 0-17.9) (A, 14.1; B, 8.1; P=0.01) and testicular prosthesis implantation at the mean age of 14.7 years (range 9-18) (A, 14.3; B, 14.6) with a mean delay of 36.1 months (A, 1.3; B, 80.3). Indications were mainly spermatic cord torsion (27%), bilateral anorchia (27%), and testicular atrophy after cryptorchidism surgery (19.2%). Complications (10.5%) included two cases of extrusion, one infection and one migration. Patient 1 had a history of acute lymphoblastic leukemia with testicle relapse 2 years after induction therapy. High-dose chemotherapy, total body irradiation and bilateral orchiectomies were performed, and bilateral prostheses were implanted 12 years after the end of chemotherapy. Complications happened 85 days after surgery. Patient 2 was followed-up for a proximal hypospadias. The tunica vaginalis flap, which was used during a redo urethroplasty, lead to testicular atrophy. Thirteen years after the last penile surgery, a testicular prosthesis was placed through an inguinal incision, and extrusion occurred 203 days after surgery. Bacterial cultures of the prostheses were sterile and histological review showed no sign of granuloma or graft rejection. The complication rate was significantly higher if the delay between the two surgeries exceeded 1 year (P=0.01). Indications of orchiectomy, prior scrotal incision, and prosthesis size were not risk factors. Testicular prosthesis implantation was relatively safe in a pediatric cohort. The complication rate was significantly higher if the delay between the orchiectomy and the prosthetic placement exceeded 1 year. These results suggest that reducing the delay between orchiectomy and prosthesis implantation may lead to fewer complications.

Clinical and anatomical features of congenital microphthalmia and anophthalmia in children and conservative methods of rehabilitation

To develop a comprehensive classification system of distinctive clinical and anatomical features of congenital microphthalmia and anophthalmia in children and to specify indications, contraindications, and optimal timing of the primary and subsequent prosthetic treatment. A total of 70 patients with congenital micro- or anophthalmia aged from 1 month to 12 years were examined. Besides the routine ophthalmic examination, all patients underwent eye and orbit ultrasound (axial length measurement and B-scan), computed tomography of the orbits and skull, and immunological tests for infectious diseases (enzyme-linked immunosorbent assays). Basing on the examination we have determined the common types of congenital micro- and anophthalmia in children. We have also developed a stepwise prosthetic treatment aimed at better cosmetic rehabilitation. Indications and contraindications for the use of ocular prostheses in children with congenital micro- and anophthalmia have been identified. The proposed method of stepwise prosthetics is the principal option for conservative rehabilitation of children with congenital micro- or anophthalmia.

Reconstruction with preservation of the epiphysis by using custom-made prosthesis in children with distal femoral osteosarcomas

Objectives To evaluate the preliminary effectiveness, investigate the clinical methods and prevent the complications of the epiphysis preservation operation by using custom-made prosthesis in children with distal femoral osteosarcomas. Methods Between August 2012 and July 2013, 3 patients (from 8 to 14 years old) who were diagnosed of osteosarcoma underwent tumor segmental resection and epiphysis preservation operation and reconstruction with custom-made prosthesis. Patients were assigned neoadjuvant chemotherapy 1 to 2 cycles. The effect of neoadjuvant chemotherapy was then evaluated by X-ray, CT and MRI. Patients were determined the disease field by MRI, customized prosthesis by computer and had surgery of tumor segmental resection and reconstruction with custom-made prosthesis. All individuals were given appropriate functional exercise after operation, standard chemotherapy after incision healing one week, and long-time follow-ups. Results The operation times were 3 hours, 4 hours and 6 hours. The bleeding losses during operation were 300 ml, 500 ml and 2200 ml, respectively. The functional scores according to the scoring system of the Musculoskeletal Tumor Society (MSTS) after 12-24 months follow-ups were 24, 26 and 13, respectively. And excellent functional results were obtained in short-time follow-ups. 1 patient had prosthesis infection and amputation was taken after failing in conservative treatment. Unequal lengths of both lower extremities in 2 patients were less than 2 cm. Conclusion For the pediatric distal femoral osteosarcomas that has surgical indications, a new theory and therapy idea on combination of epiphysis preservation operation with custom-made prosthesis and neoadjuvant chemotherapy and standardized postoperative chemotherapy is suggested. And it has advantages of effective curative effect, easy operation, short operative time and quick recovery. However, long-term outcomes of complications should be observed further. Key words: Femur; Osteosarcoma; Salvage therapy; Arthroplasty, replacement, knee

A comparison of function after limb salvage with non-invasive expandable or modular prostheses in children

BackgroundModular and non-invasive expandable prostheses have been developed to provide a functional knee joint that allows future expansion as growth occurs in the contralateral extremity in children with bone sarcomas that require removal of the growth plate. This study aimed to evaluate the functional outcomes of paediatric patients who received either a non-invasive expandable or modular prosthesis for bone sarcomas arising around the knee. MethodsWe evaluated clinician-reported, patient-reported and measured function in 42 paediatric patients at least one year (median age at assessment 19.1years) after limb salvage surgery, and compared patients who received modular system prostheses (N=29, median age 15.5), who did not require lengthening procedures to those who received non-invasive expandable prostheses (N=13, median age 11.1) requiring lengthening procedures (median 5). ResultsThe number of revisions and time to first revision did not differ between the two groups. There were no differences between the two groups in total scores on the Enneking Musculoskeletal Tumor Society Scale, the Toronto Extremity Salvage Scale, and the Functional Mobility Assessment. Children with non-invasive expandable prostheses climbed stairs (11.93±4.83 versus 16.73±7.24s, p=0.02) in less time than those with modular prostheses. ConclusionOur results suggest that the non-invasive expandable prosthesis produces similar functional results to the more traditional modular prosthesis.

Children’s orthopaedics

The August 2013 Children’s orthopaedics Roundup360 looks at: a multilevel approach to equinus gait; whether screening leads to needless intervention; salvage of subcapital slipped epiphysis; growing prostheses for children’s oncology; flexible nailing revisited; ultrasound and the pink pulseless hand; and slipping forearm fractures.

Outcome of Expandable Prostheses in Children

Expandable prostheses offer the advantages of limb-salvage and limb-length equality at skeletal maturity. However, what is the cost for achieving that goal, and in how many children this is achieved? We present 32 children (16 boys and 16 girls; mean age, 9 y) with bone sarcomas of the femur treated with limb salvage using expandable prostheses. The Kotz Growing prosthesis and the noninvasive Repiphysis and Stanmore expandable prostheses were used. The mean follow-up was 49 months. Survival analysis of the children and primary implants and functional evaluation were performed. Survival of the children was 94% and 84% at 48 and 72 months. Survival of the primary prostheses was 78% and 66% at 48 and 72 months; survival was significantly higher only for the Kotz when compared with the Repiphysis prostheses (P=0.026). The rate of implant-related complications was 51.3%; 9 prostheses (23%) were revised because of aseptic loosening, infection, and breakage. A mean total lengthening of 28 mm (4 to 165 mm) was achieved by 84 procedures (2.6 procedures/patient). Three of the 9 children who reached skeletal maturity had limb-length equality and 6 discrepancy of 15 to 30 mm. The mean Musculoskeletal Tumor Society score was excellent (79%) without a significant difference between the type of prostheses (P=0.934). The Kotz Growing prosthesis, although it requires an open lengthening procedure, has shown higher survival when compared with the noninvasive Repiphysis prosthesis. However, the total lengthening remains small, and the complications rates are high even with the noninvasive prostheses.

Mitral Valve Replacement Using Mechanical Prostheses in Children: Early and Long-Term Outcomes

Compared with mitral repair, mitral valve replacement is an uncommon procedure in children due to associated high mortality and morbidity rates. The present study investigated early and late outcomes after MVR with mechanical prostheses in children at our institution. Between January 1994 and December 2009, 19 children underwent MVR. Mean patient age was 7.6±5.5years (range 3months-16years), and mean body weight was 23.7±15.1kg (range 5.0-58.1kg). Mean prosthesis size was 25.8±4.2mm (range 19-31mm). There were no operative or late mortalities. Three patients showed decreased left-ventricular function before surgery, and one of them underwent successful heart transplantation due to progressive LV dysfunction at 10months after MVR. The proportion of patients with freedom from reoperation at 10years was 94.7±5%. There were no major thromboembolic or bleeding episodes. Although the small number of patients in our study was a limitation, MVR in children was found to result in excellent early and long-term outcomes. It appears that MVR could be considered in children before LV dysfunction develops.

Custom Ocular Prosthesis in Children: How Often is a Change Required?

Purpose: To evaluate the indications, outcome and replacement schedule of custom ocular prostheses (COP) in children.Methods:Retrospective review evaluating indications, outcome and replacement schedule of COP in children (≤16 years).Results:Three hundred and thirty (330) children were fitted with COP. With average follow-up of 18.05 months (range 1-50 months), 136(41.2%) children needed replacement/modification of the prosthesis. Information regarding indications for replacement/modification of prosthesis was available in 125 cases. Indications included enophthalmic prosthesis in 34(27.2%), prosthesis rotation within the socket in 25(20%), loose fit in 16(12.8%), decentration of the cornea in 15(12%), color touch up in 13(10.4%), lost prosthesis in 8(6.4%), cosmetically significant ptosis in 2(1.6%), replacement following implant exchange surgery in 2(1.6%) and combination of above factors in 10(8%). Time for replacement/modification of prosthesis was assessed in 3 age groups. In ≤3 years, 47% (36 out of 76) children underwent replacement/modification at a mean duration of 18 months (range 3–39 months) from the date of prosthesis fitting. In the 3–12 years age group, 43% (80 out of 184) underwent replacement/modification at 21 months (range 2–48 months); and in the 12–16 year age group, 29% (20 out of 70) underwent replacement/modification of prosthesis at a mean duration of 26 months (range 3-50 months).Conclusion: A change of prosthesis is required between 18-26 months following prosthesis placement in children.Over an average of 18 months, a change in the prosthesis was required in 41%, with the youngest age group having the highest exchange rate (47%), and the oldest group the lowest (29%).

Long term results of ossiculoplasties with partial and total titanium Vario Kurz prostheses in children

Objective To assess and compare the efficacy of the Kurz titanium prostheses for total or partial ossicular reconstruction in children. Patients and methods Retrospective chart review was performed for 71 consecutive children who underwent 74 ossicular reconstructions with Kurz prostheses between December 1999 and October 2007 (27 PORP and 47 TORP). Audiological parameters using four-frequency averages (0.5, 1, 2 and 4 kHz) were assessed pre- and postoperatively. Clinical and audiometric follow-up times were respectively 33 ± 18.6 and 30 ± 17.7 months (mean ± SD). Results Fifty-two percent of all patients achieved an air bone gap (ABG) ≤20 dB, 53.8% in the PORP group and 51.1% in the TORP group. The improvement of the mean ABG was 13.3 dB, 9.4 dB for PORP and 14.6 dB for TORP. Overall mean pure tone averages improved 13.2 ± 1.8 dB (mean ± SEM) with 10 ± 2.7 dB for PORP and 15 ± 2.4 dB for TORP. The sensory neural hearing loss rate was 1.4% (one TORP) and the extrusion rate was 2.7% ( n = 2/74). Conclusion The success rate (ABG ≤ 20 dB) and the pure tone averages were not different between PORP and TORP. Kurz titanium ossicular prostheses offer high biocompatibility and high stability with low complication rates in pediatric ossicular reconstruction.

Seven‐year experience of using Repiphysis® expandable prosthesis in children with bone tumors

Results of the use of the non-invasive expandable endoprosthetic device Repiphysis in limb salvage surgery for skeletally immature children with bone cancer have been promising. In this report, we analyze the outcomes and complications associated with using 17 Repiphysis prosthesis from January 2002 to March 2009 in 17 skeletally immature children with bone sarcoma around the knee. The average follow-up was 61.7 months. All patients who underwent active expansion experienced successful lengthening with a total of 38 lengthening sessions and an average of 8.6 mm gained per session. The Musculoskeletal Tumor Society functional scores averaged 90% at the most recent follow-up. The average survival time of the device from implementation to revision or last follow-up was 2 years and 8 months. There were 12 complications in 12 patients, including 6 mechanical problems, 2 tibial fractures and 3 infections. For the 17 insertions, 7 revision operations were performed, 3 of which were done using a new Repiphysis device. Despite the high rate of complications, the goal of achieving equal leg length at skeletal maturity with fewer surgeries per patient has been relatively achieved with the use of this device.

Temporal and Spatial Parameters of Crawling in Children With Limb Loss: Implications on Prosthetic Knee Prescription

In Brief Children with limb loss at or above the knee face unique challenges at different stages of development. When transitioning from crawling to walking, and during the intermediate activity of pull-to-stand, a prosthesis must accomplish disparate goals: the mobility necessary for crawling and the stability necessary for standing and walking. This investigation tested the hypothesis that crawling mobility would be reduced when the traditional treatment protocol of a prosthesis lacking an articulating knee joint is followed. Crawling pattern, velocity, and cadence were measured in five children within 3 weeks of the fitting of their first prosthesis, which included an articulating knee. Two conditions were tested: prosthetic knee in its fully articulating state and prosthetic knee locked into extension. In all cases, the locked knee condition reduced velocity and cadence. With one exception, the children exhibited a more typical “step-through” crawling pattern when the knee was unlocked and a less efficient “step-to” pattern when the knee was locked. These data indicate that the traditional prescription protocol for children with transfemoral limb loss may inhibit crawling, which may in turn have long-term implications on motor development. A prosthesis for children with limb loss at or above the knee must accomplish disparate goals when transitioning from crawling to walking: the mobility necessary for crawling and the stability necessary for standing and walking. This investigation tested the hypothesis that crawling mobility would be reduced when the traditional treatment protocol of a prosthesis lacking an articulating knee joint is followed. Two conditions were tested: prosthetic knee in its fully articulating state and prosthetic knee locked into extension. Results indicate that the traditional prescription protocol for children with transfemoral limb loss may inhibit crawling, which may in turn have long-term implications on motor development.

Mitral valve replacement in infants and children 5 years of age or younger: Evolution in practice and outcome over three decades with a focus on supra-annular prosthesis implantation

Successful mitral valve replacement in young children is limited by the lack of small prosthetic valves. Supra-annular prosthesis implantation can facilitate mitral valve replacement with a larger prosthesis in children with a small annulus, but little is known about its effect on the outcomes of mitral valve replacement in young children. One hundred eighteen children underwent mitral valve replacement at 5 years of age or younger from 1976-2006. Mitral valve replacement was supra-annular in 37 (32%) patients. Survival was 74% +/- 4% at 1 year and 56% +/- 5% at 10 years but improved over time (10-year survival of 83% +/- 7% from 1994-2006). Factors associated with worse survival included earlier mitral valve replacement date, age less than 1 year, complete atrioventricular canal, and additional procedures at mitral valve replacement, but not supra-annular mitral valve replacement. As survival improved during our more recent experience, the risks of supra-annular mitral valve replacement became apparent; survival was worse among patients with a supra-annular prosthesis after 1991. A pacemaker was placed in 18 (15%) patients within 1 month of mitral valve replacement and was less likely in patients who had undergone supra-annular mitral valve replacement. Among early survivors, freedom from redo mitral valve replacement was 72% +/- 5% at 5 years and 45% +/- 7% at 10 years. Twenty-one patients with a supra-annular prosthesis underwent redo mitral valve replacement. The second prosthesis was annular in 15 of these patients and upsized in all but 1, but 5 required pacemaker placement for heart block. Supra-annular mitral valve replacement was associated with worse survival than annular mitral valve replacement in our recent experience. Patients with supra-annular mitral valve replacement were less likely to have operative complete heart block but remained at risk when the prosthesis was subsequently replaced.

The effect of direct measurement versus cadaver estimates of anthropometry in the calculation of joint moments during above-knee prosthetic gait in pediatrics

Joint reaction forces, moments and powers are important in interpreting gait mechanics and compensatory strategies used by patients walking with above-knee prostheses. Segmental anthropometrics, required to calculate joint moments, are often estimated using data from cadaver studies. However, these values may not be accurate for patients following amputation as prostheses are composed of non-biologic material. The purpose of this study was to compare joint moments using anthropometrics calculated from cadaver studies versus direct measurements of the residual limb and prosthesis for children with an above-knee amputation. Gait data were collected for four subjects with above-knee prostheses walking at preferred and fast speeds. Joint moments were computed using anthropometrics from cadaver studies and direct measurements for each subject. The difference between these two methods primarily affected the inertia couple (I α term) and the inertial effect due to gravity, which comprised a greater percentage of the total joint moment during swing as compared to stance. Peak hip and knee flexor and extensor moments during swing were significantly greater when calculated using cadaver data ( p<0.05). These differences were greater while walking fast as compared to slow speeds. A significant difference was not found between these two methods for peak hip and knee moments during stance. A significant difference was found for peak ankle joint moments during stance, but the magnitude was not clinically important. These results support the use of direct measurements of anthropometry when examining above-knee prosthetic gait, particularly during swing.

Prescription of the First Prosthesis and Later use in Children with Congenital Unilateral Upper Limb Deficiency

The prosthetic rejection rates in children with an upper limb transversal reduction deficiency are considerable. It is unclear whether the timing of the first prescription of the prosthesis contributes to the rejection rates. To reveal whether scientific evidence is available in literature to confirm the hypothesis that the first prosthesis of children with an upper limb deficiency should be prescribed before two years of age. We expect lower rejection rates and better functional outcomes in children fitted at young age. A computerized search was performed in several databases (Medline, Embase, Cinahl, Amed, Psycinfo, PiCarta and the Cochrane database). A combination of the following keywords and their synonyms was used: "prostheses, upper limb, upper extremity, arm and congenital". Furthermore, references of conference reports, references of most relevant studies, citations of most relevant studies and related articles were checked for relevancy. The search yielded 285 publications, of which four studies met the selection criteria. The methodological quality of the studies was low. All studies showed a trend of lower rejection rates in children who were provided with their first prosthesis at less than two years of age. The pooled odds ratio of two studies showed a higher rejection rate in children who were fitted over two years of age (pooled OR = 3.6, 95% CI 1.6 - 8.0). No scientific evidence was found concerning the relation between the age at which a prosthesis was prescribed for the first time and functional outcomes. In literature only little evidence was found for a relationship between the fitting of a first prosthesis in children with a congenital upper limb deficiency and rejection rates or functional outcomes. As such, clinical practice of the introduction of a prosthesis is guided by clinical experience rather than by evidence-based medicine.

Early Experience With Valve-Sparing Aortic Root Replacement in Children

Aortic valve-sparing root replacement has become an established treatment for adults with aneurysms of the ascending aorta, but there is limited experience in children, for whom the advantages of avoiding valve prostheses are particularly attractive. A retrospective clinical study was undertaken to examine results of aortic valve-sparing operations in pediatric patients at a single institution. Clinical and echocardiographic data were obtained from chart review and outpatient follow-up examination. Between 1997 and 2004, 19 children underwent aortic valve-sparing root replacement. Mean age was 12.2 +/- 4.4 years, and mean weight was 51.5 +/- 22.9 kg. Median length of clinical follow-up was 58 months (range, 5 to 91). Fifteen of 19 patients (78.9%) had Marfan syndrome and 1 had aortic root dilation late after the arterial switch operation. Mean preoperative root diameter was 4.7 +/- 0.6 cm, with an average Z score of 7.7 +/- 1.9. Fourteen patients (73.7%) underwent root remodeling, whereas 5 (26.3%) had a reimplantation procedure. One patient required concomitant mitral valve repair. There was no operative mortality and only 1 reoperation for bleeding (5.3%). Median length of hospital stay was 5 days (range, 3 to 12). At latest follow-up, 3 of 19 patients (15.8%) have required late aortic valve replacement. Fifteen patients have no or mild aortic valve insufficiency, and 1 has moderate but stable valve regurgitation. No patient with a reimplantation procedure has had a reoperation or more than mild insufficiency, and no patient has suffered endocarditis or thromboembolism. Valve-sparing aortic root replacement is a viable alternative to root replacement with mechanical or biological prostheses in children, and can be accomplished with minimal morbidity and mortality. Reimplantation procedures appear to have more durable results than root remodeling techniques, and should be strongly considered for pediatric patients with aortic root enlargement secondary to connective tissue disorders and other forms of congenital heart disease.