Delayed fixation of displaced type II and III pediatric femoral neck fractures

BACKGROUND: Time from injury to fixation of femoral neck fractures has been postulated as a vital determinant for rate of complications; however, no prospective study is available in the English literature. Delay, unfortunately, is inevitable in developing countries. The aim of the present study is to retrospectively review the outcome after delayed fixation of displaced type II and III femoral neck fractures in children. MATERIALS AND METHODS: Using a standard assessment chart, we retrospectively reviewed medical records of all pediatric patients having femoral neck fractures presenting to our institution from June 1999 to May 2006. Inclusion criteria were children between 5 and 15 years of age sustaining displaced Delbet type II and III femoral neck fractures having a complete follow-up of at least 2 years. Patients with known metabolic disease, poliomyelitis or cerebral palsy, were excluded from the study. After application of inclusion and exclusion criteria, 22 patients having 22 fractures (13 type II and 9 type III) were studied. Surgery could be performed after a mean delay of 11.22 days (ranging from 2 to 21 days). Closed reduction was achieved in 14 cases and 8 cases required open reduction through anterolateral approach. RESULT: Osteonecrosis was noted in eight patients (36.37%) who included two of nine patients (22.22%) operated in the first week, three of eight patients (37.51%) operated in the second week, and three of five patients (60%) operated in the third week of injury. Nonunion was seen in four (18.18%) cases, and two of them were associated with failure of implants. One was treated by valgus osteotomy and the other by Meyer's procedure. Fractures united in both children but the latter developed avascular necrosis. Functional results, as assessed using Ratliff's criteria, were good in 14 (63.63%), fair in 2 (9%), and poor in 6 (27.27%) patients. CONCLUSION: Delay in fixation, type of fracture, and ability to achieve and maintain reduction are factors primarily responsible for the outcome. We also found that delay after the first week further adversely affects the outcome

Small intestinal CD8+TCRγδ+NKG2A+ intraepithelial lymphocytes have attributes of regulatory cells in patients with celiac disease

Intraepithelial lymphocytes (IELs) bearing the γδ TCR are more abundant in the small intestinal mucosa of patients with celiac disease (CD) compared with healthy individuals. However, their role in disease pathogenesis is not well understood. Here, we investigated the functional attributes of TCRγδ+ IELs isolated from intestinal biopsies of patients with either active celiac disease (ACD) or those on a gluten-free diet (GFD). We found that compared with individuals with ACD, individuals on GFD have a higher frequency of CD8+TCRγδ+ IELs that express the inhibitory NK receptor NKG2A and intracellular TGF-β1. TCR triggering as well as cross-linking of NKG2A increased both TGF-β1 intracellular expression and secretion in vitro. Coculture of sorted TCRγδ+NKG2A+ IELs, IL-15–stimulated TCRαβ+ IELs, and HLA-E+ enterocytes resulted in a decreased percentage of cytotoxic CD8+TCRαβ+ IELs expressing intracellular IFN-γ and granzyme-B and surface NKG2D. This inhibition was partially abrogated by blocking either TGF-β alone or both NKG2A and HLA-E. Thus, our data indicate that suppression was at least partially mediated by TGF-β secretion as a result of engagement of NKG2A with its ligand, HLA-E, on enterocytes and/or TCRαβ+ IELs. These findings demonstrate that human small intestinal CD8+TCRγδ+ IELs may have regulatory potential in celiac disease