Osteogenesis imperfecta (OI) is a genetic disorder characterized by bone fragility and fractures. Patients with OI have clinical features that may range from mild symptoms to severe bone deformities and neonatal lethality. Numerous approaches for the classification of OI have been published. The Sillence classification is the most commonly used. In this study, we aimed at developing a more refined sub-classification by applying a proposed scoring system for the quantitative assessment of clinical severity in different types of OI.
Subjects and methods
This study included 43 patients with OI. Clinical examination and radiological studies were conducted for all patients. Cases were classified according to the Sillence classification into types I–IV. The proposed scoring system included five major criteria of high clinical value: number of fractures per year, motor milestones, long bone deformities, length/height standard deviation score (SDS), and bone mineral density (BMD). Each criterion was assigned a score from 1 to 4, and each patient was marked on a scale from 1 to 20 according to these five criteria.
Applying the proposed clinical scoring system showed that all 11 patients with Sillence type I (100%) had a score between 6 and 10, denoting mild affection. The only patient with Sillence type II had a score of 19, denoting severe affection. In Sillence type III, 7 patients (31.8%) were moderately affected and 15 patients (68.2%) were severely affected. Almost all patients with Sillence type IV (88.9%) were moderately affected.
Applying the proposed scoring system can quantitatively reflect the degree of clinical severity in OI patients and can be used in complement with the Sillence classification and molecular studies.
Osteogenesis imperfecta; Sillence classification; Clinical scoring system; Radiological manifestations; Genetics
Osteogenesis imperfecta (OI) has been treated with bisphosphonates for many years, with some clear clinical benefits. In adults, there are reports of a new pattern of atraumatic subtrochanteric fractures with bisphosphonate treatment. This study assesses if bisphosphonate treatment leads to an altered pattern of femoral fractures.
Retrospective review of imaging for a cohort of 176 bisphosphonate-treated OI patients to identify the locations of femoral fractures over a two-year period, as compared to a historical control group managed pre-bisphosphonates.
Sixteen femoral fractures were identified in this time period in the bisphosphonate-treated group. All but two were within the subtrochanteric region. In comparison, the historical group—composed of 26 femoral fractures—had a more widespread fracture pattern, with the most frequent location being the mid-diaphysis. Many of the subtrochanteric fractures in the treatment group occurred with minimal trauma.
It appears that concerns over the treatment of the adult osteoporotic population with bisphosphonates are amplified and mirrored in OI. It is possible that the high bending moments in the proximal femur together with altered mechanical properties of cortical bone secondary to the use of this group of drugs increase the risk of this type of injury, which warrants further modification of surgical management of the femur.
Osteogenesis imperfecta; Bisphosphonates
The erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count are frequently obtained in the work-up of post-operative fever. However, their diagnostic utility depends upon comparison with normative peri-operative trends which have not yet been described. The purpose of this study is to define a range of erythrocyte sedimentation rates and white blood cell counts following spinal instrumentation and fusion in non-infected patients.
Seventy-five patients underwent spinal instrumentation and fusion. The erythrocyte sedimentation rate and white blood cell count were recorded pre-operatively, at 3 and 7 days post-operatively, and at 1 and 3 months post-operatively.
Both erythrocyte sedimentation rate and white blood cell count trends demonstrated an early peak, followed by a gradual return to normal. Peak erythrocyte sedimentation rates occurred within the first week post-operatively in 98% of patients. Peak white blood cell counts occurred with the first week in 85% of patients. In the absence of infection, the erythrocyte sedimentation rate was abnormally elevated in 78% of patients at 1 month and in 53% of patients at 3 months post-operatively. The white blood cell count was abnormally elevated in only 6% of patients at 1 month post-operatively. Longer surgical time was associated with elevated white cell count at 1 week post-operatively. The fusion of more vertebral levels had a negative relationship with elevated erythrocyte sedimentation rate at 1 week post-operatively. The anterior surgical approach was associated with significantly lower erythrocyte sedimentation rate at 1 month post-operatively and with lower white cell count at 1 week post-operatively.
In non-infected spinal fusion surgeries, erythrocyte sedimentation rates are in the abnormal range in 78% of patients at 1 month and in 53% of patients at 3 months post-operatively, suggesting that the erythrocyte sedimentation rate is of limited diagnostic value in the early post-operative period.
Sedimentation rate; Leukocyte count; Surgical site infection; Spinal instrumentation; Spinal fusion
The recognition of the importance of femoral acetabular impingement (FAI) as a potential cause of hip pain has been stimulated by major efforts to salvage hip joints by reconstruction in order to prevent or delay the need for replacement. The purpose of this review is to define the nature of FAI, the various types, and how to make the diagnosis.
The review describes the characteristics of the hip that cause FAI and emphasizes understanding that the femoral and acetabular components normally function as a unit, complementing each other.
The methods of making the diagnosis of FAI and their limitations are described. If the acetabulum and femur are considered to be independent of each other, conflict may occur, hindering function, and not be apparent. The increasing frequency of making this diagnosis based on abnormal anatomy on one side of the joint, often in face of unclear physical findings, can bring the diagnosis into question. FAI seen in Perthes disease and acetabular dysplasia is explained. Knowing how to analyze the hip, being aware of the limitations of various available clinical and diagnostic studies, and recognizing the continued and ever-changing extensive body of literature is important and challenging. This primer is just the beginning.
Femoro-acetabular impingement; Pincer impingement; Cam impingement; Acetabular retroversion; Posterior wall sign; Ischial spine sign; Crossover sign
Pamidronate, used for the treatment of paediatric osteoporosis, reduces the fracture rate and improves ambulatory status. Intravenous pamidronate therapy has known complications which have not been stratified based on its dose and distribution. This study aims to assess the early minor and major medical and late surgical complications and the effect of the dose and regimen of infusion on these events in paediatric osteoporosis.
Materials and methods
Three regimens for pamidronate infusion were followed in sequential periods in 10 years. Regimen A delivered 1.5 mg/kg/day as a single dose once in 3 months. Regimen B delivered 2 mg/kg/day for 3 days twice a year, while regimen C delivered 1 mg/kg/day for 3 days every 3–4 months. Adverse events were classified as early (major and minor) or late (surgical).
Forty-eight children received 158 infusions using one of the three regimens. Twenty-nine complications occurred in 24 children. A significant difference in the complication rate was present among the three regimens (P = 0.005). Nineteen children had minor complications, mainly febrile reaction or asymptomatic hypocalcaemia. Four major complications consisting of one seizure, one respiratory distress and two hypocalcaemic tetany were encountered, all with regimen B. Intraoperative complication faced was loss of position due to splintering of the cortex while rush rodding. This was seen in 20% of the long bone segments operated in those who received pamidronate as compared to 4.4% of the segments which were operated prior to the initiation of pamidronate therapy; the odds of splintering were 5.4 times higher for those patients who were bone segment rodded after pamidronate therapy.
Intravenous pamidronate is associated with complications in 50% of children with paediatric osteoporosis, with a dose-dependent significant difference. Major complications are not uncommon with higher doses and can be avoided by increasing the number of doses per year and decreasing the dose per cycle. Surgical difficulty, when possible, can be avoided by correcting any major deformities at presentation prior to the induction of pamidronate therapy.
Bisphosphonates; Osteogenesis imperfecta; Surgery; Symptomatic hypocalcaemia
The clinical features that define congenital talipes equinovarus (CTEV) are the presence of four principal components, equinus, varus, adductus and cavus. Classification systems in CTEV often include a form of assessment of these components and also other concurrent clinical parameters which feature in the condition.
Over a 14-year period from 1992 to 2006, 95 consecutive cases of CTEV were prospectively assessed and data recorded in order to investigate the relationships between the clinical parameters in CTEV and to compare these relationships with those that one would expect from our knowledge of the pathological anatomy and mechanics of the condition, relating these findings to the commonly used systems for classification.
Ninety-five cases of CTEV had failed conservative treatment and had undergone surgical release. The mean age at surgical release and assessment was 9 months. Cluster analysis demonstrated that there were, broadly, two groups of patients. The first group was those patients with a greater equinus deformity (greater than 31°). This group had a greater adductus deformity and the presence of other parameters indicating increased severity (multiplanar stiffness with the presence of cavus and medial skin crease). The second group was those patients with a smaller equinus deformity (less than 31°) who were more heterogenous with regards to the other parameters.
We analysed on a statistical basis the relevant aspects of the deformity in CTEV. We have demonstrated that there are certain parameters, namely, equinus and adductus, whose severity can reasonably predict the severity of other components of the deformity. With regards to hindfoot parameters, increased equinus is related to less sagittal plane reducibility and to stiff hindfoot varus (coronal plane stiffness). In terms of midfoot parameters, the degree of adductus is related to the presence of cavus deformity and the presence of a medial skin crease is associated with less reducibility of the adductus (axial plane stiffness). This is consistent with our current understanding of the pathological anatomy of CTEV and bears implications with regards to treatment and the design of proposed classification systems that are in use.
Congenital talipes equinovarus; Classification; Adductus; Cavus
Unstable paediatric diaphyseal both-bone forearm fractures requiring fixation have traditionally been treated with rigid internal fixation with plate and screws. Intramedullary stabilisation has grown in popularity over the last 25 years but may be associated with rotational deformity and subsequent loss of pronosupination. This systematic review aims to establish which treatment method provides better functional outcome.
A systematic review of the published literature was performed, searching Medline, Embase, Pubmed and the Cochrane Library for English-language studies comparing intramedullary nailing with plate and screws in patients less than 18 years old with both-bone diaphyseal forearm fractures.
Seven studies met the inclusion criteria. They were all retrospective comparative studies (level III or IV). One was age- and sex-matched. Three looked specifically at older children. No study reported a significant difference in functional outcome with either treatment.
The currently available literature shows no difference in functional outcome between intramedullary nailing and plate and screw fixation, even in older children with less remodelling potential. Intramedullary nailing may therefore be the treatment of choice for simple fracture patterns due to shorter operative time, better cosmesis and ease of removal. Plating may still have a role in more complex injuries.
Child; Fracture fixation; Radius fracture; Ulna fracture; Treatment outcome
Persistent tibial torsion in the older child can be treated with a derotation osteotomy. Distal tibial osteotomy has been recommended due to concerns of peroneal nerve palsy, vascular injury, and compartment syndrome with a proximal tibial osteotomy. However, an osteotomy in the proximal tibia may achieve union more rapidly and skin issues, as described for distal tibial osteotomies, are less likely. This study investigates the safety and efficacy of proximal tibial derotation osteotomies.
We retrospectively reviewed 43 tibiae in 25 consecutive children with persistent tibial torsion treated with a proximal tibial derotation osteotomy between 1991 and 2006. Patients with concomitant varus or valgus osteotomies were excluded. Diaphyseal fibular osteotomies were performed in five patients, while all patients had a prophylactic anterior compartment fasciotomy.
The mean age at surgery was 10.4 ± 4.0 years and the mean follow-up was 3.2 ± 3.5 years. Patients with internal tibial torsion had a mean preoperative thigh–foot angle (TFA) of −14° ± 6° and a mean postoperative TFA of 8° ± 4°. Patients with external tibial torsion had a mean preoperative TFA of 38° ± 9° and a mean postoperative TFA of 7° ± 5°. The overall mean correction was 26° ± 9°. Major postoperative complications occurred in 4 patients (9%), including one peroneal nerve palsy which resolved, one delayed union requiring revision surgery, and two patients with mild postoperative valgus deformities.
Proximal tibial derotation osteotomy with an anterior compartment fasciotomy is a reliable method for treating tibial torsion with an acceptable complication rate. Given the larger bony surface area and improved soft tissue envelope, proximal tibial derotation osteotomy can be considered as an alternative to a distal tibial derotation osteotomy.
Tibial derotation osteotomy; Internal tibial torsion; External tibial torsion; Complications
Isolated congenital clubfoot can be treated either operatively (posteromedial release) or conservatively (Ponseti method). This study retrospectively compared mid-term outcomes after surgical and Ponseti treatments to a normal sample and used multiple evaluation techniques, such as detailed gait analysis and foot kinematics.
Twenty-six children with clubfoot treated surgically and 22 children with clubfoot treated with the Ponseti technique were evaluated retrospectively and compared to 34 children with normal feet. Comprehensive evaluation included a full gait analysis with multi-segment and single-segment foot kinematics, pedobarograph, physical examination, validated outcome questionnaires, and radiographic measurements.
The Ponseti group had significantly better plantarflexion and dorsiflexion range of motion during gait and had greater push-off power. Residual varus was present in both treatment groups, but more so in the operative group. Gait analysis also showed that the operative group had residual in-toeing, which appeared well corrected in the Ponseti group. Pedobarograph results showed that the operative group had significantly increased varus and significantly decreased medial foot pressure. The physical examination demonstrated significantly greater stiffness in the operative group in dorsiflexion, plantarflexion, ankle inversion, and midfoot abduction and adduction. Surveys showed that the Ponseti group had significantly more normal pediatric outcome data collection instrument results, disease-specific indices, and Dimeglio scores. The radiographic results suggested greater equinus and cavus and increased foot internal rotation profile in the operative group compared with the Ponseti group.
Ponseti treatment provides superior outcome to posteromedial release surgery, but residual deformity still persists.
Clubfoot; Ponseti; Pediatrics; Foot; Kinematics; Gait analysis
Magnetic resonance imaging (MRI) has been successfully used in the determination of the adequacy of the surgical reduction of congenitally dislocated hips in children. We present the results of a prospective series of patients treated conservatively. MRI was performed in all hips after positioning was deemed adequate on radiographs after spica cast application. The goal of this study was to evaluate the usefulness of MRI in this indication.
After the study was approved by our local ethics committee, 31 patients for a total of 36 dislocated hips were included. After the traction period, hip testing was performed and a hip spica cast was applied under general anaesthesia. All children had MRI within 1 week of reduction, without the need for contention or general anaesthesia. Hip reduction was assessed on axial and coronal MRI images.
The concentric reduction of the hip was confirmed in 30 cases out of 36. In three cases, the dislocation was retrospectively suspected on radiographs and then confirmed. In the three remaining cases, hip dislocation was only diagnosed on MRI.
MRI screening of congenitally dislocated hips after reduction procedures is a safe and reliable procedure to assess the concentric reduction of the hip. Even in doubtful cases, MRI detected persistent hip dislocations and was conducive to iterative reduction and satisfactory outcome and result.
Congenital dislocation of the hip; MRI; Conservative treatment; Hip spica cast; Traction
Tibial tubercle fractures often occur in athletic adolescents close to skeletal maturity. These fractures can present with marked displacement of the apophysis, intra-articular extension, and associated soft tissue injuries, such as tibial meniscal ligament tears. Here, we present our surgical technique which focuses on recreating the meniscal–articular relationship (using suture anchors) in severely displaced fractures.
We retrospectively reviewed all tibial tuberosity fractures treated with this technique over the last 2.5 years. Fractures with a minimum of a 12-month follow-up post-fixation were identified. Clinical records and radiographs were reviewed. Data included patient age, gender, involved side, injury classification (modified Ogden), mechanism of injury, treatment, return to activity, and complications.
Six patients met the inclusion criteria. Mean age at time of surgery was 14.9 (range 13.2–16.8) years. All patients were male and the mean follow-up period was 14 (12–26) months. Range of motion was started at 4 weeks post-operatively in a hinged knee brace, and return to sports occurred at an average of 3.75 months postoperatively (range 3–5 months). No evidence of growth disturbance of the proximal tibia or recurvatum at final follow-up was evident.
We speculate that patients who sustain a tibial tubercle avulsion fracture types III or V will likely have intra-articular pathology, specifically capsular avulsion or coronary ligament disruption. By utilizing suture anchors, our technique emphasizes renewing the anatomic articular environment to ensure better long-term results and maintaining these active individuals in sports.
Tibial tuberosity fracture; Open reduction tibial tubercle; Pediatric avulsion injury; Intra-articular involvement
The purpose of this study was to determine the risk factors for loss of reduction in patients with an isolated distal radius fracture and intact ulna.
Outpatient records and initial, post-reduction, and follow-up radiographs of children with displaced distal radial metaphyseal fractures and intact ulnas that required closed reduction and casting at our institution were reviewed for demographic factors, body mass index (BMI), initial fracture displacement, residual displacement after reduction, and 3-point cast index. Loss of reduction was defined as angulation ≥15° in the coronal plane for all ages and/or angulation ≥20° in the sagittal plane for patients ≥11 years of age and ≥30° for children <11 years of age. Additionally, all patients who were remanipulated and/or pinned were considered to have lost reduction.
Thirty-five of the 76 patients in our series met the criteria for loss of reduction (46%). Multivariate logistic regression revealed that initial angulation in the coronal plane and post-reduction translation in the coronal plane were independent predictors for loss of reduction. Patients with >11° of initial angulation in the coronal plane were 6.3 times as likely to lose reduction (confidence interval [CI]: 1.43–28.3, P = 0.015) and those with any amount of residual translation in the coronal plane after closed reduction were 7.8 times as likely to lose reduction (CI: 2.5–24.0, P < 0.001).
Our study, the largest dedicated series of distal radial metaphyseal fractures with intact ulnas, indicates that loss of reduction is common, and that risk factors include initial angulation in the coronal plane and post-reduction translation in the coronal plane.
Isolated distal radius fracture; Loss of reduction; Risk factors; Intact ulna
The aim of the study was to assess the role of residual hip dysplasia as a risk factor for osteoarthritis (OA) in developmental dysplasia of the hip (DDH).
Fifty-one patients (60 hips) with late-detected DDH were studied. Reduction had been performed at a mean age of 19 months (range 4–65 months). On radiographs at age 8–10 years, at skeletal maturity, and at long-term follow-up, femoral head coverage was assessed using the migration percentage (MP) and centre-edge (CE) angle. OA was diagnosed if the minimum joint space width of the upper part of the joint was <2.0 mm.
The mean age at the last follow-up was 45 years (range 43–49 years) in patients who had not undergone total hip replacement (THR). Ten patients had developed OA and eight of them had undergone THR at a mean age of 40 years (range 32–47 years). There was a clear association between OA and residual hip dysplasia. At the last follow-up, 37 hips had normal CE angles (20° or higher) and OA had developed in only two of them (5%; 95% confidence interval [CI] 1–18%). Hip dysplasia without subluxation (CE angle 10–19°) was seen in 18 hips, of which 14 hips had good outcome and four had OA (22%; 95% CI 6–48%). Subluxation occurred in five hips, of which one had a good long-term outcome and four had OA (80%; 95% CI 28–99%). In patients without late reconstructive surgery, MP increased from the age of 10 years to skeletal maturity; thereafter, no significant change occurred. The CE angle did not change significantly between the age of 10 years and the last follow-up.
Hip dysplasia without subluxation has a relatively good long-term prognosis. Subluxation is a risk factor for osteoarthritis. Thus, children with MP above 33% and CE angle under 10° should be evaluated for reconstructive surgery in order to improve the long-term outcome.
Developmental hip dislocation; Residual hip dysplasia; Long-term follow-up; Osteoarthritis of the hip
Both congenital and acquired orthopaedic deformities are common in patients with spina bifida. Examples of congenital deformities, which are present at birth, include clubfoot and vertical talus. Acquired developmental deformities are related to the level of neurologic involvement and include calcaneus and cavovarus. Orthopaedic deformities may also result from postoperative tethered cord syndrome. The previously published Part I reviewed the overall orthopaedic care of a patient with spina bifida, with a focused review of hip, knee, and rotational deformities. This paper will cover foot and ankle deformities associated with spina bifida, including clubfoot, equinus, vertical talus, calcaneus and calcaneovalgus, ankle and hindfoot valgus, and cavovarus. In addition, this paper will address the issues surrounding skin breakdown in patients with spina bifida.
Spina bifida; Foot deformity; Ankle deformity
Missed Monteggia fracture dislocation in children is a serious condition. The treatment of this rare condition is controversial and reports on the long-term outcome are sparse. We present a series of patients treated with open reduction and ulnar osteotomy with a mean long-term follow-up of 8 years (range 3–17).
All 16 patients had Bado type 1 (anterior radial head) dislocation. The mean delay from injury to surgery was 17 months (range 1–83). Bilateral radiographs, Oxford Elbow Score, strength measurements, and range of motion were obtained in all patients.
There were no major complications to surgery. The radiographic results showed ten patients with reduction of the radial head and with no arthrosis, four patients with arthrosis or subluxation, and two patients with a dislocated radial head. We found a significant correlation between radiographic outcome and delay to ulnar osteotomy (P = 0.03). Typical clinical findings were a small but significant extension deficit and mean loss of supination of 10° (range 0–90, P < 0.01). Ligament reconstruction or transfixation of the radial head did not influence the radiographic or clinical outcome.
Case reports of similar patients treated conservatively demonstrate high morbidity, and, therefore, open reduction and ulnar osteotomy seemed justified. However, this study underlines the importance of minimizing the delay between injury and ulnar osteotomy. If surgery is performed within 40 months after injury, good to fair long-term radiographic results can be obtained. Open reduction and ulnar osteotomy were performed because patients treated conservatively demonstrate high morbidity.
Trauma; Pediatric; Dislocation; Osteotomy; Ulna
The aim of this study was to retrospectively evaluate the impact of neonatal sonographic hip screening using Graf’s method for the management and outcome of orthopaedic treatment of decentered hip joints with developmental dysplasia of the hip (DDH), using three decades (1978–2007) of clinical information compiled in a medical database.
Three representative cohorts of consecutive cases of decentered hip joints were selected according to different search criteria and inclusion and exclusion parameters: (1) cohort 1 (1978–1982; n = 80), without sonographic screening; (2) cohort 2.1 (1994–1996; n = 91), with nationwide established general sonographic screening according to the Graf-method; (3) cohort 2.2 (2003–2005; n = 91), with sonographic screening including referred cases for open reduction from non-screened populations. These three cohorts were compared for the following parameters: age at initial treatment, successful closed reduction, necessary overhead traction, necessary adductor-tenotomy, rate of open reduction, rate of avascular necrosis (AVN) and rate of secondary acetabuloplasty.
The age at initial treatment was reduced from 5.5 months in the first cohort to 2 months in the two subsequent two cohorts and the rate of successful closed reduction increased from 88.7 to 98.9 and 95.6%, respectively. There was a statistically significant improvement in six out of seven parameters with sonographic hip screening; only the rate of secondary acetabuloplasty did not improve significantly.
Compared to the era before the institution of a sonographic hip screening programme according to the Graf-method in Austria in 1992, ultrasound screening based-treatment of decentered hip joints has become safer, shorter and simpler: “safer” means lower rate of AVN, “shorter” means less treatment time due to earlier onset and “simpler” means that the devices are now less invasive and highly standardized.
Developmental dysplasia of the hip; Decentered hip joints; Sonographic hip screening; Outcome of treatment; Retrospective comparative cohort study
Pediatric tibial shaft fractures are common injuries encountered by the orthopaedic surgeon. Flexible intramedullary nailing has become popular for pediatric patients with tibial shaft fractures that require operative fixation. The purpose of our study was to evaluate the incidence of, and the risk factors for, compartment syndrome (CS) after flexible intramedullary nailing of these injuries.
A retrospective review of tibial shaft fractures treated consecutively with flexible intramedullary nailing at our institution from 2003 to 2010 was performed. The incidence of CS after flexible nailing was recorded. In addition, age, weight, mechanism of injury, polytrauma, presence of an open fracture, presenting neurovascular exam, fracture pattern, delay in treatment (>24 h from injury), prior closed reduction attempts, method of reduction (open vs. closed) in the operating room, total fluoroscopy time, and operative time were recorded. Comparisons were made between children who developed CS and those who did not.
Thirty-one children met inclusion criteria with a mean age of 11.2 years (range, 6.3–15.3 years); all were boys. Nearly, 20% of children developed CS after flexible nailing of their fractures. Those who developed CS after flexible nailing were heavier than the unaffected group (52.6 ± 14.5 kg vs. 39.4 ± 15.2 kg, P = 0.05); with a greater percentage of children 50 kg or greater (83.3% vs. 26.1%, P = 0.02) within the CS group. Children who developed CS were also more likely to present with neurologic deficits in the absence of compartmental swelling prior to surgery (66.7% vs. 9.1%, P = 0.009), and more likely to have comminuted/complex fracture patterns (83.3% vs. 29.1%, P = 0.02). There was no difference between patients who did and did not develop CS in regards to age (P = 0.42), high-energy injury mechanism (P = 0.30), polytrauma (P = 1.0), delay in treatment (P = 0.28), prior closed reduction attempts (P = 1.0), method of reduction (open vs. closed; P = 1.0) in the operating room, total fluoroscopy time (P = 0.96), and total operative time (P = 0.45). In addition, there was no difference (P = 0.65) in the rates of CS between children with open and closed fractures.
There is a high risk of CS after flexible intramedullary nailing of pediatric tibial shaft fractures regardless of whether an injury is open or closed. Variables that would seemingly be associated with the development of CS (high-energy injury mechanisms, polytrauma, treatment delay, prior closed reduction attempts, and closed reduction in the operating room) were not statistically associated with CS in our study. Clinicians should be wary for the development of CS whenever utilizing flexible nails for tibial shaft fractures, especially when the following co-morbidities are present: the child weighs greater than 50 kg, has complex/comminuted fracture patterns, or has a neurologic deficit in the absence of compartmental swelling prior to operative intervention.
Compartment syndrome; Tibia fracture; Flexible nailing; Pediatric
This case report presents a new and unique surgical greater trochanter split procedure for reconstructing a hip joint after an infantile hip sepsis with consequent aplasia of the femoral head.
One patient underwent the new trochanter split osteotomy for postinfectious aplasia of the femoral head at the age of 4 years. A follow-up of 17 years is presented.
The remaining proximal femur is sagittally split and the medial part is shifted into the acetabulum, preserving the lateral part of the greater trochanter. The osteotomy is fixed by an osseous wedge and K-wires. In contrast to the techniques known so far, it does not harm the vastogluteal muscle sling, thus, significantly reducing abductor lurch. Furthermore, through placing juvenile growth cartilage from the greater trochanter area into the acetabulum, there is, by far, more potential for the regeneration of a femoral head than by the procedures known so far.
The presented surgical technique is able to improve the biomechanics of a hip joint with postinfectious aplasia of the femoral head. The growth of a new femoral head and the development of a well-shaped acetabulum is enabled. A clinical outcome with a stable joint and very good clinical function can be achieved.
Septic arthritis; Infantile hip; Femoral head aplasia; Hip dislocation; Greater trochanter osteoplasty; Vastogluteal muscle sling
Evaluation of the advantages and limitations of the Taylor Spatial Frame (TSF) with regard to the healing index (HI), distraction–consolidation time (DCT), accuracy of correction complications, and cost of the device.
Comparison of results with the traditional Ilizarov apparatus and a unilateral Orthofix fixator in a consecutive patient series with 135 bony deformity corrections.
The HI did not differ significantly between all three fixators and was 57 days/cm for all patients. The DCT was significantly shorter for the TSF (148 days) compared to the Ilizarov fixator (204 days) and the Orthofix device (213 days). The accuracy of deformity correction was higher for the TSF than the other devices. The mean values of the measured angles after correction did not differ, but the variance of the results was the lowest. Also, the total rate of complications was considerably lower for the TSF. The Orthofix device showed a high rate of angular deformity during treatment, whereas both ring fixators had a relatively higher number of pin-related problems.
The findings in our patient series suggest the use of the Orthofix apparatus for simple lengthening over short to median distances and the Ilizarov device for the correction of simple bony deformities and pure lengthening over long distances. The TSF allows multiplanar corrections and lengthenings without complex modifications of the device. But, due to the remarkably higher costs, it has not yet been established as our routine device.
Level of evidence
Level IV—case series. Therapeutic Study—Investigating the Results of Treatment.
Limb lengthening; Deformity correction; Taylor Spatial Frame; Ilizarov; Orthofix
Displaced fractures of the lateral condyle of the humerus are usually treated with open reduction and fixation with smooth Kirschner wires. These may be passed through the skin and left exposed or buried subcutaneously. Exposed wires may be removed in the outpatient clinic, whereas buried wires require a formal procedure under anaesthesia. This advantage may be offset if there is a higher rate of complications with exposed wires. The aim of this study was to compare the safety and efficacy of exposed and buried wires.
Methods and materials
Children with lateral condyle fractures of the humerus who had undergone surgery were identified from our departmental database. Case records and X-rays of 75 patients were reviewed.
Forty-two patients had buried wires and 33 had exposed wires. There were no serious complications in either group. In the exposed wires group, 1 patient had a superficial wound infection that was treated effectively with 1 week of oral antibiotics, while 2 patients had hypergranulation of pin tracts treated with topical silver nitrate. None of the patients showed loss of reduction, deep infection, or any other complications requiring additional procedures.
There was no statistically significant difference in the rate of complications between the buried and exposed groups. We conclude that open reduction and exposed wiring is a safe and effective option for lateral condyle fractures, and recommend a period of 4 weeks of K-wire fixation followed by 2 weeks of backslab immobilisation as adequate for union with minimal risk of infection.
Lateral condyle; Humerus; Fracture; K-wire; Infection
The purpose of this study is to describe the kinematic changes in children with cerebral palsy (CP) after treatments performed on the forearm, wrist or thumb, with specific attention to the changes around the trunk, shoulder and elbow kinematics.
With the use of a specific kinematic protocol, we first described the upper limb kinematics in a group of 27 hemiplegic patients during two simple daily tasks. Eight of these children were treated with botulinum toxin (Botox®, Allergan) injection or surgery and were, thereafter, evaluated with another kinematic analysis in order to compare the pre- and post-therapeutic condition. The target muscles were the pronator teres, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, flexor pollicis longus and the adductor pollicis.
Significant kinematic changes were found after treatment. Patients increased forearm supination (P < 0.05) and wrist extension (P < 0.05) during both tasks. Patients also decreased trunk flexion/extension range of motion (ROM) (P < 0.05), improved elbow ROM (P < 0.05) and improved internal shoulder rotation (P < 0.05).
Dynamic shoulder or elbow limitations in children with mild hemiplegia involvement could be related to a compensatory movement strategy and/or co-contractions. As these proximal kinematics anomalies are improved after treatments performed at the forearm, wrist and thumb, they should not be treated first but should be reconsidered after the treatment of more distal problems.
Cerebral palsy; Upper limb; Kinematic analysis; Hemiplegia
Synovial sarcoma (SS) is an aggressive soft-tissue tumor noted for late local recurrence and metastasis. This study investigates the long-term outcome of SS in patients of pediatric age and evaluates potential prognostic factors for SS.
We performed a retrospective review of 13 SS cases in patients younger than 20 years at the time of diagnosis who had a minimum follow-up of 10 years. The mean follow-up for living patients (n = 8) was 20.1 years (12.1–27.6) and for nonsurvivors (n = 5) 4.9 years (range: 2.6–9.3). Nine patients had unplanned excisions (69%), of which 6 (67%) were performed prior to their referral. Re-excisions were necessary in all 13 patients. The factors sex, tumor site, tumor size, tumor grade, histological subtype, fusion type, and type of treatment were evaluated for their prognostic value.
Only 2 patients (15%) met the criteria of adequate tumor treatment. Overall, the 5- and 10-year survival rates were 77 and 61%, respectively. The mean time until a local recurrence (n = 5) was 3.2 years (range: 0.7–10.2), while there was a mean time of 2.1 years until the occurrence of late metastases (n = 5; range: 0.8–4.8). A high tumor grade and having a tumor in the trunk were adverse factors in terms of overall, local recurrence-free, and metastasis-free survival. Patients with wide resections or amputations had fewer local recurrences than patients with marginal or intralesional resections.
Inadequate primary excision of SS results in incomplete excision in the majority of cases. The tumor site, size, and histological grade should be considered when determining a risk-adapted treatment for SS, and wide surgical excision is the surgical intervention of choice. While local recurrence and late metastases appear to occur after a shorter time period in pediatric patients than in adults, in view of the tendency for late recurrence and metastasis with SS, follow-up should be at least 10 years.
Synovial sarcoma; Soft-tissue tumors; Children; Multicenter study
A multidisciplinary workshop was convened at the National Institutes of Health (NIH) to discuss the management of the orthopedic and other complications of Proteus syndrome (PS), a progressive, disproportionate overgrowth disorder. While PS poses many complex challenges, the focus of the workshop was the management of the asymmetric and disorganized skeletal overgrowth that characterizes this multisystem disorder.
Workshop participants developed recommendations for clinical research and patient management and surveillance to maximize the benefits and reduce the risks of surgical and other interventions.
Recommendations for clinical care and management included assessments of skeletal overgrowth and its progression with modalities such as X-ray, magnetic resonance imaging (MRI), dual-energy X-ray absorptiometry, and computerized tomography (CT) imaging. The recommendations also cover the assessment of non-orthopedic complications of PS that significantly impact surgical risk, such as pulmonary embolism and lung bullae. Surgical considerations in PS include assessment of the contribution of contractures to deformities and prophylactic soft-tissue release, aggressive and early use of epiphysiodesis and epiphysiostasis, amputation, and spinal bracing.
Decisions on the timing of orthopedic procedures in children with PS are challenging because they entail balancing the risks of intervention in this high-risk and complex population against the increasing morbidity that patients experience with progressive bony overgrowth. If surgery is delayed too long, the condition may become inoperable. We hope that these recommendations will help clinicians gather appropriate data and assist their patients in making timely treatment decisions.
Proteus syndrome; Overgrowth; Scoliosis; Limb-length inequality
Despite advances in limb reconstruction, there are still a number of young patients who require trans-tibial amputation. Amputation osteoplasty is a technique first described by Ertl to enhance rehabilitation after trans-tibial amputation. The purpose of the study reported here was to evaluate the results of the original Ertl procedure in skeletally immature patients and to assess whether use of this procedure would result in a diminished incidence of bony overgrowth.
The cases of four consecutive patients (five amputations) treated between January 2005 and June 2008 were reviewed. Clinical evaluation consisted of the completion of the prosthesis evaluation questionnaire (PEQ) and physical examination. Radiographic analysis was performed to evaluate bone-bridge healing, bone overgrowth, and the development of genu varum as measured by the medial proximal tibial angle (MPTA).
The best mean PEQ score in the question section was 91.8 (range 74–100) for ‘well being’ and the worst mean score was 66.6 (range 50–78) for ‘residual limb health’. Examination of the residual limbs revealed no bursae, and all knees were stable with full range of movement. All bony bridges united at an average age of 1.7 (range 1–2) months. One case required stump revision for bony overgrowth, and one case developed asymptomatic mild genu varum.
The original Ertl osteomyoplasty may serve as one of the options for treatment of trans-tibial amputation in older children.
Our results suggest that the Ertl osteomyoplasty is a feasible option in this challenging patient population.
Ertl osteomyoplasty; Child amputation; Stump overgrowth