Perthes disease may result in deformity of the proximal femoral epiphysis and incongruity of the hip, and shelf acetabuloplasty has been frequently used for treatment. The aim of this study was to review the published articles about the outcome of shelf acetabuloplasty as a containment or reconstruction–salvage procedure in Perthes disease.
We utilized the PubMed online database for peer review articles using the following search terms: shelf arthroplasty, acetabuloplasty, and Perthes. To be included in this meta-analysis, we isolated studies on children with Perthes disease who received shelf acetabuloplasty as a treatment, conducted in any geographic location with the Stulberg classification outcome. Twenty articles were identified for a qualitative systematic review. The fixed effect and random effect meta-analysis were performed as appropriate for the summary pool estimate following the heterogeneity test. The meta-analysis was performed on 11 articles in three categories: all articles, articles for shelf arthroplasty in the early stages of Perthes disease, and in the late stages.
Overall, shelf acetabuloplasty provided 84 % good outcome of Stulberg classes I, II, and III. Shelf acetabuloplasty performed in early stages for containment provided good outcome in 85 %, while only 69 % good outcome was achieved when shelf acetabuloplasty was performed in late stages for reconstruction–salvage.
Shelf acetabuloplasty provides a good or fair Stulberg outcome when performed in early Perthes stages (Waldenström stages I and II) as a containment surgery, but less favorable outcomes were observed when shelf surgery was used for reconstructive–salvage purposes in late Perthes disease stages (Waldenström stages III and IV). Caution is advised in performing the shelf procedure in children over 10–11 years of age.
Perthes disease; Shelf acetabuloplasty; Containment; Reconstruction–salvage; Meta-analysis
Severe lower extremity trauma presents challenges in decision-making in terms of reconstruction or amputation. While injury severity scores have been developed to aid decision-making in adults, evaluation of their use in children is limited.
Children presenting with severe lower limb trauma from 2000 to 2010 in a major trauma centre were identified from a trauma registry. Records were reviewed for details of the injury, surgical intervention, amputation and scores for the Mangled Extremity Severity Score, Limb Salvage Index, Predictive Salvage Index, Nerve injury, Ischaemia, Soft tissue injury, Skeletal injury, Shock, Age System and the Hanover Fracture Scale 1998.
Twenty children (average age 8.7 years) were eligible for inclusion. There were three primary amputations and no secondary amputations. All of the scoring systems had poor specificity and would have recommended amputation in several limbs that were successfully reconstructed.
Currently available injury severity scores behave differently in children and adults. In their current format, these scores should not be used as an absolute indication for early amputation in children.
Limb trauma; Trauma score; Prognosis; Amputation; Reconstruction
The aim of this cross-sectional cohort study is to describe the incidence of joint laxity and the correlation between joint laxity and radiological migration of the hip in children with Down syndrome.
Sixty-five children (2–19 years) with Down’s syndrome were examined for joint laxity. For each subject, laxity scores for joints were carried out with the Bulbena method. Plane pelvic radiographs were used to determine the migration of the hip, according to Reimer’s migration index.
In this study, 26 out of 65 children with Down’s syndrome (40 %) were diagnosed with general joint laxity. On the radiographs of the hips we found a mean Reimer’s Migration Index of 5.2 % for all the subjects. Children with general joint laxity showed a lower Reimer’s Migration Index (2.1 %). No significant correlation was found between general joint laxity and migration of the hip.
This study showed no relationship between joint laxity and migration of the hip in children with Down’s syndrome. This implicates that we were not able to prove that joint laxity is the major factor in developing hip migration in children with Down’s syndrome.
Down’s syndrome; Children; Joint laxity; Hip dysplasia; Migration of the hip
To investigate both volume and length of the three muscle compartments of the normal and the affected leg in unilateral congenital clubfoot.
Volumetric magnetic resonance imaging (VMRI) of the anterior, lateral and postero-medial muscular compartments of both the normal and the clubfoot leg was obtained in three groups of seven patients each, whose mean age was, respectively, 4.8 months, 11.1 months and 4.7 years. At diagnosis, all the unilateral congenital clubfeet had a Pirani score ranging from 4.5 to 5.5 points, and all of them had been treated according to a strict Ponseti protocol. All the feet had percutaneous lengthening of the Achilles tendon.
A mean difference in both volume and length was found between the three muscular compartments of the leg, with the muscles of the clubfoot side being thinner and shorter than those of the normal side. The distal tendon of the tibialis anterior, peroneus longus and triceps surae (Achilles tendon) were longer than normal on the clubfoot side.
Our study shows that the three muscle compartments of the clubfoot leg are thinner and shorter than normal in the patients of the three groups. The difference in the musculature volume of the postero-medial compartment between the normal and the affected side increased nine-fold from age group 2 to 3, while the difference in length increased by 20 %, thus, showing that the muscles of the postero-medial compartment tend to grow in both thickness and length much less than the muscles of the other leg compartments.
Congenital clubfoot; Muscle atrophy; Volumetric MRI muscle study; Muscle growth; Pathogenesis of congenital clubfoot
Pediatric supracondylar humerus fractures commonly require surgical intervention and hospital admission, which is costly and consumes significant health care resources. There are few data regarding temporal characteristics (month, day and hour of injury) of this particular pediatric fracture. We wished to investigate the month, day of the week, and time of occurrence of these fractures to guide appropriate use of health care resources and prevention strategies.
This study was a retrospective review of clinical records and radiographs of 353 children with operative supracondylar humerus fractures in a temperate climate region over 6 years. Date and time of injury and demographic data (gender, age, laterality) were extracted. Variation in month, weekday, and time of injury was analyzed using circular analysis, cosinor analysis, probability distributions and topographical distribution.
There was a statistically significant increase in the number of fractures during the summer with a peak in early July. When analyzing by month and day of the week, a peak was seen Thursday-Saturday during May–July and middle of the week September–October. Weekdays demonstrated a higher proportion of fractures occurring in the morning and at school. The injuries occurred in the am in 37 and the pm in 241; detailed data were known in 227 with 37 between 0000 and 1159, 51 between 1200 and 1559, and 139 between 1600 and 2359 h. The peak time of injury was 1800 h.
The increase in supracondylar humerus fractures in the spring through autumn in temperate regions indicates that education campaigns reinforcing fall prevention and landing surfaces should be done in the early spring. The hourly data support the need for dedicated early morning operating rooms to care for these fractures.
Level of evidence
Prevalence study, retrospective cohort, Level II .
Supracondylar humerus fracture; Surgery; Month; Weekday; Time of injury
A double osteotomy for correcting tibial deformity in combination with medial plateau elevation is recommended for the management of neglected Blount disease cases. We report our clinical experience with the application of this surgical technique and describe the long-term follow-up of the patients who were operated on.
During a 10-year period, eight children (8 boys) with mean age of 12 years (range 9–14 years) underwent surgery (9 operations) due to neglected infantile tibia vara. All patients suffered from stage V or VI Blount disease according to the Langenskiold and Riska classification. Two simultaneous combined osteotomies were performed for medial plateau elevation and for correction of the tibial deformity. The correction was immediate using K-wires for stabilization and a long-leg cast for immobilization. The mean duration of follow-up was 10 years (range 5–15 years), and the evaluations were based on clinical and radiological criteria.
At the latest follow-up, there was no observable knee flexion or extension restriction and no signs of instability or lateral thrust. All patients had returned to a higher activity level. Leg-lengthening surgery was performed in one child, but the length discrepancy was already present before the double osteotomy was performed. No other complications were noticed. All the angles measured on X-rays had been corrected, and this correction was retained until the latest follow-up.
This method results in very good outcomes in patients who suffer from Blount disease of stage V or greater. With this technique, the tibial deformity is corrected, the articular surface is restored, and future recurrence is prevented.
Neglected Blount disease; Tibia vara; Tibial plateau elevation; Pediatric knee; Double osteotomy
Assessment of lower extremity (LE) torsional profile using computed tomography (CT) imaging is a well-recognized imaging method that supplements the clinical examination. Magnetic resonance imaging (MRI) is another advanced imaging modality that can be used as an alternative, since there are many growing concerns of radiation exposure with traditional CT studies, particularly in the skeletally immature population.
Sixty-two patients between the ages of 7 and 19 years were included. Thirty-four had CT and 28 had MRI for assessment of LE torsional profile. All patients had clinical evidence of torsional malalignment. CT and MR images were randomized and de-identified. Two observers measured femoral anteversion and tibial torsion based on previously published methodologies. This exercise was repeated 2 weeks later and the data were tabulated and statistical analysis was performed. Radiation exposure for the patients studied by CT was estimated.
The mean age of the patients was 14.4 years (range 9.5–18.9 years) and 13.8 years (range 7.3–18.9 years) for the CT and MRI groups, respectively. Inter-observer reliability for both CT and MRI studies were excellent. The intra-class correlation coefficient (ICC) for femoral anteversion and tibial torsion studied by CT and MRI for both observers at both times were excellent. The radiation exposure for CT examination averaged 0.3–0.5 mSv, compared to none with the MRI method.
MRI provides a reproducible method for assessing the torsional profile in children and adolescents using similar anatomic landmarks for measurements as those used on CT torsional profile. In circumstances where MRI methods are readily available (and affordable), the CT torsional profile can be replaced with MRI methods, in the current era of growing concerns of radiation hazards and increasing awareness about radiation safety.
Level of evidence
Diagnostic Level III.
Computed tomography; Magnetic resonance imaging; CT; MRI; Torsional profile; Torsional malalignment
We encountered problems with the Curtis and Fisher technique of quadricepsplasty for congenital quadriceps contracture, including wound dehiscence, insufficient lengthening of the quadriceps and instability of the knee. We modified the operative technique to address these three problems. We undertook this study to evaluate the results of the modified technique of quadricepsplasty to determine if we succeeded in overcoming these limitations of the original technique.
Twenty children (33 knees) underwent the modified Curtis and Fisher quadricepsplasty through a lateral incision; a long tongue of the rectus femoris was raised and the vasti mobilised without dividing the lateral retinaculae till the collateral ligaments. The children were followed up for a mean period of 63 months and evaluated. The healing of the wound, active and passive range of motion (ROM) of the knee, the stability of the knee, quadriceps power and knee function were assessed.
Primary wound healing occurred in 32 of 33 knees. Adequate lengthening of the quadriceps sufficient to facilitate knee flexion to 90° was possible. Considerable improvement in the ROM was noted. In non-syndromic congenital dislocation of the knee (CDK), the quadriceps power was Grade 5, but minor degrees of extensor lag was noted. In a proportion of patients, minor degrees of joint instability was present. The majority of children were community walkers. The overall results were better in non-syndromic CDK than in children with arthrogryposis, but differences of some variables were not significant.
The modifications to the original Curtis and Fisher technique overcame the specific problems they were expected to avoid.
Congenital quadriceps contracture; Congenital dislocation of the knee; Quadricepsplasty; Knee instability
The recognition of the importance of femoro-acetabular impingement (FAI) as a potential cause of hip pain has been stimulated by major efforts to salvage hip joints by reconstruction to prevent or delay the need for replacement. A previous review addressed the nature of FAI, the various types, and how to make the diagnosis. When FAI occurs, the structure between the femur and acetabular rim, the labrum, is initially impinged upon and subsequently injured.
Injury to the labrum should be recognized when treating the osseous causes of FAI. Preserving or recovering labral function, enhancing hip stability and protecting the articular surface, is critical to restoring the hip to normal or near-normal mechanical and physiologic function. The present review collected the varied essential information about the labrum in a succinct manner, independent of treatment algorithms.
Advanced knowledge of the labrum is presented, including the anatomy, circulation, histology, embryology, and neurology, as well as how the labrum tears, the types of tears, and how to make the diagnosis. The advantages and limitations of diagnostic magnetic resonance techniques are discussed, including magnetic resonance imaging (MRI), indirect magnetic resonance arthrography (i-MRA), and direct magnetic resonance arthrography (d-MRA). The review recognizes the complexity of the labrum and provides a greater understanding of how the labrum is capable of stabilizing the joint and protecting the articular surface of the hip. This information will act as a guide in developing treatment plans when treating FAI.
Labrum; Magnetic resonance imaging; MRI; Magnetic resonance arthrography; MRA; Consolidation
A type 2 recombinant human bone morphogenetic protein (rhBMP2) and Masquelet’s procedure were used in three children presenting with congenital pseudarthrosis of the tibia (CPT). Recent studies on CPT suggested the presence in situ of pathologic tissues promoting pseudarthrosis. The authors hypothesized that large segmental resection of pseudarthrosis could improve prognosis of the CPT. Masquelet’s procedure and rhBMP2 have been advocated for the treatment of long bone defect.
The authors report three cases of CPT in children treated with Masquelet’s procedure and application of rhBMP2. They analyzed all published cases of CPT similarly treated.
In the present study, Masquelet’s procedure did not improve the results in the treatment of CPT, but segmental bone reconstruction was possible. Bone healing was obtained in three out of the five applications of rhBMP2. In one case, the patient’s parents asked for leg amputation. Analysis of the 33 published cases with the application of BMP in CPT points to a 62 % healing rate in this pathology.
The authors confirmed that segmental bone reconstruction is possible in CPT using Masquelet’s procedure. In the literature, the success rate of the application of rhBMP in CPT appears to be lower than the healing rate usually reported without BMP. Nevertheless, the strict selection of patients, limited number of cases, and their heterogeneity make interpreting the results difficult. However, the theoretical risk which the children are exposed to during the use of BMP makes rigorous selection of the indications necessary. Finally, the interest of rhBMP2 application in Masquelet’s procedure remained to be proven.
Bone morphogenetic proteins; Induce membrane; Congenital pseudarthrosis; Neurofibromatosis; Child
Kabuki syndrome is characterized by distinctive facial features, skeletal anomalies, persisting fingertip pads with dermatoglyphic abnormalities, postnatal growth deficiency and mental retardation. This report reviews our results in the operative treatment of hip dislocations in patients with Kabuki syndrome.
Between 2001 and 2009, seven dislocated hips (three unilateral and two bilateral hips) in five patients (all girls) were operatively treated at our institution. The operative treatment consists of open reduction, femoral derotation varus osteotomy, pelvic osteotomy (Salter in one and incomplete periacetabular osteotomy in six hips) and capsular plication. The age of the patients at the time of surgery ranged from 2.4 to 5.7 years, with an average of 3.6 years.
The follow-up postoperative period ranged from 3.2 to 6.3 years, with an average of 5.0 years. At the final follow-up, all patients reported no click and no pain, and showed well-contained hips by radiographs. All seven hips were graded as Severin class I-II. One patient presented as having habitual dislocation of the hip 4.4 years after surgery. Computed tomographic (CT) scans revealed posterior acetabular wall deficiency, which was not corrected by the anterolaterally directed Salter osteotomy. The incomplete periacetabular osteotomy provided sufficient posterolateral coverage of the acetabulum.
Operative treatment combining open reduction, femoral derotation varus and incomplete periacetabular osteotomies, and capsular plication provided successful results in patients with Kabuki syndrome who had the characteristics of hip instability such as ligamentous laxity, muscular hypotonia and posterior acetabular wall deficiency.
Kabuki syndrome; Operative treatment; Hip dislocation; Open reduction; Periacetabular osteotomy
This study hypothesizes that the use of continuous passive motion (CPM) following open femoroacetabular impingement (FAI) surgery in the adolescent population improves clinical outcomes in terms of the modified Harris hip score (mHHS).
Twenty-nine symptomatic adolescent FAI patients were postoperatively divided into one of three groups; no CPM, two days of inpatient CPM, and two weeks of CPM. mHHS was used preoperatively and postoperatively at six weeks, three months, six months, and nine months in all cases. Kruskal–Wallis (KW) analysis was performed to determine statistical differences in mHHS. mHHS was then re-evaluated using the Mann–Whitney test.
There were no statistically significant differences in hip scores between the three groups preoperatively (p = 0.158). There were statistically significant differences (p < 0.001) in mHHS between the three groups at all postoperative time periods. The group that received two weeks of CPM had the best outcome scores.
The results of this study suggest that postoperative CPM use following open hip preservation surgery for symptomatic FAI in adolescents improves clinical outcomes. These benefits seem to be related to the duration of CPM.
Level of evidence
Retrospective comparative study, Level III. Patients treated one way compared with patients treated another way at the same institution.
Continuous passive motion (CPM); Adolescents; Hips; Femoroacetabular impingement
The aim of our study is to report our complication rate and analyze the associated risk factors when removing cannulated stainless steel screws for SCFE fixation.
This was a multicenter retrospective study of patients who underwent removal of cannulated stainless steel screws after a mean time of 2.03 years of implantation. Thirty-two patients were included (38 hips) with a mean of 13.7 years of age during screw removal surgery. The mean post-removal follow up time was 1.6 years. In all cases the removal of screws was done systematically. Demographic data, possible risk factors related to removal failure, as well as post-removal complications such as post-removal fractures, infections and scar issues were recorded.
A removal failure rate of 15.79 % (6/38) was found. The removal surgical time was longer than the initial fixation time but without statistical significance (70.78 vs 61.84 m, p = 0.196). However, the duration of screw implantation (r2: 7.09; IC: 1.12–13.06) and screw head bony coverage (r2: 21.32; IC: 5.58–37.06) were both related to this prolonged time. Multivariant analysis revealed that a fully threaded cannulated screw had the lowest removal failure risk (OR: 0.3; IC: 0.14–0.61). There were no postremoval complications recorded.
We recommend to use full threaded cannulated stainless steel screws and to perform the procedure as soon as the physis are closed to decrease the surgical time. It is a safe procedure based on a low rate of complications such as post-removal fractures, infection and scar issues.
Slipped capital femoral epiphysis; Stainless steel screws; Removal failure rate; Titanium screws; Full threaded screws
The traditional treatment for congenital vertical talus, which involves serial casting and extensive soft-tissue releases, has been associated with severe stiffness and other complications in adolescents and adults. Our hypothesis is that favorable results will be obtained using the Dobbs method of serial manipulation, casting, and limited surgery for vertical talus correction, even in older children and syndromic cases. Therefore, the present study aimed at evaluating the Dobbs method in such cases.
Materials and methods
We treated 15 feet of 10 patients (aged from 1 month to 9 years) using manipulation and serial casting or the reverse Ponseti method followed by percutaneous Achilles tenotomy and limited open reduction of the talonavicular joint. All patients were evaluated both clinically and radiologically in a mean follow-up period of 2 years.
After 2 years, all patients had plantigrade and flexible feet with good radiographic correction. The mean talocalcaneal angle before (70.5° ± 10.5) and after (31° ± 5.2) treatment and the talar axis metatarsal base angle before (60° ± 11.4) and after (15° ± 6.7) treatment were significantly improved (P < 0.001).
Recent research has shown that manipulation and serial casting followed by limited surgery (Dobbs method) was successful in treating idiopathic congenital vertical talus. Our results also showed that this method resulted in an excellent outcome in both idiopathic and syndromic congenital vertical talus, even in older children.
Congenital vertical talus; Casting; Conservative treatment
Temporary hemiepiphysiodesis has gained increasing popularity after the introduction of the eight-Plate Guided Growth System. Since its introduction, the eight-Plate has largely supplanted the traditional Blount staple. The eight-Plate offers better purchase in the bone and a more precise insertion technique. However, the Blount staple is less expensive than the various guided growth plates. Further, some surgeons feel that the Blount staple may work faster, making it more appropriate for children who are approaching skeletal maturity. Unfortunately, the original instrumentation and technique for inserting the Blount staple is over 50 years old and has not been updated.
The purpose of this study was to develop new instrumentation to make Blount staple insertion as accurate and minimally invasive as eight-Plate insertion. We developed wire/drill guides to accommodate all three sizes of the Blount staple. Two wires are inserted through the wire guide under image intensifier control. After confirming the accurate position of the guidewires, a 3.2-mm cannulated step drill is used to drill over the wires to a depth of 5 mm. This creates two pilot holes for the two tines of the Blount staple. The final insertion is guided under an anteroposterior image intensifier view. We also developed a small staple holder that permits insertion through a small incision.
We developed a working prototype of the new instrumentation and used it in three clinical cases.
With the new staple inserter and instrumentation, Blount staples can now be inserted through a smaller incision with similar accuracy as eight-Plate insertion.
Temporary hemiepiphysiodesis; Blount staple; Eight-Plate; Growth plate; Surgical instrumentation; Angular deformity
The treatment of unstable slipped capital femoral epiphysis (SCFE) remains controversial. Surgical dislocation and open reduction has the potential to significantly reduce the rate of avascular necrosis (AVN) by allowing direct preservation of the femoral head blood supply. The purpose of this study was to determine if open reduction of the unstable SCFE by means of surgical hip dislocation reduced the risk of AVN compared with closed reduction and percutaneous pinning.
We reviewed the medical records and radiographs of patients treated at our institution between the years 2000 and 2008. Sex, age, side of slip, precipitating event, pre- and post-operative anterior physeal separation (APS) and slip angle, slip severity, time between inciting event and surgical treatment, number of screws used, development of AVN, and need for subsequent surgery were evaluated. Statistical analysis was performed to compare risk factors and occurrence of AVN.
From 2004 to 2008, we treated 12 patients with unstable SCFEs: six had closed reduction and percutaneous pinning and six underwent open reduction by means of surgical hip dislocation. There were no statistically significant differences between the two groups regarding sex, age, slip angle, APS, time to surgery, and AVN rate. At follow-up, 4 (66.7 %) patients had AVN in the group which had open reduction, while 2 (33.3 %) patients had AVN in the group which underwent closed reduction. (p = 0.57).
Open reduction of the unstable SCFE by means of surgical dislocation of the hip does not decrease the rate of AVN when compared to closed reduction.
Slipped capital femoral epiphysis; Closed reduction; Open reduction; Surgical dislocation of the hip; Percutaneous pinning; Avascular necrosis
To report the functional and cosmetic results of cases with Sprengel’s shoulder who underwent the Woodward procedure.
Materials and methods
Twelve children were operated at a mean age of 5.58 years and reviewed at an average follow up of 31.83 months.
The mean preoperative Cavendish grade for cosmetic evaluation was 3.17, which decreased to 1.25 postoperatively (statistically significant, p < 0.0005, Wilcoxon signed-rank test). Similarly, the range of abduction at the shoulder increased from a mean of 115.83° preoperatively to 153.33° at final review (p < 0.0005). Age had a negative correlation with both functional improvement (r = −0.55, Spearman correlation coefficient) and cosmetic improvement (r = −0.11), although the latter suggested a very weak association, if any. Cavendish grade improvement and increase in abduction had a strong positive association (r = 0.713). However, there was no correlation between the increase in abduction and lowering of the scapula achieved (r = 0.131). The presence of an omovertebral bar did not affect the final functional outcome, nor did the presence of associated congenital anomalies.
The Woodward procedure is a reliable method for obtaining uniformly predictable results in Sprengel’s shoulder. The surgery should be performed at a younger age in order to optimise the functional outcome.
Sprengel’s shoulder; Woodward procedure; Scapula; Congenital
The study was undertaken to: (1) describe the characteristic radiological features and problems of management of the loss of one condyle of the femur or tibia following septic arthritis of the knee in infancy and (2) test a hypothesis of the cause of the loss of a single condyle.
Radiographs of eight children with the loss of one condyle of the femur or the tibia following septic arthritis in infancy were reviewed. The course and outcome in two of these children who underwent reconstructive operations were studied. The knees of 35 stillborn foetuses were dissected to determine if the presence of synovial septae could account for the isolated loss of one condyle following infection.
All eight cases showed characteristic features of loss of half the epiphysis, the underlying physis and part of the adjacent metaphysis; the other condyle was totally spared. The two children who underwent elaborate reconstructive procedures had poor outcomes at skeletal maturity, despite a series of additional operations. The foetal cadaveric study showed that complete infrapatellar synovial septae are present in some foetuses approaching 40 weeks of gestation.
The pattern of loss of a femoral or tibial condyle following septic arthritis is consistent with total preservation of the other condyle. The outcome of surgical reconstruction of the missing condyle is poor. The presence of a complete synovial septum could result in the localisation of infection to one half of the joint, with the destruction of one condyle.
Septic arthritis; Knee; Condyle loss; Missing condyle; Synovial plica; Infrapatellar plica
The pathogenesis of unicameral bone cysts (UBCs) remains largely unknown. Osteoclasts have been implicated, but the role of osteoblastic cells has, to date, not been explored. This study investigated the pathophysiology of UBCs by examining the interactions between the cyst fluid and human bone marrow stromal cells (hBMSCs) and the effect of the fluid on osteogenesis.
Fluid was aspirated from two UBCs and analysed for protein, electrolyte and cytokine levels. Graded concentrations of the fluid were used as culture media for hBMSCs to determine the effects of the fluid on hBMSC proliferation and osteogenic differentiation. The fibrocellular lining was analysed histologically and by electron microscopy.
Alkaline phosphatase (ALP) staining of hBMSCs that were cultured in cyst fluid demonstrated increased cell proliferation and osteogenic differentiation compared to basal media controls. Biochemical analysis of these hBMSCs compared to basal controls confirmed a marked increase in DNA content (as a marker of proliferation) and ALP activity (as a marker of osteogenic differentiation) which was highly significant (p < 0.001). Osteoclasts were demonstrated in abundance in the cyst lining. The cyst fluid cytokine profile revealed levels of the pro-osteoclast cytokines IL-6, MIP-1α and MCP-1 that were 19×, 31× and 35× greater than those in reference serum.
Cyst fluid promoted osteoblastic growth and differentiation. Despite appearing paradoxical that the cyst fluid promoted osteogenesis, osteoblastic cells are required for osteoclastogenesis through RANKL signalling. Three key cytokines in this pathway (IL-6, MIP-1α, MCP-1) were highly elevated in cyst fluid. These findings may hold the key to the pathogenesis of UBCs, with implications for treatment methods.
Unicameral bone cyst; Osteoblast cell; Osteoclast; Cytokine; RANK ligand
Patients with neuromuscular diseases such as cerebral palsy (CP) and meningomyelocele (MMC) are prone to develop fixed knee flexion contracture. Distal femoral extension osteotomy allows acute correction of the deformity, but it is an extensive surgical procedure, and the complication rate is rather high. Immobilization can prolong the rehabilitation period, and may even result in deteriorated walking ability. The aim of this retrospective study was to evaluate the results of using anterior hemiepiphysiodesis of the distal femur to treat fixed flexion contracture of the knee.
Materials and methods
We studied 21 patients in our department from 2003 to 2009. Mean age was 10 years (5–15). Twelve suffered from MMC, five from CP, two from arthrogryposis, one had an enzyme defect, and one had Down’s syndrome. Thirteen patients had a bilateral and eight a unilateral procedure. None of the patients underwent any other procedures. Two staples or 8-plates were inserted using two parapatellar incisions. Nine were operated on with staples and 12 with 8-plates. The plates or staples were removed when the desired effect of full knee extension was achieved or the patient reached skeletal maturity.
Mean fixed flexion contracture was 20° (10°–40°). Staples or 8-plates were removed after a mean of 24 (6–42) months. Mean fixed flexion contracture at removal was 10° (0°–30°). Two complications were seen: one infection and one supracondylar fracture.
Anterior distal femoral hemiepiphysiodesis using 8-plates or staples seems to be effective for correcting fixed knee flexion deformity in skeletally immature individuals. The complication rate is low (10 %). Our results are comparable to those of Kramer, Klatt, and Stevens. This procedure should be the primary treatment for fixed knee flexion contractures in neuromuscular patients with sufficient remaining growth.
Anterior femur; Neuromuscular; Fixed knee contracture
The active or aggressive character in certain localisations of aneurysmal bone cysts in children requires either curettage with a considerable recurrence rate or a radical segmental excision, raising complex reconstructive challenges. Cyst maturation with subsequent ossification may be observed either spontaneously or after incisional biopsy.
Five new cases of active aneurysmal bone cysts (ABCs) with healing of the cyst after biopsy alone are reported. All patients had no treatment of the cyst after the biopsy.
In two cases, the lesion initially increases in size immediately after the biopsy, and it is only secondarily that the lesion decreases in size. Four out of five cases of the spontaneous healing occurred in pelvic bone. The cysts healed after, respectively, 36, 24, 12, 32 and 12 months.
The emergence of these new cases of spontaneous healing encourages promoting clinical and radiological supervision after biopsy in selected cases. Unfortunately, it is impossible to predict a possible aggressive behaviour in ABCs. Then, if the lesion is quickly aggressive with clinically and radiologically increasing size after biopsy, it would be illogical and dangerous to let this ABC evolve. It would be necessary to treat it without delay. On the other hand, if the lesion moderately increased after the biopsy, it is possible to wait and observe the patient during a period of 5 months for a possible healing, if the ABC localisation is not dangerous. Of course, if the lesion does not increase in size after biopsy, there is no delay to treat it.
Aneurysmal bone cyst; Spontaneous healing; Benign bone tumour; Adolescent
Adolescent idiopathic scoliosis (AIS) is the most prevalent spine deformity within the pediatric population. Orthosis is the mainstay of conservative treatment for mild to moderate AIS. The Rigo System Chêneau (RSC) brace is a custom-made thoracolumbar sacral orthosis (TLSO) based on a three-dimensional correction concept. The purpose of this study was to identify factors that could predict the therapeutic success/failure of the RSC brace.
Materials and methods
A retrospective cohort study was performed on all consecutive patients according to the Scoliosis Research Society (SRS) criteria for the success of conservative treatment. Participants had a 2-year follow-up beyond the termination of brace treatment. All patients were treated with the RSC orthotic device.
Ninety-three patients met the inclusion criteria. At treatment onset, their average age was 12.9 years, average Cobb angle 31.97°, Risser score 1.07, and the mean angle of thoracic rotation (ATR) was 10.2°. The mean brace treatment period was 36 months. Treatment was successful in 83.8 % of these patients (n = 79). The average final Cobb angle was 28.97°, Risser score 4.88, and ATR 8.09°. The pre-treatment factors associated with the success of applying the RSC brace were a high Risser score [odds ratio (OR) = 2.97, 95 % confidence interval [CI] 1.18–7.44; p = 0.02), a low Cobb angle (OR = 0.92, 95 % CI 0.85–0.99; p = 0.02), and low ATR (OR = 0.86, 95 % CI 0.75–0.99; p = 0.04).
The treatment of mild to moderate AIS with the RSC brace provides excellent clinical results. Its added benefit is enabling a three-dimensional correction of a three-dimensional deformity. Pre-treatment high Risser score, low Cobb angles, and low ATRs are associated with treatment success.
Level of evidence
Retrospective analysis, Level III.
Scoliosis; Treatment; Rigo System Chêneau brace
Magnetic resonance imaging (MRI) is often used in the evaluation of lower back pain in adolescents. The purpose of our study is to report on the frequency of MRI missing spondylolysis in adolescents with back pain in a pediatric orthopaedic practice.
A retrospective review of all patients with a diagnosis of spondylolysis who presented from January 2000 to March 2010 was performed. All patients were evaluated at a single institution by the senior author. Inclusion criteria were patients with spondylolysis confirmed on computed tomography (CT) or plain film that also received an MRI.
Eleven patients with spondylolysis had an MRI performed. The mean age of the study patients was 14.2 years (range 10–17). The diagnosis of spondylolysis was missed in the MRI radiology reading in 7 out of 11 (64 %) studies.
MRI missed a spondylolysis in over half of the adolescents in this consecutive series. In patients with a history or physical findings suggestive of spondylolysis, such as localized pain of the lumbar spine with back extension, further radiographic evaluation should be considered, even if an MRI is negative.
Level of evidence
III, retrospective review.
Spondylolysis; Radiology; Adolescent back pain