Concurrent femoral head reduction and periacetabular osteotomies for the treatment of severe femoral head deformities.

AIMS: The aims of this study were to review the surgical technique for a combined femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO), and to report the short-term clinical and radiological results of a combined FHRO/PAO for the treatment of selected severe femoral head deformities. PATIENTS AND METHODS: Between 2011 and 2016, six female patients were treated with a combined FHRO and PAO. The mean patient age was 13.6 years (12.6 to 15.7). Clinical data, including patient demographics and patient-reported outcome scores, were collected prospectively. Radiologicalally, hip morphology was assessed evaluating the Tönnis angle, the lateral centre to edge angle, the medial offset distance, the extrusion index, and the alpha angle. RESULTS: The mean follow-up was 3.3 years (2 to 4.6). The modified Harris Hip Score improved by 33.0 points from 53.5 preoperatively to 83.4 postoperatively (p = 0.03). The Western Ontario McMasters University Osteoarthritic Index score improved by 30 points from 62 preoperatively to 90 postoperatively (p = 0.029). All radiological parameters showed significant improvement. There were no long-term disabilities and none of the hips required early conversion to total hip arthroplasty. CONCLUSION: FHRO combined with a PAO resulted in clinical and radiological improvement at short-term follow-up, suggesting it may serve as an appropriate salvage treatment option for selected young patients with severe symptomatic hip deformities.

Comparison of contemporary periacetabular osteotomy for hip dysplasia with total hip arthroplasty for hip osteoarthritis.

We report patient-reported outcomes and complications associated with contemporary periacetabular osteotomy (PAO) surgery in treating symptomatic acetabular dysplasia and compare these outcomes with total hip arthroplasty (THA) in patients with similar demographic details. Two consecutive cohorts included patients between aged 18 to 40 years who had undergone either PAO (100 hips; 24 male, 76 female) or THA (55 hips; 18 male, 37 female). At a mean follow-up of 5.9 years (2 to 13), there was significant improvement in the modified Harris hip pain (p < 0.001, PAO and p < 0.001, THA), function (p < 0.001, PAO and p = 0.001, THA), and total scores (p < 0.001, PAO and p < 0.001, THA) within each cohort. There were no significant differences in the clinical outcome scores between the groups. Complication rates were low and similar in each cohort (p = 0.68). Similar to THA, contemporary PAO surgery is a clinically effective procedure that improves function and activity levels, provides pain relief and is associated with an acceptable complication rate.

Obstructive sleep apnoea syndrome in morbidly obese children with tibia vara.

Morbid obesity and its association with obstructive sleep apnoea syndrome have been increasingly recognised in children. Orthopaedic surgeons are often the primary medical contact for older children with tibia vara, which has long been associated with obesity, but are unfamiliar with the evaluation and treatment of sleep apnoea in children. We reviewed all children with tibia vara treated surgically at one of our institutions over a period of five years. Thirty-seven patients were identified; 18 were nine years of age or older and 13 of these (72%) had morbid obesity and a history of snoring. Eleven children were diagnosed as having sleep apnoea on polysomnography. The incidence of this syndrome in the 18 children aged nine years or older with tibia vara, was 61%. All these patients required pre-operative non-invasive positive-pressure ventilation; tonsillectomy and adenoidectomy were necessary in five (45%). No peri-operative complications related to the airway occurred. There is a high incidence of sleep apnoea in morbidly obese patients with tibia vara. These patients should be screened for snoring and, if present, should be further evaluated for sleep apnoea before corrective surgery is undertaken.

Evaluation of the efficacy of pelvic shielding in preadolescent girls.

SUMMARY: A standing anteroposterior pelvic radiograph with gonadal shielding is used as a screening tool for all patients evaluated for intoeing at our institution. Sixty-two normal consecutive screening pelvic radiographs obtained in 61 female patients between the ages of 4 and 6 years were evaluated. Radiographs were evaluated for the adequacy to assess the hips as well as the protection afforded the ovaries from radiation exposure. Radiographs were judged to be inadequate because the shield covered essential landmarks in at least one hip in eight radiographs (13%). Five radiographs (8%) covered >50% of the area of both ovaries, and only one radiograph covered >75% of the area of both ovaries. Standard techniques of positioning gonadal shields in preadolescent girls are inadequate and provide minimal protection with a high rate of interference with vital landmarks. We no longer advocate using gonadal shields on initial screening radiographs of preadolescent girls.

Fracture stability after pinning of displaced supracondylar distal humerus fractures in children.

Between January 1, 1994 and December 31, 1997, we evaluated 138 children with displaced supracondylar distal humerus fractures treated by closed reduction and percutaneous pinning. There were 49 type II fractures and 89 type III fractures. Three principal pin configurations were used at the surgeon's discretion: 2 lateral pins (42 fractures), 1 medial and 1 lateral pin (37 fractures), and 1 medial and 2 lateral pins (57 fractures). There was no statistically significant difference in clinical stability between these groups. One type III fracture pinned using two lateral pins showed marked rotational instability. We recommend using two lateral pins when treating type II fractures. Type III fractures should be treated using two lateral pins initially and, if the elbow demonstrates significant intraoperative rotational instability, a medial pin should be added. If a medial pin is necessary, and the ulnar nerve cannot be identified by palpation, a small incision should be made and the pin placed under direct vision.

Isolated thoracolumbar and lumbar hyperlordosis in a patient with cerebral palsy.

A severe isolated thoracolumbar and lumbar hyperlordosis spinal deformity occurring in a patient with cerebral palsy is rare and has not been reported before. The authors describe the presentation, operative considerations, and treatment of patients with this unusual hyperlordotic spinal deformity, particularly those with cerebral palsy. A multiple-stage surgical reconstruction was required to correct this complex spinal deformity. The patient underwent bilateral femoral extension osteotomies along with spinal extensor myotomies to ensure proper prone positioning for his anticipated spinal surgery. Then he had staged anterior releases and spinal fusion from T8 to the sacrum followed by 2 weeks of "90-90" femoral skeletal traction. Finally, a posterior spinal fusion with instrumentation from T2 to the pelvis definitively corrected his deformity. The patient responded well to surgical intervention without complications and continues to have stable correction of his hyperlordosis deformity 2 years after surgery. Severe lordotic sagittal plane spinal deformities can be treated with anterior and posterior spinal fusion and instrumentation with intervening traction in the properly selected and prepared patient who has cerebral palsy.

Painful idiopathic rigid flatfoot in children and adolescents.

Nine patients (13 feet) were identified whose primary complaints were of atraumatic-onset, chronic pain in the hindfoot exacerbated with increased activity and who had the diagnosis of idiopathic rigid flatfeet. Eight of 11 were greater than the 95th percentile in weight for their age. Exam under anesthesia showed moderate to significant improvement in hindfoot motion in 9 feet; 4 feet required fractional peroneal lengthenings. Only 5 of 11 patients have had sustained relief of pain and report unlimited activity level. Children and adolescents with painful idiopathic rigid flatfeet without known causation can have significant, persistent, disability and do not uniformly respond well to traditionally-described nonoperative Interventions.

Pin site care during external fixation in children: results of a nihilistic approach.

We prospectively followed 27 consecutive children with tibial circular external fixators applied between July 1, 1995, and June 30, 1997. A simple pin care system with no physical pin cleansing except that provided by daily showers was used. Children with inflamed or infected pin sites were placed on an oral antibiotic (cephalexin) for 10 days. Pin sites were graded according to the system of Dahl et al. on a 0 to 5 scale. A total of 4,473 observations was made. Patients developed 178 pin tract infections (4.0% per observation), with 151 (85%) grade 1 and 27 (15%) grade 2 infections. No pin was removed because of infection. Diaphyseal half pin sites were less commonly infected (1.6%) than periarticular wire or half pin sites (4.5%). We recommend only showering without other physical pin cleaning procedures in children undergoing external fixation procedures.

External fixation of femoral shaft fractures in children: enhanced stability with the use of an auxiliary pin.

From 1989 through 1994, we used a monolateral external fixator (Orthofix) to treat 39 femur fractures in 37 patients. The average age of the patients was 9.5 years (range, 5+11 to 18+8 years); 38 fractures were closed, and one was a grade I (Gustillo-Anderson classification) open fracture. Twenty-two fractures were treated by using the standard Orthofix pin configuration with two or three pins held in the pin clamps both above and below the fracture. We treated the remaining 16 fractures identically, except for the addition of an auxiliary pin, which was secured to the body of the fixator by using wire and methylmethacrylate. All patients were followed up to union and fixator removal at a mean of 97 days after fixator placement (range, 50-175 days). Thirty-one (84%) patients were followed up for 1 year after injury. Six of 22 femurs without an auxiliary pin required remanipulation for loss of reduction. Only one of 16 femurs treated with an auxiliary pin required remanipulation. Four of 22 femurs without an auxiliary pin went on to malunion. No femur with an auxiliary pin went on to malunion.

Fate of the psoas muscle after open reduction for developmental dislocation of the hip (DDH).

We evaluated the anatomic and functional consequences of psoas lengthening during operative intervention for developmental dislocation of the hip (DDH). Possible anatomic changes were assessed by magnetic resonance imaging (MRI), and functional assessment included strength determination by an isokinetic dynamometer and gait analysis. Six girls and one boy, ranging in age from 15 to 20 months, had operative reduction of a unilateral DDH. One closed and six open reductions (three anteromedial and three anterolateral approaches) were performed. Follow-up ranged from 4 years 0 months to 9 years 2 months. The cross-sectional area determined by MRI of the lengthened psoas muscles was markedly reduced for all of the six open-reduction patients (three moderate and three severe). Atrophy of the iliacus muscle also was apparent by MRI in five of the six open-reduction patients. Maximum flexion torque, as determined by the isokinetic dynamometer, was diminished on the DDH side for the three patients whose hips were reduced open through the anteromedial approach. Average hip-flexion torque over the entire range of motion was decreased for both anteromedial and anterolateral groups on the operated-on side. Lengthening of the psoas tendon during open reduction of a DDH is associated with considerable atrophy of the psoas muscle.

Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment.

A retrospective review was performed of 106 patients to determine the effect of knee pain as the initial complaint of slipped capital femoral epiphysis (SCFE). Sixteen (15%) patients had a primary complaint of distal thigh or knee pain or both at initial presentation to our institution or to a referring physician. Ninety (85%) patients described primarily hip, groin, or proximal thigh discomfort. Of the 106 patients with SCFE, 65 patients received no operative treatment before being evaluated at our institution and were the subject of the remainder of the study. Of these, 15 (23%) patients had distal thigh or knee pain or both as their chief complaint (group I), and 50 (77%) patients had hip, groin, or proximal thigh pain (group II). There was no difference between the groups with respect to age, gender, or slip stability. Group I patients were more likely to receive a misdiagnosis (p < 0.05) and undergo unnecessary or uninformative radiographs (p < 0.05). Additionally, patients in group I were found to have slips of greater radiographic severity (p < 0.05). Although not statistically significant, there was a trend for group I patients to experience a longer delay to diagnosis and to require a proximal femoral osteotomy as treatment for their slips. We conclude that isolated distal thigh or knee pain or both is a common presentation of SCFE. Furthermore, this symptom complex, when compared with the more classic presentation of SCFE, leads to higher rates of unnecessary radiographs, misdiagnoses, and severe slips, potentially increasing long-term morbidity.

Surgical treatment of congenital dislocation of the patella.

Eleven patients with 17 involved knees were surgically treated for congenital dislocation of the patella between 1978 and 1993. Ten patients with 13 involved knees followed up for a minimum of 2 years postoperatively composed the study group. Six patients had both involved knees operatively treated. In four patients, congenital dislocation of the patella was associated with a recognizable syndrome. All patients had fixed, painful lateral dislocation of the patella that could not be reduced. The average age at presentation was 7 years and 9 months (range, 2 months to 15 years). All patients underwent an extensive procedure including lateral release and advancement of the vastus medialis obliquus. Skeletally immature children underwent medial transfer of the entire patellar tendon. Skeletally mature patients underwent medial transfer of the tibial tubercle. Ten patients with 13 involved knees were followed up for > or = 2 years. Mean follow-up was 5.1 years (range, 1-17.5). At last follow-up, all patients reported a marked increase in activity tolerance and relief of pain. Average extension lag improved from 15 degrees before to 2 degrees after surgery. One superficial wound infection occurred; no patient developed a deep infection. One peroneal neurapraxia occurred but resolved with observation. Redislocation of the patella occurred in the immediate postoperative period in one patient. Operative treatment of congenital dislocation of the patella can predictably improve knee function when all aspects of the complex pathologic anatomy are addressed.

Symptomatic talocalcaneal coalition resection: indications and results.

We report our results of talocalcaneal coalition (TCC) resection in 25 feet after failed nonoperative treatment. Preoperative computed tomography (CT) scans were used to quantify the amount of heel valgus and the size of the coalition relative to the posterior facet. The ratio of mean TCC cross-sectional area to the surface area of the posterior facet was 53.4%. Mean hindfoot valgus was 17.8 degrees. The mean AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot score was 81.9, at an average of 2.5 years after surgery. Statistical analysis determined a significant association between TCC > 50% the size of the posterior facet and poor outcome (p = 0.014). Similarly, heel valgus > 21 degrees was associated with poor outcome (p = 0.014). However, there were good postoperative results in feet with heel valgus > 21 degrees and in those whose TCC was > 50% of the posterior facet. Therefore we advocate using these CT-scan criteria for preoperative discussions with patients and families and not for determination of the index operative procedure (resection vs. arthrodesis). Hindfoot arthrodesis should only be used as a salvage procedure. We recommend those feet with heel valgus > 21 degrees use an orthosis postoperatively to stabilize the hindfoot or a secondary calcaneal procedure should nonoperative management fail.

The effect of unilateral varus rotational osteotomy with or without pelvic osteotomy on the contralateral hip in patients with perinatal static encephalopathy.

Forty-eight patients with perinatal static encephalopathy were treated with unilateral varus rotational femoral osteotomy for hip subluxation. Twenty-one of the 48 also had concomitant pelvic osteotomy. Twenty-seven of the patients were nonambulators. Bilateral soft-tissue releases had been performed previously in 20 patients. At the time of varus rotational osteotomy, the mean age was 8 years, 11 months. The indication for a varus rotational osteotomy was femoral head subluxation or dislocation in all cases. The preoperative center-edge angle ranged from -8 degrees to 18 degrees (mean, 4 degrees), and on the contralateral side, the center-edge angle ranged from 0 degree to 32 degrees (mean, 19 degrees). The center-edge angle on the operative side at follow-up averaged 25 degrees (-10 degrees to 78 degrees), an improvement of 21 degrees, and on the contralateral side averaged 27 degrees (range, 9 degrees-40 degrees), an improvement of 8 degrees. Forty-seven patients have had no subsequent surgery on the contralateral hip. One patient had a varus rotational osteotomy on the contralateral hip 5 years postoperatively; however, this hip was subluxated at the time of the index procedure. Twelve patients have had no surgery at any time on the contralateral side. None of these patients had deterioration of the contralateral hip. Surgery on one hip should not, in itself, be an indication for surgery on the contralateral concentrically reduced hip with adequate abduction in patients with acetabular dysplasia secondary to perinatal static encephalopathy.

Intramedullary fixation of unstable both-bone forearm fractures in children.

A retrospective study was performed to evaluate the results of intramedullary fixation used in the management of unstable, diaphyseal both-bone forearm fractures in skeletally immature patients. Twenty-five patients with 25 fractures were identified whose fracture management included only intramedullary fixation. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded from this analysis. Mean age at fracture was 10 + 8 years. There were 15 closed and 10 open fractures (eight grade I and two grade II). Smooth Kirschner wires or Rush rods were used for fixation. Average length of immobilization was 8 + 2 weeks; 6 + 2 in a long-arm cast and 2 + 0 weeks in a short-arm cast. All 25 regained normal elbow motion, with 17 regaining full forearm rotation. Eight patients had an average loss of 13 degrees of supination and 9 degrees of pronation. There were four minor and two major complications (one rod migration and one delayed union). No infections, malunions, or synostoses occurred in this patient group. Using the grading scheme adapted by Price there were 21 excellent results (84%), four good (16%), and no fair or poor results. In our experience, intramedullary fixation of the unstable both-bone forearm fractures is a safe, effective, and user-friendly technique when alignment jeopardizes fracture position at union and eventual forearm motion.

Subtalar arthroereisis for the correction of planovalgus foot in children with neuromuscular disorders.

We studied the results of 140 STA-peg arthroereisis procedures performed for the treatment of planovalgus foot deformity in 78 ambulatory children with neuromuscular disease. Patient age at surgery ranged from 2 + 2 to 14 + 11 years, with a mean of 7 + 9 years. Patients were followed up for an average of 4 + 6 years. The ultrahigh-molecular-weight polyethylene (UHMWPE) STA-peg implant is inserted laterally into the subtalar joint such that its stem extends inferiorly into the calcaneus and its collar abuts the inferior surface of the lateral process of the talus, thereby blocking excessive valgus tilt of the calcaneus. All but five patients (nine feet) had concomitant soft-tissue procedures to balance the foot. The talocalcaneal angle and the talar declination angle were measured on lateral radiographs preoperatively, postoperatively, and at the latest follow-up visit. Patients were evaluated for the presence of pain and hindfoot valgus deformity. Satisfactory results were achieved in 135 (96.4%) feet. Results were unsatisfactory in one foot of each of five patients who had bilateral procedures; one was painful, and four developed varus. The STA-peg was removed in these five patients. No infections or adverse tissue reactions to the STA-peg implant were observed. STA-peg arthroereisis, combined with satisfactory muscle-balancing procedures, can predictably achieve control of planovalgus foot deformity in children with neuromuscular disorders and may obviate the need for long-term orthotic wear.

Polyarticular pigmented villonodular synovitis in a child.

Pigmented villonodular synovitis is rare in the younger child. Polyarticular involvement in this condition, regardless of patient age, is distinctly uncommon. The authors describe a case of pigmented villonodular synovitis involving multiple joints in a young boy who also had congenital anomalies of the genitourinary tract. Although rare, pigmented villonodular synovitis should be considered in the differential diagnosis of multiple joint swellings in children with congenital anomalies.

Pemberton osteotomy for the treatment of developmental dysplasia of the hip in older children.

A retrospective analysis was done of the results of the Pemberton osteotomy for the treatment of developmental dysplasia of the hip in 16 hips of 14 children older than 7 years. The average age of the patients at the time of surgery was 11+6 years and the average follow-up was 4+10 years. Eleven hips required one or more surgical procedures concomitant with the Pemberton osteotomy to achieve a concentric and congruous reduction of the hip joint. None of the hips developed avascular necrosis of the acetabular fragment. The center-edge angle improved from a preoperative average of 1 degree to an average of 30 degrees at the most recent follow-up. Correction of acetabular dysplasia was noted in 14 of the 16 hips, as demonstrated by the improvement in the acetabular index, the center-edge angle, and the Severin class. We believe that the Pemberton osteotomy can be a safe and effective procedure for the treatment of developmental dysplasia of the hip in the older child.

Management of lower-extremity deformities in osteogenesis imperfecta with extensible intramedullary rod technique: a 20-year experience.

Twelve patients (seven boys, five girls) who had osteogenesis imperfecta were treated with an extensible-rod system in 21 femurs and 15 tibias. Indications for use of extensible rods were multiple fractures, long-bone deformity prohibiting bracing and ambulation, and significant remaining linear growth. The average patient age at the time of placement of the extensible rods was 6 + 8 years (range, 2 + 4-10 + 10). Six femurs were treated with overlapping Rush rods; Bailey-Dubow rods were used in the remaining femurs and in all tibias. The average length of follow-up was 5 + 9 years (range, 2 + 0-3 + 2). Preoperatively, four of the 12 patients had never walked; postoperatively, all were ambulators with varying levels of assistance. Fourteen complications occurred, 12 of which required operative revision of the extensible rods. The average time between primary extensible rodding and revision was 5 + 1 years. No complications have occurred to date related to the use of overlapping Rush rods. No growth disturbance resulted from the use of the extensible-rod systems.

The prognostic importance of the ossific nucleus in the treatment of congenital dysplasia of the hip.

Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip. Some investigators have suggested that the presence of the ossific nucleus of the femoral head at the time of closed or open reduction is associated with a lower rate of ischemic necrosis. This finding, if verified, could lead to a delay in the treatment of a dislocated hip until ossification of the femoral head has begun, which may be well after the age when the patient has started to walk. We conducted a computerized search of the medical records at our two tertiary-care children's hospitals to identify all patients with congenital dysplasia of the hip who had had a closed or open reduction between January 1, 1979, and December 31, 1993. One hundred and twenty-four patients (153 hips) who satisfied the criteria for inclusion were identified. The ossific nucleus was present in ninety hips and absent in sixty-three. Closed reduction was used in 112 hips and open reduction, in forty-one. Ischemic necrosis was identified in five hips (3 percent): four (6 percent) of the sixty-three hips that did not have an ossific nucleus and one (1 percent) of the ninety hips that had an ossific nucleus at the time of the reduction. With the numbers available for study, we could not detect a difference between these two groups. The age at reduction (p > 0.99), the method of reduction (p = 0.611), previous treatment with a Pavlik harness (p = 0.592), the use of preliminary traction (p = 0.602), concomitant procedures (p > 0.99), and a failure of the primary closed reduction (p = 0.579) were not associated with the development of ischemic necrosis after reduction. In our analysis of patients who were managed over a fifteen-year period, the data did not support the hypothesis that the presence of an ossific nucleus at the time of reduction of a congenitally dislocated hip is associated with a lower prevalence of ischemic necrosis of the femoral head. Sound operative principles dictate that operative reduction of a congenitally displaced hip should be performed when the child can be safely placed under anesthesia and without regard to the presence or absence of the ossific nucleus.