Bone alterations of pamidronate therapy in children with cerebral palsy complicating orthopedic management.

Cerebral palsy (CP) is a heterogeneous group of disorders with different clinical types and underlying genetic variants. Children with CP are at risk for fragility fractures secondary to low bone mineral density, and although bisphosphonates are prescribed for the treatment of children with bone fragility, there is limited information on long-term bone impact and safety. Children with CP usually present overtubulated bones, and the thickening of cortical bone by pamidronate treatment can potentially further narrow the medullary canal. Our purpose was to report bone alterations attributable to pamidronate therapy that impact orthopedic care in children with CP. The study consisted of 41 children with CP treated with pamidronate for low bone mineral density from 2006 to 2020. Six children presented unique bone deformities and unusual radiologic features attributed to pamidronate treatment, which affected their orthopedic care. The cases included narrowing of the medullary canal and sclerotic bone, atypical femoral fracture, and heterotopic ossification. Treatment with bisphosphonate reduced the number of fractures from 101 in the pretreatment period to seven in the post-treatment period (P < 0.001). In conclusion, children with CP treated with bisphosphonate have a reduction in low-energy fractures; however, some fractures still happen, and pamidronate treatment can lead to bone alterations including medullary canal narrowing with sclerotic bone and atypical femoral fractures. In very young children, failure to remodel may lead to thin, large femoral shafts with cystic medullary canals. More widespread use of bisphosphonates in children with CP may make these bone alterations more frequent. Level of evidence: Level IV: Case series with post-test outcomes.

Walking status and spinopelvic parameters in young children with achondroplasia: 10-year follow-up.

PURPOSE: Thoracolumbar kyphosis (TLK) is common in children with achondroplasia and resolves in 90% by 10 years of age. Our purpose was to describe the natural progression of TLK in a cohort of pre-walking children with achondroplasia. METHODS: A single-center, retrospective review identified 62 children (32 male, 30 female) with achondroplasia. Clinical information and sagittal spinopelvic parameters were collected. The children were divided into positive pelvic tilt (PT) and negative PT. All parents were routinely counseled about unsupported sitting. RESULTS: Spontaneous resolution rate was 64.5% at 1-year post-walking, 74.2% at 5 years of age, and 88.7% at 10 years of age. None of the children required posterior spinal decompression and fusion for progressive deformity or symptomatic spinal stenosis. At 1-year post-walking, the negative PT group had a higher sacral slope (p = 0.006), higher lumbar lordosis (p < 0.001), and lower pelvic incidence (p < 0.001). This relationship remained constant up to 10 years of age, and there was no association with TLK. CONCLUSION: In this largest series to date, spontaneous resolution of TLK in children with achondroplasia was 64.5% at 1-year post-walking, 74.2% at 5 years of age, and 88.7% in children followed to 10 years of age. With early identification and regular follow-up with patient education, no patient in this series required treatment or developed symptomatic spinal stenosis. While not predictive of resolution of TLK, the dichotomous presentation of PT in young children with achondroplasia persists at 5 and 10 years of age and reliably predicts the spinopelvic parameters. LEVEL OF EVIDENCE: III-retrospective comparative study.

A Sonography-based Decision Model for Use in Treatment of Developmental Dysplasia of the Hip.

The objective of this study was to delineate a model for management of developmental dysplasia of the hip (DDH) treatment that incorporates hip ultrasound with objective/predicative parameters at key decision-making times. Hip sonograms of 74 infants (59 females, 15 males; 141 hips) with DDH were retrospectively reviewed. Hip sonographic score (HSS; ranges 0-10) was developed to reflect hip status based on sonographic position, stability, and morphology. Analysis on different management groups (i.e., no treatment, successful treatment, and failed treatment) showed that the trend of HSS is helpful in predicting course of the disease and determining effectiveness of treatment. A model for the management of DDH that utilizes an HSS and frequency schedule for hip sonography that is aligned with times of critical treatment decisions is proposed. This model illustrates how hip sonography can bring added value when timed to guide critical treatment decisions. (Journal of Surgical Orthopaedic Advances 32(1):047-054, 2023).

Three different techniques for pelvic fixation in the management of neuromuscular scoliosis in nonambulatory spastic cerebral palsy: A comparative study of Galveston Rod, iliac screw, and sacroiliac screw.

OBJECTIVE: This study aimed to compare the clinical and radiographic results of three different pelvic fixation techniques, i.e., Galveston Rod, Iliac Screw, and Sacroiliac Screw, in managing neuromuscular scoliosis in nonambulatory children with spastic cerebral palsy (CP). METHODS: This retrospective study included nonambulatory children aged < 18 years with neuromuscular scoliosis secondary to CP, undergoing a spinal fusion and pelvic fixation by either Galveston rod, iliac screw, or sacroiliac screw techniques. The primary outcome variable was to determine the stability of the major curve angle and pelvic obliquity over timeline intervals for each pelvic fixation tech nique. The two radiographic parameters were measured at five timeline intervals and were compared to define stability among the groups. RESULTS: One hundred and one patients (54 females [53%]) with spastic nonambulatory CP met the inclusion criteria; the mean age at sur gery was 13.5±3.1 years. Mean follow-up intervals were first-year (12.9±1.5) and second-year (25.8±2.5). Forty-one patients had minimum five-year (81.5±23 months) postoperative follow-up. Groups were based on pelvic fixation techniques: 25 patients with the Galveston rod, 24 with the iliac screw, and 52 with the sacroiliac screw. Of the 41 patients with a minimum five-year follow-up, 10 had the Galveston rod, 11 had an iliac screw, and 20 had sacroiliac screw fixation. Gross Motor Function Classification System level, medical comorbidities, intra thecal baclofen pump, and vitamin D level were compared with each pelvic fixation technique (P > .05). Major curve angle parameters were measured at the five timelines as 70.5°±21.1°, 15.7°±13°, 15.7°±12°, 17.5°±12.7°, and 15.1°±9.6°, and pelvic obliquity as 14.8°±10.4°, 4.9°±4.2°, 5.7°±4.6°, 5°±4.4°, and 7.2°±4.4°, respectively. After the surgery, corrected major curve angle and pelvic obliquity showed no sta tistically significant difference between pelvic fixation techniques (P > .05) and remained stable over timeline intervals (P > .05). Fifteen patients had complications requiring additional surgery. The iliac screw group (nine patients) had the highest rate of complications. CONCLUSION: All three pelvic fixation techniques can provide equivalent correction for major curve angle and pelvic obliquity in managing neuromuscular scoliosis in nonambulatory CP children. Pelvic obliquity after surgery may remain stable regardless of pelvic fixation type. A higher rate of postoperative complication can be encountered with the iliac screw. LEVEL OF EVIDENCE: Level III, Retrospective Study.

Infantile Tibia Vara (Blount Disease) with Iatrogenic Changes Causing Residual Tibial Deformities.

Treatment of infantile tibia vara or Blount disease (ITV/BD) in patients < 3 years old and Langenskiold stages I-III consists of orthosis and, in relapsing cases, proximal tibial osteotomy and/or proximal tibial guided growth laterally with a tension band plate. Our aim was to evaluate the results of treatments in a consecutive group. After Institutional Review Board approval, data from 2002 to 2018 were collected. Thirty-nine knees (average age 22.4 months) with ITV/BD were treated with orthoses, and 10 knees failed. Six knees showed hyperintense T2-weighted signal in the medial proximal tibial epiphyseal cartilage on magnetic resonance imaging. Three of six knees with tibial osteotomy failed and underwent guided growth. Tibial plateau slopes were abnormal medially from the ITV/BD and laterally from the guided growth (triangular physis and depressed plateau deformities) because of factors such as orthotic treatment, tibial osteotomy, magnetic resonance imaging "physis severity score," and guided growth. (Journal of Surgical Orthopaedic Advances 29(3):141-148, 2020).

Anterior Hip Dislocation from Post-injection Gluteal Muscular Fibrosis: Case Report.

CASE: A female with 24 years of follow-up who received multiple intramuscular injections of penicillin in the buttock at age 2 years. By age 6 years, she had left hip subluxation and underwent operative soft-tissue release and femoral plating. At age 12 years, she developed progressive anterior hip dislocation and had release of the gluteal contracture, open reduction, and femoral osteotomy. Currently, she is aged 26 years, fully employed, and active at home. CONCLUSIONS: This is the first reported case associated with anterior hip dislocation after progressive post-injection gluteus muscle fibrosis with a follow-up of 24 years.

Orthopedic Manifestations of Bruck Syndrome: A Case Series with Intermediate to Long-term Follow-Up.

The aim of this study was to evaluate the association of contractures, fractures, and deformities in four patients with Bruck syndrome treated in our facility. Data were collected from medical records, radiographs, dual-energy X-ray absorptiometry (DEXA) scans, genetic tests, and gait analysis. All had contractures at birth and genotypic findings including mutations in PLOD2 or FPKB10. Three cases were treated with bisphosphonates with improvement in bone density verified by DEXA. In Bruck syndrome, orthopedic deformities include the following sequential aspects: contractures, characterized by upper and lower extremity contractures such as clubfeet; fractures, characterized by multiple diaphyseal fractures in the long bones of the extremities; and deformities, characterized by malalignment of extremities and the spine. Physical therapy and bracing proved helpful for the contractures to try to stop progression. Bone fragility needs to be considered when deciding to attempt cast correction. Surgeries in the soft tissues can be performed to retain joint movement. In fractures with angulation, intramedullary nail fixation was useful, and in cases without deformity, casting alone was successful. We suggest monitoring the bone density with DEXA, nutrition support with vitamin D and calcium, and treatment with bisphosphonates. Spine deformities were successfully treated by spinal fusion and instrumentation.

Patchy increased echogenicity: a sonographic sign of femoral head necrosis following reduction and casting for developmental dysplasia of the hip.

A developmental dysplasia of the hip (DDH) case treated by closed reduction and casting and subsequently confirmed to have avascular necrosis (AVN) was retrospectively noted to have an abnormal pattern of echogenicity in the femoral head on sonograms obtained within 1.5 months of surgery. Patchy increased echogenicity in parts of the unossified cartilage replaced the normal pattern of central coalescence of vessels described with development of the ossification center. An additional case with similar findings confirms this should be considered a sign of evolving AVN following closed reduction.

Hypertrophy Associated With Vascular Malformations: Analysis of Growth and Results of Epiphysiodesis.

Limb-length inequality is a clinical problem in children with hypertrophy associated with vascular malformations. The purpose of this study was to determine a pattern of growth, predict discrepancy at maturity, and evaluate the timing and results of epiphysiodesis. Hypertrophy with vascular malformation, follow-up from childhood until maturity, annual physical examination, and annual orthoroentgenograms and anteroposterior left hand-wrist radiographs were the inclusion criteria. The developmental pattern of the growth discrepancy was established. Limb-length discrepancy and remaining growth were calculated. All 3 patients underwent distal femur or proximal tibia and fibula percutaneous epiphysiodesis. All cases showed the constant upward slope of the developmental pattern of discrepancy until the time of epiphysiodesis. The length of the uninvolved limb at maturity corresponded to the length predicted by the methods that used skeletal age, allowing calculation of the proper timing for epiphysiodesis. The multiplier and the rule of thumb methods failed, with skeletal age not corresponding to chronological age. In these 3 cases, limb-length discrepancy was successfully treated with percutaneous epiphysiodesis, and there were no complications. [Orthopedics. 2018; 41(4):e574-e579.].

Comparing Percutaneous Physeal Epiphysiodesis and Eight-Plate Epiphysiodesis for the Treatment of Limb Length Discrepancy.

BACKGROUND: Either percutaneous or eight-plate epiphysiodesis have been shown to be effective growth modulation techniques for the treatment of limb length discrepancies (LLD). However, few studies compared the outcomes of both techniques with some confounding results. The aim of this study was to evaluate the outcomes of the both techniques in the treatment of the LLD. METHODS: Between 2004 and 2012, medical records of all cases that underwent either eight-plate or percutaneous epiphysiodesis (PE) were reviewed. Age at surgery, sex, diagnosis, surgical site (proximal tibia/distal femur), time of follow-up, complications, and additional procedures were noted. Correction of the LLD was evaluated to calculate the rate of correction and the percentage of improvement from the long-leg standing x-rays or scanograms, collected at each visit. RESULTS: There were 24 patients in the eight-plate (10 girls and 14 boys) and 48 patients in the PE group (28 girls and 20 boys). No statistically significant difference was found in the age, sex, preoperative LLD, or follow-up between groups. Both groups reached to an average LLD below 2 cm. The percentage of improvement was significantly higher in the PE group (P=0.031). The rate of individual femoral and tibial correction did not differ between the groups. CONCLUSIONS: Both methods are shown to be effective for LLD correction. However, PE led to greater improvement during the same follow-up time with fewer complications and less need for additional surgical procedures.

Electronic monitoring of orthopedic brace compliance.

PURPOSE: Brace compliance measurement in adolescent idiopathic scoliosis (AIS) has been the subject of a few recent studies. Various sensors have been developed to measure compliance. We have developed a temperature-based data logger-the Cricket-specifically for scoliosis braces, with associated custom software, that is embedded directly in the brace. The purpose of this study was to analyze patterns of brace wear and patient compliance among children with AIS using the Cricket. METHODS: Fifty-five AIS patients prescribed various brace-time regimens were monitored using the Cricket. All subjects were treated with the Wilmington brace. The compliance rate for each group was determined. RESULTS: Overall compliance among subjects was 69.9 ± 31.5 %. Only 14.5 % met or exceeded prescribed brace time. This is consistent with previous compliance monitoring results. CONCLUSION: The results of this study objectively show the difference between prescribed and actual brace wear time and reaffirm the Cricket sensor as an accurate and comfortable brace-monitoring device.

Natural history of hip instability in infants (without subluxation or dislocation): a three year follow-up.

BACKGROUND: The natural history of hip instability (without subluxation or dislocation) and treatment in infants remain controversial. We performed a retrospective cohort case-only study with blinded, prospectively collected data to assess normalization of the acetabular index in consecutive untreated infant hips with sonography instability. METHODS: Consecutive hips meeting inclusion criteria were followed by sonography/radiography and data analyzed using tabular and regression models. RESULTS: In 48 hips, acetabular index measured by radiography normalized within 3 years of age without treatment. Normalization by age occurred: 7 months in 35%, 12 months in 67%, 18 months in 75%, 24 months in 81%, and 36 months in 100%. Two patterns of normalization of the acetabular index were observed: group I showed ossification in a physiological range of normal by 7 months of age, and group II had delayed ossification with later normalization of the acetabular index measurement. Breech presentation (p =0.013) and cesarean delivery (p =0.004) statistically directly correlated with a later normalization. CONCLUSIONS: The natural history of infant hip instability (without subluxation or dislocation), which is reduced at rest and unstable with stress as diagnosed by the Harcke method of sonography, has spontaneous normalization of the acetabular index within 3 years of age. We suggest three patterns of acetabular ossification in unstable infants' hips: (I) normal ossification, (II) delayed ossification with normalization of the acetabular index by age 3 years, and (III) defective secondary centers of ossification with an upward tilt of the lateral acetabular rim in adolescence.

Protocol for MRI of the hips after spica cast placement.

BACKGROUND: In reduction of hip displacement in developmental dysplasia, concentric placement of the femoral head within the acetabulum is key. Magnetic resonance imaging (MRI) is an effective modality to assess the adequacy of the reduction, but sedation may be required due to the length of the examination. MRI is also more expensive than other imaging modalities. Our goal was to provide an MRI protocol that does not require sedation and can be performed in <15 minutes. METHODS: We retrospectively reviewed 34 consecutive MRI studies performed without sedation after spica cast placement in 24 developmental hip dysplasia patients. The MRI examinations were performed with a variety of techniques. Sequences used were evaluated for contrast, resolution, and motion artifact. RESULTS: Ninety-seven percent of studies were diagnostic, although 18% of examinations had significant motion artifact. Seven sequences were analyzed. T2-weighted fast spin echo sequences had the best overall scores and were performed in <3 minutes. T1 and fat-suppressed T2-weighted fast spin echo sequences did not score as well, and also required <3 minutes. Single-shot fast spin echo sequences scored poorly due to decreased contrast and resolution, despite shorter acquisition times of 20 to 40 seconds. Three-dimensional (3D) gradient recovery imaging scored poorly due to lower contrast and increased motion due to longer acquisition times of approximately 4 minutes. Both coronally and axially oriented sequences satisfactorily assessed femoral head position within the acetabulum. CONCLUSIONS: MRI is a useful tool in evaluating the hips without radiation exposure and without sedation in infants and toddlers after spica cast placement. Both axial and coronal T2 fast spin echo MRI sequences provided excellent anatomic definition and required ≤3 minutes per sequence. Orthopaedic surgeons can request these 2 sequences for accurate assessment of concentric reduction with a potential study time of 15 minutes, obviating the need for sedation. LEVEL OF EVIDENCE: Level II.

Adolescent Blount disease in obese children treated by eight-plate hemiepiphysiodesis.

OBJECTIVES: The aim of this study is to evaluate the outcomes of eight-plate (Orthofix) use during hemiepiphyseodesis operation for growth modulation in obese children with adolescent Blount disease. PATIENTS AND METHODS: Six limbs of five consecutive patients who underwent lateral proximal tibial eight-plate (Orthofix) hemiepiphysiodesis were evaluated. The body mass index (BMI) was >30 and the severity of the deformity was in Zone III according to the Mielke and Stevens definition. The mechanical medial proximal tibial angle (MPTA) and the mechanical axis deviation (MAD) were measured preoperatively, postoperatively, and at last follow-up. The outcome of the procedure was established by the degree of tibia vara correction degree at final plate removal or skeletal maturity. RESULTS: Mean age of the patients and mean BMI at the time of surgery was 13 years (range 12 to 14) and 33.5 kg/m2 (range 31 to 36), respectively. Patients were followed for an average of 22 months (range 13 to 31). Preoperative and last follow-up mean values for MPTA were 81 and 80 degrees, respectively. Outcome of the procedure showed two extremities demonstrated progression of the tibia vara (mean of 6.5 degrees), two extremities had no correction of the deformity, and the remaining two extremities showed minimally improvement (mean 3 degrees). The procedure failed to correct the tibia vara in all extremities and all patients were scheduled for an osteotomy to treat the deformity. CONCLUSION: We do not recommend the use of a tension band plate hemiepiphyseodesis (eight-plate, Orthofix) to treat severe adolescent Blount disease in obese children.

The role of shelf acetabuloplasty in early and late stages of Perthes disease: a meta-analysis of observational studies.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Labral support shelf arthroplasty for containment in early stages of Legg-Calve-Perthes disease.

BACKGROUND: Containment of the hip has become a popular strategy for treatment of severe Legg-Calve-Perthes disease; however, the best method remains unclear. This study describes a minimal-incision variation of the labral support shelf arthroplasty, which uses arthroscopic visualization and an allograft buttress on the shelf support. The outcome in a group of hips undergoing this minimal-incision variation is compared by the Stulberg classification with a group treated by the traditional anterolateral open operative approach. In addition, the outcomes of both groups of labral support shelf arthroplasties are compared then with other containment techniques used in our hospital consisting of Petric cast, varus femoral osteotomy, and innominate osteotomy of Salter. METHODS: Forty-two patients who fulfilled the following criteria underwent a labral support shelf arthroplasty: (1) unilateral hip disease; (2) age equal to or older than 6 years at diagnosis; (3) Catterall group III or IV; and (4) Herring B or C disease. Twenty patients had a traditional open approach (group I) and 22 had an approach using a minimal-incision arthroscopic visualization and allograft buttress on the shelf support (group II). Outcomes by the Stulberg classification were then compared between these groups (I and II) and with 29 cases of Petri casting, 15 of varus femoral osteotomies, or 15 of innominate osteotomies of Salter. RESULTS: There is no statistical difference in Stulberg classification outcomes between group I and group II, which demonstrates that a minimally invasive technique is satisfactory and prevents substantial tissue dissection as is required in a standard anterior lateral approach to the hip, P>0.05. In addition, there is no statistical difference in Stulberg classification outcomes between the labral support shelf arthroplasties and common containment methods such as Petri casting, varus femoral osteotomies, or the innominate osteotomy of Salter, P>0.05. CONCLUSIONS: The labral support shelf arthroplasty by either the traditional method or the minimal-incision variation offers similar Waldenstrom class outcomes when compared with a Petric cast, a varus femoral osteotomy, or an innominate osteotomy of Salter. We believe the labral support shelf arthroplasty technique is simple to perform and does not induce a permanent deformity in the proximal femur or acetubulum.

Possible mistakes in prediction of bone maturation in fibular hemimelia by Moseley chart.

The purpose of this study was to establish a nomogram in order to predict limb length discrepancies in children with unilateral fibular hemimelia more accurately. In 31 children with unilateral fibular hemimelia the femoral-tibial length and skeletal age were determined an average of seven times per case by sequential radiographs during growth. From the data, a skeletal age nomogram was developed which shows a steeply declining mean skeletal age pattern in unilateral fibular hemimelia (the slope in girls was -0.59 and in boys -0.64). This nomogram crosses the normal mean skeletal age line of the Moseley straight-line graph at 10.5 years in girls and at 12 years in boys, and continues to decline until maturity. The results demonstrate an abnormal skeletal maturation process in patients with unilateral fibular hemimelia. The consistently declining steep skeletal age nomogram in unilateral fibular hemimelia makes prediction of skeletal maturity and limb length discrepancy inaccurate by the standard predictive methods particularly when using early skeletal ages. The skeletal age nomogram from our data determines skeletal maturation in children with unilateral fibular hemimelia more accurately, and allows a correct prediction of limb length discrepancy.

Vertebral growth modulation by electrical current in an animal model: potential treatment for scoliosis.

BACKGROUND: The concept of modulating spinal growth to correct scoliosis is intriguing, and this study proposes a new model. Inhibition of vertebral growth on the convex side of a curve would allow continued normal growth on the concave side to correct the scoliosis. In an earlier study, we induced bony bridges across the physis of the femur producing an epiphysiodesis in rabbits by using a stimulator modified to deliver a current of 50 muA. This study builds on this finding to design a model with an aim of inhibiting growth in a unilateral peripheral portion of the vertebral endplate physis, which induces asymmetric spinal growth. METHODS: The study was conducted with 8-week-old rabbits; 6 were treated with electrical current through an implantable 4-lead device; 3 were age-matched normal rabbits. The device was implanted and delivered a constant current of 50 muA from each electrode, continuously for 6 weeks. Weekly radiograph monitoring and endpoint histology were carried out. RESULTS: Spinal growth was modified by inducing asymmetric growth of the vertebra of young rabbits using electric stimulators delivering 50 muA of direct current through electrodes implanted in a left peripheral portion of the endplate physis. CONCLUSIONS: This concept study, based on our earlier study, involved a method and device for inhibiting growth in one aspect of the vertebral endplate using electrical current at an amplitude that induced a hemiepiphysiodesis. Our results showed that this technique both establishes an in vivo model of scoliosis and suggests that if this technique were applied to an existing curve it could potentially induce asymmetrical growth of the spine, thereby correcting scoliosis by continuing the normal growth on the concavity of the curve. CLINICAL RELEVANCE: A potential new method for modulating spinal growth was developed, and, with further research, this method may be useful in treating children with scoliosis by delivering a growth-inhibiting current to the physeal areas of vertebra through electrodes placed percutaneously.

Labral support shelf arthroplasty for the early stages of severe Legg-Calvé-Perthes disease.

The best treatment for Legg-Calvé-Perthes disease remains unknown, and various methods of treatment have been shown to yield conflicting results. Treatment with a labral support shelf arthroplasty is ideal when an increased arc of the acetabulum is needed to contain an enlarged femoral head, when extension of the lateral border of the acetabulum is needed to prevent hinge subluxation, and when a larger surface area is needed for remodeling. Twenty patients with unilateral Catterall classes III and IV and lateral pillar groups B and C disease in the necrotic or fragmentation stage were treated with a shelf arthroplasty. Eleven hips demonstrated hinge subluxation. Success was defined as achievement of a round or oval femoral head, and failure was defined as a flat femoral head. Clinical examination evaluated the presence of pain, limp, and range of motion. Eighteen of the 20 hips (90%) had a successful result. Hinge subluxation was eliminated in all 11 hips. All 18 patients with a successful result had no pain, no limp, and a functional range of motion. The 2 hips considered a failure were in the oldest patients. Treatment with a labral support shelf arthroplasty fostered femoral head sphericity and prevented incongruence in hips otherwise at risk for poor results. Ninety percent of hips had a round or oval femoral head with no pain, no limp, and a functional range of motion.

Electronic monitoring of scoliosis brace wear compliance.

PURPOSE: Accurate evaluation of patient compliance with scoliosis brace usage has been a challenge for physicians treating patients with adolescent idiopathic scoliosis. This inability to accurately measure compliance has resulted in difficulty in determining brace treatment efficacy. This prospective study was performed to demonstrate the efficacy of using a new electronic brace compliance monitor, the Cricket. METHODS: The Cricket is a small encased circuit that can be attached to the brace and, by means of a temperature sensor, can record brace wear times. This study included ten subjects with adolescent idiopathic scoliosis who were prescribed the Wilmington scoliosis brace (thoraco-lumbo-sacral orthosis) into which the Cricket sensor was incorporated. Subjects kept a diary of brace wear times. RESULTS: Comparisons of data for the Cricket, subject diaries, and prescribed brace wear were evaluated. The mean error between the diary times and Cricket recording was 2%. Patient compliance was 78%. CONCLUSIONS: The Cricket is a reliable, accurate, and sensitive device to determine patient compliance with scoliosis brace usage.