The Fate of DDH Hips Showing Cartilaginous or Fibrous Tissue-filled Joint Spaces Following Primary Reduction.

BACKGROUND: Because the use of magnetic resonance imaging is still not universal for the patients with developmental dysplasia of the hip patients, orthopaedists do not generally distinguish widened joint spaces which are "empty" after primary treatment (and therefore still reducible), from those which are filled and much more difficult to treat. To date no studies have focused on the latter hips. We treated and observed the outcomes for 19 hips which showed filled joint spaces after primary treatment. METHODS: We retrospectively reviewed 19 cases of developmental dysplasia of the hip: (1) who showed a widened joint space on radiographs after primary treatment; and (2) whose magnetic resonance imaging showed that the widened joint space was accompanied by acetabular cartilage hypertrophy and/or was filled with fibrous tissues. All patients were over 1 year old at the time of primary reduction (reduction was closed in 4 patients, open in 6, and open with pelvic osteotomy in 9). Thirteen patients received at least 1 secondary treatment. Final results were classified using a modified Severin classification. RESULTS: Final outcomes were satisfactory in 10 (52.6%) and unsatisfactory in 9 (47.4%). The widened joint spaces gradually filled with bone, resulting in a shallow acetabulum in the patients with unsatisfactory results. Of 9 patients who underwent combined pelvic osteotomy at the time of primary reduction, results were satisfactory in 6 (66.7%), whereas all patients who had only closed or open primary reduction had unsatisfactory results. CONCLUSIONS: Combined pelvic osteotomy at the time of primary reduction is advisable in hips with widened joint spaces. However, hips with filled joint spaces after primary treatment often have unsatisfactory results even after additional pelvic and/or femoral osteotomy. LEVEL OF EVIDENCE: Level IV-prognostic study.

A Graphic Overlay Method for Selection of Osteotomy Site in Chronic Radial Head Dislocation: An Evaluation of 3D-printed Bone Models.

PURPOSE: Three-dimensional (3D) computed tomography imaging is now being used to generate 3D models for planning orthopaedic surgery, but the process remains time consuming and expensive. For chronic radial head dislocation, we have designed a graphic overlay approach that employs selected 3D computer images and widely available software to simplify the process of osteotomy site selection. METHODS: We studied 5 patients (2 traumatic and 3 congenital) with unilateral radial head dislocation. These patients were treated with surgery based on traditional radiographs, but they also had full sets of 3D CT imaging done both before and after their surgery: these 3D CT images form the basis for this study. From the 3D CT images, each patient generated 3 sets of 3D-printed bone models: 2 copies of the preoperative condition, and 1 copy of the postoperative condition. One set of the preoperative models was then actually osteotomized and fixed in the manner suggested by our graphic technique. Arcs of rotation of the 3 sets of 3D-printed bone models were then compared. RESULTS: Arcs of rotation of the 3 groups of bone models were significantly different, with the models osteotomized accordingly to our graphic technique having the widest arcs. CONCLUSIONS: For chronic radial head dislocation, our graphic overlay approach simplifies the selection of the osteotomy site(s). Three-dimensional-printed bone models suggest that this approach could improve range of motion of the forearm in actual surgical practice. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Does valgus femoral osteotomy improve femoral head roundness in severe Legg-Calvé-Perthes disease?

BACKGROUND: Many surgeons perform a varus femoral or Salter pelvic osteotomy in patients with Legg-Calvé-Perthes (LCP) disease. However, more severely deformed femoral heads show greater congruency in adduction rather than in abduction. Therefore, a valgus-(flexion) femoral osteotomy (VFO) seems preferable rather than a varus femoral or Salter pelvic osteotomy. QUESTIONS/PURPOSES: We evaluated whether the VFO improves (1) femoral head roundness, (2) radiographic parameters reflecting hip subluxation, and (3) function. METHODS: We treated 25 patients (25 hips; 18 lateral pillar C and seven B) in the late fragmentation stage by VFO. Seven patients had additional pelvic procedures. VFO was performed at a mean age of 9.8 years. Three hips were Stulberg Class II, 20 were Class III, and two were Class IV. The following components of femoral head roundness were calculated from preoperative MRI and final radiographs: lateral and medial head roundness (LHR and MHR); anterior and posterior head roundness (AHR and PHR); central head height; and the ratios MHR/LHR and PHR/AHR. Continuity of Shenton's line, medial gap ratio were evaluated. Function was determined with the Iowa hip score. Minimum followup was 3.1 years (mean, 6.3 years; range, 3.1-11.2 years). RESULTS: All femoral head roundness measurements improved, with greatest improvement in the lateral and anterior head. Pillar C hips showed greater relative improvement than pillar B hips. The continuity of Shenton's line improved and the mean medial gap ratio decreased. Mean Iowa hip score improved from 71 before surgery to 90 at the last followup. CONCLUSIONS: VFO appears to help the deformed femoral head in the fragmentation stage to remodel to fit the acetabulum. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Metatarsal lengthening by callotasis in adults with first brachymetatarsia.

BACKGROUND: Brachymetatarsia is a rare clinical entity that presents a challenging problem for surgeons. One-stage lengthening with an autologous bone graft has been preferred for metatarsals that require a limited lengthening. With a gradual lengthening of metatarsals, callus distraction (callotasis) can achieve a greater length gain and a concomitant lengthening of the soft tissue. This article presents results of callotasis for adults with first brachymetatarsia. METHODS: The outcomes of nine cases of first brachymetatarsia in five adult patients who underwent metatarsal lengthening by callotasis between March 1999 and February 2005 were retrospectively reviewed and analyzed. RESULTS: The average length gain was 16.4 mm and the average lengthening percentage was 43.7%. In addition, the average healing index was calculated as 3.8 months/cm, which was higher than that reported previously in the fourth brachymetatarsia. CONCLUSION: It was concluded that the period of bony consolidation following callotasis is longer in the first brachymetatarsia than in the fourth brachymetatarsia. Presumably, this might be because of the anatomically larger osteotomized cut surface and its weight-bearing function.

MR imaging as a supplement to traditional decision-making in the treatment of LCP disease.

BACKGROUND: Heretofore, the general concept in treating Legg-Calve-Perthes (LCP) disease has been containment of the diseased femoral head into the acetabulum. However, surgery or bracing for containment of a deformed femoral head without accurate information on its dynamic relationship with the hip may aggravate hip congruity and lead to impingement between the femoral head and the acetabulum. We used magnetic resonance imaging on an outpatient clinic basis to evaluate the relationship between the deformed femoral head and the acetabulum in moderate-to-severe LCP disease, and applied these findings to management. METHODS: For 103 moderately and severely affected LCP patients (mean age 7.5 y), we made a total of 151 range of motion-magnetic resonance imagings (termed range of motion as each patient was scanned in 5 positions: neutral, abduction, abduction-internal rotation, abduction-internal rotation-flexion, and adduction). For each position, we calculated epiphyseal extrusion index (EEI), head coverage (HC), and medial gap ratio (MGR), and looked for differences between parameter values in neutral and the other positions. Disease severity was noted for each patient according to 3 classification systems (lateral pillar, Catterall, and Salter-Thompson), and differences in parameter values were examined for the various severity grades. The position of greatest congruity, and adjacent soft tissue changes, were also noted. Stulberg results were obtained for 54 patients who had reached skeletal maturity. RESULTS: For moderately affected (lateral pillar-B) patients, all 3 parameters (EEI, HC, and MGR) improved on abduction, supporting traditional containment theory. For severely affected (lateral pillar-C) patients, EEI and HC improved on abduction, but MGR did not, indicating hinge abduction by the deformed femoral head. The results do not seem to be greatly affected by 1 of the 3 classification systems which we use. In these patients, congruency was improved in adduction, and was aided by the surrounding soft tissues. Our pillar-B patients were treated conservatively and had mostly Stulberg I and II outcomes. Both conservative and operative treatment of our pillar-C patients resulted in mostly Stulberg III outcomes. CONCLUSIONS: For moderately affected patients, we support traditional treatment aimed at containment of the diseased femoral head into the acetabulum. For severely affected patients who show improved congruency in adduction, a valgus femoral osteotomy, aimed at achieving stable congruency rather than containment, may be used as a primary treatment to minimize acetabulofemoral impingement. LEVEL OF EVIDENCE: Therapeutic study, level II.

Preoperative plan for corrective osteotomy of the hip: a method using picture-editing software.

BACKGROUND: As the Picture Archiving and Communication System (PACS) has been adopted by many health centers for radiographic image storage and analysis, fewer and fewer physicians are using radiographic films and the traditional paper-drawing technique for creating preoperative surgical plans. Therefore, a new technique is required using the digital images in stored PACS. Any new method should not only be easy to perform while accurately reflecting the actual techniques of hip osteotomy, but also it should hopefully not require the purchase of expensive software. METHODS: We developed a method using widely available commercial image-editing software (Adobe Photoshop and Microsoft PowerPoint) that works with preoperative anteroposterior and lateral radiographs in stored PACS. To compare our technique with the traditional paper-drawing approach, we measured the time it took for 5 orthopaedic residents to prepare 1 surgical plan using each technique, for 6 different procedures (3 femoral osteotomy and 3 femoral plus pelvic osteotomy). RESULTS: The new method has been used in planning surgery on 133 hips. For femoral osteotomy, the average time required for the traditional and new techniques was 54 and 49 minutes, respectively; whereas for a combined femoral and pelvic osteotomy, the traditional technique took 71 minutes compared with 63 for the new approach. CONCLUSIONS: The new technique is not only cost effective and easy to learn, but also is more efficient and clearer than the conventional method using hand-made drawings, thus making the surgery itself easier to perform. LEVEL OF EVIDENCE: Level III, therapeutic study.

Fibrous hamartoma of infancy in the hand: unusual location and MR imaging findings.

Fibrous hamartomas of infancy (FHIs) are benign, poorly-circumscribed, soft tissue growths presenting during the first 2 years of life and characteristically affecting the axilla, upper arm, upper trunk, inguinal region, and external genital area. Involvement of the hands and feet is extremely rare. We report a case of FHI unusually occurring in a deep portion of the hand. MRI revealed atypical features similar to that of a vascular malformation, hemangioma, fibromatosis, or neurofibromatosis of the hand. Partial resection of the mass was performed to correct the contracture of the second finger and an additional operation was not performed because of the benign nature of FHIs.

Anterolateral Approach in the Treatment of Femoroacetabular Impingement of the Hip.

Background: Ganz surgical hip dislocation via a posterior (Kocher-Langenbeck) approach is a popular procedure in the management of femoroacetabular impingement (FAI). We report the results of surgery performed through an anterolateral (Watson-Jones) approach in the management of anterolateral FAI. Methods: Twenty-one hips in 20 patients (mean age at the time of operation, 17.3 years) were treated surgically using an anterolateral approach: 12 hips with Legg-Calvé-Perthes disease, three septic hips, three hips with avascular necrosis (combined with slipped capital femoral epiphysis [SCFE], femoral neck fracture, and developmental dislocation of the hip), two hips with epiphyseal dysplasia, and one hip with SCFE. All patients had anterolateral FAI. Surgical hip dislocation was performed in four hips with trochanteric osteotomy. Combined osteotomies were for neck lengthening in 11 hips, varus or valgus osteotomy in the proximal femur in four hips, and pelvic osteotomy in four hips. Clinical results were evaluated using a modified Harris hip score (mHHS). Results: Range of hip flexion and abduction showed statistically significant improvement after surgery; however, the improvement in mean mHHS was not statistically significant. Conclusions: An anterolateral approach can be used as an alternative to a posterior approach in the management of anterolateral FAI with or without hip dislocation while safely preserving the blood supply to the femoral head and allowing simultaneous procedures in the proximal femur.

Corrigendum to "Anterolateral Approach in the Treatment of Femoroacetabular Impingement of the Hip".

[This corrects the article on p. 337 in vol. 11, PMID: 31475056.].

The proximally-based sural artery flap for coverage of soft tissue defects around the knee and on the proximal third and middle third of the lower leg: 10 patients followed for 1-2.5 years.

BACKGROUND AND PURPOSE: There have been few reports regarding the proximally based sural artery flap, which is useful for reconstruction of soft tissue defects around the knee and on the proximal third and middle third of the lower leg. Here we report our experience with 10 patients. PATIENTS: The defects in our 10 cases were around the knee (4), on the proximal third of the lower leg (4), and on the middle third (2). 8 patients had fasciocutaneous flaps and 2 had adipofascial flaps. The flap size ranged from 4 to 10 cm in length, and from 5 to 8 cm in width. The pedicle length ranged from 12 to 20 cm. RESULTS: All 10 flaps survived. Congestion and tip necrosis occurred in 1 case with a fasciocutaneous flap, which healed without complications. A superficial infection occurred in 1 case with a fasciocutaneous flap, which healed with antibiotic treatment. Necrosis of grafted skin occurred in 2 cases of adipofascial flap; only one of them, however, required additional surgery. No morbidity of the donor site and no functional deficits were detected in any of the 10 cases. INTERPRETATION: The proximally based sural artery flap is useful for reconstruction of soft tissue defects around the knee joint and on the proximal third and middle third of the lower leg. It is a relatively easy and reliable procedure.

Treatment of Brachymetatarsia Involving the Great Toe.

BACKGROUND: Brachymetatarsia is usually treated by lengthening the metatarsals, but excessive lengthening can be associated with complications. Our technique combines 1-stage step-cut lengthening of the first metatarsal with shortening and/or lengthening of the neighboring metatarsals and/or phalanges. METHODS: Twenty-four feet (15 patients) were treated for first-ray brachymetatarsia. Widely available commercial image-editing software was used to make a preoperative plan for each patient, with emphasis on the creation of a cosmetically satisfying toe-length arc with minimum shortening and lengthening of the affected metatarsals and proximal phalanges. Length gain and percentage increase were also recorded postoperatively. The American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scoring system was used for clinical evaluation. RESULTS: In all 24 feet, smooth parabolas were created at the level of the metatarsal heads and at the toe tips. All patients showed osseous union, and no complications were noted. However, most patients showed mildly restricted range of motion of the first metatarsophalangeal joint. The mean AOFAS score of the hallux significantly improved from 88.3 preoperatively to 98.1 at the latest follow-up (p < 0.001). CONCLUSIONS: One-stage step-cut lengthening of the first metatarsal combined with shortening and/or lengthening of the adjacent metatarsal and phalangeal bones provides excellent cosmetic and functional results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Double-Layered Lateral Meniscus Including a Ring-Shaped Accessory Meniscus: A Case Report.

CASE: We report the rare case of a double-layered lateral meniscus that was comprised of a normal meniscus and a ring-shaped accessory meniscus. An 11-year-old boy presented with left knee pain, and magnetic resonance imaging initially was interpreted as showing a horizontal meniscal tear. However, arthroscopic exploration revealed a double-layered meniscus. A superior accessory meniscus was fused with the inferior normal meniscus at the posterior horn and had more mobility compared with the normal meniscus. The symptoms improved substantially after resection of the superior accessory meniscus. The patient returned to sports at 4 months postoperatively; at 15 months postoperatively, radiographs demonstrated no evidence of degenerative changes. CONCLUSION: A double-layered lateral meniscus that includes a ring-shaped accessory meniscus is a rare abnormality that can be corrected arthroscopically by resection of the accessory meniscus.

Role of mitogen-activated protein kinase (MAPK) in troglitazone-induced osteoblastic cell death.

Troglitazone, a PPARgamma agonist, has been reported to induce cell death on different cell types. However, its mechanism of action remains unclear. The present study was undertaken to investigate the effect of troglitazone on cell death and to determine its underlying mechanism in MC3T3-E1 cells, an established osteoblast cell line. Troglitazone induced loss of cell viability in a dose- and time-dependent manner, which was accompanied by apoptosis. Troglitazone increased reactive oxygen species (ROS), but troglitazone-induced cell death was not affected by the antioxidant N-acetylcysteine, suggesting that the ROS generation is not involved in the cytotoxicity of troglitazone. Troglitazone-induced cell death was prevented by the PPARgamma antagonist GW9662. Troglitazone treatment inhibited activation of extracellular signal-regulated protein kinase (ERK) and stimulated p38 activation. Troglitazone-induced cell death was increased by the ERK inhibitor U0126 and prevented by transfection with constitutively active MEK1 and the p38 inhibitor SB203580. Troglitazone induced depolarization of mitochondrial membrane potential and its effect was blocked by SB203580 and GW9662. Caspase-3 was activated by troglitazone treatment and pharmacological inhibition of caspase blocked troglitazone-induced cell death. Taken together, these data suggest that troglitazone induces apoptosis via a caspase-dependent mechanism associated with down-regulation of ERK and up-regulation of p38.

Analysis of Radiographic Parameters of the Forearm in Traumatic Radial Head Dislocation.

BACKGROUND: Various deformities can occur in the forearm bones when the traumatically dislocated radial head is untreated for a long period. Without correction of all deformities, reduction of the dislocated radial head is difficult to maintain, and forearm and elbow motion will deteriorate after reduction. We evaluated radiographic parameters of forearms with traumatically dislocated radial heads (and of the normal sides) to understand the resulting deformities and the effectiveness of surgical treatment. METHODS: We analyzed pre- and postoperative anteroposterior and lateral radiographs of 22 forearms (22 patients) with traumatic radial head dislocation. We divided the forearm into three equal parts and measured various morphological parameters. All patients underwent surgical treatment and evaluation of radial head reduction and range of motion pre- and postoperatively. RESULTS: Before treatment, the middle of the ulna was significantly different from the unaffected side in both anteroposterior and lateral views. After surgery, the proximal ulna was significantly different from the unaffected side and the abnormal proximal radial neck angle persisted. The radial head was successfully reduced in 20 of 22 cases. Overall, the mean range of motion decreased after surgery, except for increased flexion-extension. CONCLUSIONS: Complicated deformities developing during long-term remodeling after injury indicate that stable reduction is difficult to achieve with conventional one-bone osteotomy. Even after successful reduction, secondary deformity in the proximal ulna and/or remaining deformity in the proximal radius can hinder forearm rotation.

Interaction of stem cells with nano hydroxyapatite-fucoidan bionanocomposites for bone tissue regeneration.

The combination of bioceramics with biopolymers are playing major role in the construction of artificial bone. Hydroxyapatite (HA) has been extensively studied as a material in bone repair and replacement in last two decades. In the present study, we have prepared the hydroxyapatite-fucoidan (HA-Fucoidan) nanocomposites by in situ chemical method and biologically characterized them for bone graft substitute. Biological results inferred that mineralization effect of HA-F nanocomposites shows significant enhancement compared to HA in adipose derived stem cell (ADSC). It may be due to the addition of fucoidan in the nanocomposites. The important gene expression such as osteocalcin, osteopontin, collagen and runx-2 were checked using ADSC with HA and HA-fucoidan nanocomposites and the results show that the enhancements were found at 7th day. Furthermore, we have performed in vivo study of HA-fucoidan nanocomposites with rabbit model and a slight amount of bone formation was observed in HA-fucoidan nanocomposites. Herewith, we suggest that HA-fucoidan nanocomposites will be good biomaterials for bone repair/replacement in future.

Role of mitogen-activated protein kinases in hydrogen peroxide-induced cell death in osteoblastic cells.

Oxidative stress is known to induce cell death in a wide variety of cell types, apparently by modulating intracellular signaling pathways. However, the underlying mechanism by which oxidants induce cell death remains unclear. The present study was undertaken to determine the role of the mitogen-activated protein kinase subfamilies in hydrogen peroxide (H2O2)-induced cell death of osteoblastic cells. H2O2 resulted in a time- and dose-dependent cell death, which was, in part, attributed to apoptosis. H2O2-induced cell death was prevented by iron chelator, hydroxyl radical scavengers. But H2O2-induced cell death was not affected by 3-aminobenzamide, an inhibitor of poly (ADP-ribose) polymerase activation. H2O2 treatment caused a transient activation of extracellular signal-regulated kinase (ERK), followed by sustained activation. Cell death induced by H2O2 was prevented by PD98059, an inhibitor of ERK upstream kinase MEK1/2. But H2O2 induced a transient activation of p38 and c-Jun N-terminal kinase (JNK) without sustained activation and inhibitors of these kinses were not effective in preventing the cell death. H2O2 increased Bax expression and produced hyperpolarization of mitochondrial membrane potential and its effect was prevented by PD98059. The ERK activation and cell death induced by H2O2 were not dependent on the phosphorylation of epidermal growth factor receptor. Taken together, these findings suggest that the ERK signaling pathway plays an active role in mediating H2O2-induced apoptosis of osteoblasts and functions upstream of mitochondria-dependent pathway to initiate the apoptotic signal.

Management of cubitus varus and valgus.

BACKGROUND: Many types of osteotomy have been proposed for the treatment of cubitus varus and valgus, but they have limitations, such as poor internal fixation, residual protrusion of the lateral or medial condyle, technical difficulty, the need for long-term immobilization, a risk of neurovascular injury, and patient discomfort. We reviewed the results of a simple step-cut translation osteotomy that overcomes these limitations. METHODS: Between 1993 and 2002, we treated nineteen cases of cubitus varus and thirteen cases of cubitus valgus with use of a simple step-cut translation osteotomy and fixation with a Y-shaped humeral plate. After surgery, the patients were observed closely for more than one year. We compared preoperative and postoperative humerus-elbow-wrist angles, ranges of motion, and lateral or medial prominence indices for all patients. The results were evaluated according to the modified criteria of Oppenheim et al. The presence of tardy ulnar nerve palsy and its duration, and postoperative lazy-s deformity or unsightly scarring, were also noted. RESULTS: There were twenty-six excellent and six good results. In the nineteen patients with cubitus varus, the average amount of correction of the humerus-elbow-wrist angle was 26.0 degrees , to a mean postoperative angle of 8.6 degrees , and the average increase in the lateral prominence index was 8.2%. In the thirteen patients with cubitus valgus, the average correction in the humerus-elbow-wrist angle was 27.6 degrees , resulting in a final angle of 9.1 degrees , and the average increase in the medial prominence index was 11.9%. In all patients, the desired range of motion, good alignment, and complete union of the bone were achieved. CONCLUSIONS: Step-cut translation osteotomy, with a wedge-shaped osteotomized surface, fixed with a Y-shaped humeral plate is a relatively simple procedure resulting in very firm fixation that allows early movement of the joint with good clinical results.

Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications.

BACKGROUND: Accurate and reliable radiographic classifications of the relative severity and outcome of Legg-Calve-Perthes disease are essential in the study of that disease. As part of a prospective multicenter study, we sought to define more clearly the lateral pillar classification of severity and the Stulberg classification of outcome; we sought especially to define the borderlines between classification groups. METHODS: We performed interobserver and intraobserver trials of the lateral pillar and Stulberg classifications using sets of twenty radiographs chosen from a prospective study of 345 hips. To establish reliable definitions of the lateral pillar classification, we added a new, intermediate group termed the B/C border group, which includes femoral heads with a thin or poorly ossified lateral pillar and those with a loss of exactly 50% of the original height of the lateral pillar. The resulting classification consists of four groups: A, B, B/C border, and C. In our application of the classification system of Stulberg et al., we defined a class-II femoral head as round and fitting within 2 mm of a circle on both anteroposterior and frog-leg lateral radiographs. We defined a Stulberg class-III femoral head as out of round by more than 2 mm on either view and a Stulberg class-IV femoral head as one with at least 1 cm of flattening of the weight-bearing articular surface. To assess interobserver and intraobserver agreement, we performed two trials of each classification with six orthopaedic surgeons reviewing twenty radiographs or pairs of radiographs. RESULTS: In the first trial of the lateral pillar classification, there was 81% agreement per radiograph and the average weighted kappa was 0.71. In the second trial, there was 85% agreement per radiograph and the weighted kappa averaged 0.79. Intraobserver reliability testing showed a 77% match between Trials 1 and 2, an average weighted kappa of 0.81, and an average generalizability coefficient of 0.91. In Trial 1 of the Stulberg classification, there was 91% agreement per radiograph and an average weighted kappa of 0.82. In Trial 2, there was 92% agreement per radiograph and an average weighted kappa of 0.82. Intraobserver reliability testing showed an 89% match between Trials 1 and 2, an average weighted kappa value of 0.88, and an average generalizability coefficient of 0.92. CONCLUSIONS: The interobserver and intraobserver trials of these classifications produced kappa values and generalizability coefficients in the excellent range. The modified lateral pillar classification and the redefined Stulberg classification are sufficiently reliable and accurate for use in studies of Legg-Calve-Perthes disease.

Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome.

BACKGROUND: The treatment of Legg-Calve-Perthes disease has been based on uncontrolled retrospective studies with relatively small numbers of patients. This large, controlled, prospective, multicenter study was designed to determine the effect of treatment and other risk factors on the outcome in patients with this disorder. METHODS: We enrolled 438 patients with 451 affected hips in a prospective multicenter study in which each investigator applied the same treatment method to each of his or her patients. The five treatment groups consisted of no treatment, brace treatment, range-of-motion exercises, femoral osteotomy, and innominate osteotomy. All patients were between 6.0 and 12.0 years of age at the onset of the disease, and none had had prior treatment. Three hundred and forty-five hips in 337 patients were available for follow-up at skeletal maturity. All hips were classified with the modified lateral pillar classification and the system of Stulberg et al. RESULTS: There were no differences in outcome among the hips with no treatment, those treated with bracing, and those treated with range-of-motion therapy. There were also no differences between the hips treated with a femoral varus osteotomy and those treated with an innominate osteotomy. Treatment did not have a significant effect on children who had a chronologic age of 8.0 years or less or a skeletal age of 6.0 years or less at the onset of the disease. In the lateral pillar B group and B/C border group, the outcomes of surgical treatment were significantly better than those of nonoperative treatment in children over the age of 8.0 years at the onset of the disease (p < or = 0.05). Patients who were 8.0 years old or less at the onset of the disease in lateral pillar group B did equally well with nonoperative and operative treatment. Hips in lateral pillar group C had the least favorable outcomes, with no differences between the operative and nonoperative groups. The lateral pillar classification (p < 0.0001) and the age at the onset of the disease (p = 0.0001) were both strong prognostic factors. Female patients did significantly worse than male patients if they were over the age of 8.0 years at the onset of the disease (p = 0.004). CONCLUSIONS: The lateral pillar classification and age at the time of onset of the disease strongly correlate with outcome in patients with Legg-Calve-Perthes disease. Patients who are over the age of 8.0 years at the time of onset and have a hip in the lateral pillar B group or B/C border group have a better outcome with surgical treatment than they do with nonoperative treatment. Group-B hips in children who are less than 8.0 years of age at the time of onset have very favorable outcomes unrelated to treatment, whereas group-C hips in children of all ages frequently have poor outcomes, which also appear to be unrelated to treatment.

Z-lengthening of the Achilles tendon with transverse skin incision.

BACKGROUND: The risk of various complications after Achilles tendon lengthening is mainly related to the length of surgical exposure and the lengthening method. A comprehensive technique to minimize the complications is required. METHODS: The treatment of Achilles tendon tightness in 57 patients (95 ankles) were performed by using a short transverse incision on a skin crease of the heel and by Z-lengthening of the tendon. In the severe cases, two or three transverse incisions were required for greater lengthening of the tendon, and a serial cast or Ilizarov apparatus was applied for the gradual correction. The results of these 95 ankles were compared to those of 18 ankles, which underwent percutaneous sliding lengthening, and to the 19 ankles, which received Z-lengthening with a medial longitudinal incision. RESULTS: The functional and cosmetic satisfaction was achieved among those who underwent the tendon lengthening with the new technique. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score improved from 56.1 to 81.8. The second operations to correct recurrence were performed in the two cerebral palsy patients. CONCLUSIONS: The new technique has a low rate of complications such as scarring, adhesion, total transection, excessive lengthening, and recurrence of shortening. The excellent cosmesis and the short operation time are the additional advantages.