Removal of Metaphyseal Screw Only After Hemiepiphysiodesis Correction of Coronal Plane Deformities Around the Knee Joint: Is This a Safe and Advisable Strategy?

PURPOSE: Correcting lower limb angular deformities in the skeletally immature patient with guided growth is a very common procedure. Using an 8-plate construct to produce reversible hemiepiphysiodesis allows correction of the mechanical axis of the limb. It has become routine strategy to remove only the metaphyseal screw from the 8-plate construct after desired correction is achieved, in order to ease its reinsertion in case of deformity recurrence. In this study, we evaluated the efficacy and safety of this technique. METHODS: We reviewed the results of 80 patients (133 limbs) who were treated by guided growth using 8-plate hemiephisiodesis around the knee. After achievement of the correction goal, both screws and plate were removed in 78 limbs while only the metaphyseal screw was removed in 55 limbs. RESULTS: The mean age of patient was 8.9 years at the time of surgery. Within the group whose metaphyseal screw was removed, 12 limbs showed radiographic signs of deformity recurrence and underwent reinsertion of the metaphyseal screw. In 9 of the cases of metaphyseal screw reinsertion, the plate or its location had to be changed (mean follow-up after screw removal was 14 mo). There were 2 cases where leaving the plate with an epiphyseal screw caused a radiographic bone bar and undesired clinical growth arrest. CONCLUSIONS: On the basis of our experience, leaving the 8-plate construct with an epiphyseal screw in place exposes the patient to risks of bony bar, growth arrest, and an additional surgery for hardware removal. The majority of 8-plate constructs are not suitable for reinsertion of the metaphyseal screw.

Treatment of Adolescent Blount Disease Using Taylor Spatial Frame With and Without Fibular Osteotomy: Is There any Difference?

BACKGROUND: In adolescents, Tibia Vara (Blount disease) patients usually present with combination of marked genu varum, procurvatum, and internal tibial torsion. When no growth remaining, standard treatment protocol for correction is osteotomy of the proximal tibia and fibula. In our study we compared 2 groups of patients: group A was treated with fibular osteotomy and group B was treated without fibular osteotomy. METHODS: Twenty-three patients (25 tibias), 21 males and 2 females, mean age of 14.7 years (range, 13 to 21 y) were included in our study. All patients underwent correction with Taylor spatial frame. Group A (with fibular osteotomy) included 11 tibias and group B (no fibular osteotomy) included 14 tibias. Group A underwent correction by proximal tibial and fibular osteotomies (fibula was fixed distally by 2 ilizarov wires to the distal ring). Group B was treated by proximal tibial osteotomy only (fibula was not osteotomized and was not fixed to the tibia). RESULTS: Correction goal was achieved in 9 cases in group A and 12 in group B. Mean time in frame was 15.9 weeks in group A and 14.14 in group B. Mean lengthening was 16.5 mm in group A and 12.8 mm in group B. Mean proximal tibia-fibula distance was 21.1 mm (group A) and 14.9 mm (group B). Mean distal tibia-fibula distance was 9.8 mm (group A) and 9.6 mm (group B). There was no ankle malalignment in both the groups. Complications included pin-tract infection in 11 patients and delayed union in 2 patients (1 in each group). CONCLUSION: We believe that in patients with minimal lengthening as needed in patients with adolescent Tibia Vara correction might be performed safely without osteotomy and fixation of the fibula. LEVEL OF EVIDENCE: Level III.

Correction of residual clubfoot deformities in older children using the Taylor spatial butt frame and midfoot Gigli saw osteotomy.

BACKGROUND: Residual clubfoot deformities in older children are a difficult surgical problem. The foot is stiff and almost always has already undergone some surgical intervention. The traditional approach includes soft-tissue release or osteotomy and external fixation (usually with an Ilizarov frame). METHODS: In this study, we summarized our experience with the treatment of residual clubfoot deformities in older children using a percutaneous midfoot Gigli saw osteotomy and the Taylor spatial frame. There were 11 children in the study, with a mean age of 14.7 years, and mean frame fixation time was 15.1 weeks. Because the primary problems in these children were midfoot and forefoot deformities (forefoot adduction, supination, and cavus), a Butt frame was applied after the midfoot osteotomy. RESULTS: At the time of frame removal, the goal of deformity correction was achieved in all the children. Two patients had partial recurrence of the deformities and were reoperated. One patient with residual supination is planned to be operated close to maturity. Complications included superficial pin-tract infection in 5 patients and premature consolidation of the osteotomy that needed reosteotomy. CONCLUSIONS: On the basis of our experience, we believe that midfoot osteotomy and correction by Taylor spatial frame is an effective and reliable surgical option for this challenging problem. LEVEL OF EVIDENCE: Level 4--case series.

Treatment of arthrogrypotic foot deformities with the Taylor Spatial Frame.

BACKGROUND: Treatment of foot deformities in arthrogryposis is a challenging problem. Most deformities are very rigid clubfeet, such as deformities with severe equinus, supination, cavus, hindfoot varus, and forefoot adduction. Vertical talus with severe rocker bottom is also common. Traditional approaches included casting and soft tissue release, which are usually only partially successful. We describe our experience with the treatment of arthrogrypotic foot deformities with the Taylor Spatial Frame. METHODS: Over a period of 5 years, we treated 7 patients (10 feet) with various arthrogrypotic foot deformities. There were 4 girls and 3 boys with a mean age 10.6 years (range: 4 to 16 y). Six patients had clubfoot deformities and 1 had vertical talus. All patients had previous surgeries, including soft tissue release in 8 feet and Ilizarov correction in 3 feet. Three patients underwent bilateral correction, 3 patients underwent midfoot osteotomies, and 2 patients had supramalleolar osteotomies and lengthening to compensate for growth arrest of the distal tibia. The remaining feet had correction of their deformities by soft tissue distraction. Six patients underwent correction using a Butt frame and 5 by standard frame configuration. RESULTS: All patients achieved the preoperative correction goal and their frames were removed at an average of 16.1 weeks (range: 14 to 18 wk). Complications included pin tract infections in 4 patients. One patient had iatrogenic regenerate translation that was reduced by a residual program, 1 patient had recurrence of equines, and another had partial recurrence of forefoot supination. Two hindfoot varus deformities were successfully treated by calcaneal osteotomy at the time of Butt frame removal. CONCLUSIONS: On the basis of our preliminary experience, we believe that the Taylor Spatial Frame is a reliable and accurate method of correction of complex foot deformities in children with arthrogryposis.

Prevention of ulnar nerve injury during fixation of supracondylar fractures in children by 'flexion-extension cross-pinning' technique.

No consensus exists concerning the best pin configuration for displaced supracondylar fractures of the humerus in children. Although cross-pinning is the most stable biomechanically, this configuration may cause iatrogenic ulnar nerve palsy. For the last 7 years, we have been using a three-pin fixation technique with insertion of two K wires from the lateral side (elbow in full flexion) and the third wire through the medial side (elbow in full extension). We used this technique in 67 displaced supracondylar fractures without any complications related to the ulnar nerve. The technique provides excellent stability and eliminates the risk of iatrogenic ulnar nerve palsy.

Achilles tendon length in children evaluated sonographically.

The purpose of this study was to improve our knowledge of the behavior of the Achilles tendon as a basis for decision-making in Achilles lengthening or tenotomy, we sonographically measured the normal and club feet of 101 babies, mean age 4 months, in standard parameters: tibio-talo-calcaneal angle, length of Achilles tendon, distance from tibia to calcaneus, and distance from a line parallel to the posterior cortex of the tibia to the calcaneus. All measurements were age-matched from birth to 1 year in maximal plantar and dorsal flexion. In conclusion, we describe the normal values for the four parameters in plantar and dorsal flexion. These can serve as a basis for decision-making in clubfoot management.

A novel elastic exsanguination tourniquet as an alternative to the pneumatic cuff in pediatric orthopedic limb surgery.

We describe our experience with a novel surgical exsanguination tourniquet (S-MART; OHK Medical Devices, Haifa, Israel) in clinical pediatric orthopedics. We evaluated the surgical exsanguination tourniquet's properties and clinical use in 51 patients and compared our observations with our long-standing experience with the Esmarch bandage, pneumatic tourniquet and sterile stockinet. Using the surgical exsanguination tourniquet, we found superior exsanguination quality, quick application and the ability to place the occlusion ring closer to the surgical field. No side effects or ischemic complications were observed. After removal, the skin under the ring was intact in all cases. We conclude that the surgical exsanguination tourniquet is safe and valuable in our practice.

Correction of deformities in children using the Taylor spatial frame.

The Taylor spatial frame is a unique external fixator. Despite its growing popularity, few reports on its use have been published. We evaluated the effectiveness of the Taylor spatial frame in the treatment of various deformities in 31 children and adolescents. All but one patient were anatomically corrected. Complications included superficial pin tract infection (45%), three fractures of the femoral regenerate, transient peroneal palsy, and injury to the genicular artery. Despite many challenging problems, our results compared favorably with the results achieved by others. We believe that the Taylor spatial frame is a very capable and accurate fixator for the precise correction of complex deformities.

Treatment of true developmental dysplasia of the hip using Pavlik's method.

Ultrasound is the most sensitive method for detecting hip pathology in the first year of life. However, it has been shown that neonatal sonography, or combined sonographic-clinical screening, can cause some over-diagnosis which, when not used properly, can lead to over-treatment. We developed the concept of 'true developmental dysplasia of the hip' on the basis of our experience. Despite the still-growing popularity of Pavlik's method in the treatment of the condition, we were unable to find a study dealing with the relationship between sex, sonographic and clinical pathology, age at the start of treatment, and duration and outcome of treatment. To answer these questions, we assessed patients we had treated using Pavlik's method in a 5-year period at a special developmental dysplasia of the hip clinic. The influence of sex, clinical stability, severity of sonographic pathology and age when treatment was started was assessed according to duration, outcome of treatment and rate of avascular necrosis. In spite of the relatively small number of hips treated in this study, some conclusions can be drawn. The short period of treatment for clinically unstable hips can be surprising. As treatment was started before the age of 14 weeks, the favorable results can be attributed to this fact. There are hips which, according to our theory, will not improve spontaneously to normal; therefore, we believe that our figures reflect the real results of treatment using Pavlik's method. Practically 0% avascular necorosis for all the treated population (only one child had transient avascular necorosis of type 1) is, in our opinion, due to this fact. The high rate of success (98%) can also be attributed to early treatment.

[Method not stirrups--treating DDH according to Pavlik].

Developmental dysplasia of the hip (DDH), previously termed "congenital dislocation of the hip" (CDH), encompasses a group of related pediatric disorders, some diagnosed soon after birth or later. These include clinical instability of the hip, with or without anatomical dysplasia, subluxation or dislocation. These days, such disorders are usually diagnosed soon after birth, and can develop to normal or worsen to severe disability in time. Most of the hips are not dislocated but all pathological hips show some degree of dysplasia and a minority is dislocated. The keystone to successful treatment of DDH is early diagnosis. Screening is successful only if followed by correct early treatment. Various methods and devices have been proposed for the treatment of DDH. After closed reduction of the hip is done, sometimes with violence, rigid fixation might cause avascular necrosis of the femoral head (AVN). These methods are used less and less, having been replaced by Pavliks method, whereby, if strictly used, the AVN rates are almost zero.

[Practical significance of sonographic type IIa of dysplastic hip joint according to Graf's classifications].

Hip joint assessment in newborns and neonates is currently performed with ultrasonography due to the high degree of sensitivity and specificity of this technology as compared to the usual radiography. Measuring the alpha and beta angles is indicative in assessing the hip joint. The alpha angle represents the bony acetabular components and the beta angle represents the cartilaginous roof. According to Graf's classifications, type IIa is subdivided into two subgroups; type IIa- and IIa+. This study examined the need for following-up on these hip joints in newborn and neonate. The study population included the newborns and neonates born in our facility between the period 1/1/1999 to 1/4/2002. We routinely screened 10,432 newborns both clinically and ultrasonographically. This included a total of 20,862 hip joints, of which 915 were pathological according to Graf's classifications. Type IIa was diagnosed in 232 newborns and a total of 330 hip joints. The follow-up examinations were performed at 6 and 12 weeks of age, and at six months of age. Each follow-up visit included clinical and sonographic evaluation and alpha angle measuring. The incidence of type IIa was 1.6% of all hips and 36.9% of the pathological hip joints. These joints were divided into two subgroups. Group A included 254 hip joints among 156 newborns, 116 girls [74.3%] and 40 boys [25.6%]. Group A members had bilateral or unilateral type IIa hip joints. In the latter case, the other joint was type I-normal. Group B included 76 hip joints among 76 newborns, 72 girls [94.5%] and four boys [5.5%]. Group B members had one type IIa hip joint and a second more severely graded hip joint. Follow-up only was required in 88% of the type IIa hip joints and 12% were treated using Pavlik's method. Surprisingly, all the joints with unilateral type IIa hips developed into normal or type I by six months of age without treatment, independent of the alpha angle value, and the pathology on the opposite side.

New treatment option for sclerosing osteomyelitis of Garré.

Sclerosing osteomyelitis of Garré continues to be a puzzling entity, with a nonspecific clinical description and course, an obscure pathogenesis, and no consensus on a predictable and helpful method of treatment. The proposed treatment options according to the literature are observation, analgesics and NSAIDs, and bone curettage. Here we present a 15-year-old girl treated by resection of a 12 cm-long lesion after failed conservative treatment, followed by bone transport using a circular external fixator. This treatment method has not been described previously for this condition. The duration of bone transport was 3 months, and the total duration of the frame treatment was 12 months. After hardware removal, and at 2.5-year follow-up, the patient was asymptomatic and achieved good functional results. To the best of our knowledge, this is the first description of bone resection and transport for the treatment of this condition, even though it is well described for the treatment of chronic osteomyelitis and other conditions necessitating bone resection. On the basis of this case we suggest that resection and bone transport using a circular external fixator for the treatment of sclerosing osteomyelitis of Garré might be an effective and safe method. Of course, being a rare entity, large cohorts are difficult to obtain, and more data and longer follow-up are required to form a convincing recommendation. Level IV evidence.

Deformity correction using supramalleolar gigli saw osteotomy and Taylor spatial frame: how to perform this osteotomy safely?

Supramalleolar osteotomy (SMO) is useful for the correction of various deformities around the ankle joint,especially deformities of the distal tibia secondary to partial growth arrest, foot equinus, and hind foot deformities. By definition, this osteotomy cuts through the tibia and fibula approximately 2­3 cm above the ankle joint.It can be performed by various techniques, each of them have advantages and disadvantages. Gigli saw SMO can be performed percutaneously with minimal soft tissue dissection, leaving a very smooth bone surface, which is especially useful for the correction of rotational deformities. Over a period of 6 years we performed eight gigli saw SMO in seven male patients and one female patient with a mean age of 13.6 years. All patients had multiplanar deformities with some shortening (range 15­40 mm) and underwent correction and lengthening by Taylor spatial frame. Treatment goal was achieved in all patients with minimal complications. On the basis of our experience, we believe that gigli saw SMO can be performed safely. This osteotomy, in conjunction with the Taylor spatial frame, became our treatment of choice for the correction of ankle and hindfoot deformities.The evidence is level 4, case series.

Submuscular plating of femoral fractures in children: the importance of anatomic plate precontouring.

Despite many treatment options, the treatment of metaphyseal pediatric femoral fractures remains to be controversial. Fixation of most metaphyseal femoral fractures in older children is difficult to perform. Recently, bridging fixation of such fractures by submuscular plating has become popular. Plate precontouring as close as possible to anatomic bony structure is important, as the femur will subsequently reduce to the contour of the plate with screw placement. Our technique is using plates that are anatomically precontoured to a cadaver adolescent femur to ensure proper postoperative alignment. In this study we evaluate the effectiveness of submuscular plating performed in our institution using this technique, in 11 patients. All fractures united with good alignment. No major complication occurred. In conclusion, submuscular plating of adolescent femoral fractures with precontoured plates is an effective, predictable, and safe procedure.

Treatment duration of developmental dysplasia of the hip: age and sonography.

We retrospectively assessed babies treated according to Pavlik's method and followed up in our outpatient clinic between the years 2001 and 2005, investigating the influence of age at onset of treatment and severity of sonographic pathologies on the rates of avascular necrosis and treatment duration of 343 pathological hips in 311 neonates. No osteonecrosis was observed at the 1-year follow-up. Early detection of developmental dysplasia of the hip and early initiation of treatment using Pavlik's method are important in preventing osteonecrosis, and have high success rates. When using Pavlik's method for treating developmental dysplasia of the hip, starting treatment at 13 weeks and later increases the duration of treatment.

Treatment of complex tibial fractures in children with the taylor spatial frame.

Most tibial shaft fractures in children can be treated with closed reduction and cast fixation, but some fractures need external or internal fixation. The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a relatively new external fixator that can correct 6-axis deformities with computer accuracy. This article reports our experience using the Taylor spatial frame as a rewarding treatment modality for complex tibial fractures in children and adolescents.

Treatment of complex foot deformities in children with the taylor spatial frame.

The Taylor spatial frame is a relatively new external fixator able to correct 6-axis deformities with computer accuracy using a virtual hinge. The Taylor spatial frame has gained tremendous popularity, but its use for the correction of foot deformities is still limited. Various ring configurations and a new foot program have recently become available and allow correction of the most difficult foot deformities. This article reports the results of 13 patients (15 frames) with various foot deformities treated at our institution with 3 different Taylor spatial frame configurations (standard rings construction, miter frame, and butt frame). Treatment goals were achieved in 11 patients, while mild residual deformities persisted in 2 patients. Most complications during treatment consisted of pin tract infections. One patient had premature consolidation, which was treated with additional midtarsal osteotomy; 1 had metatarsophalangeal joint subluxation, which was fixed with tendon lengthening and pining of the joint; and 1 had talar subluxation, which was reduced with residual program correction. Based on our experience, we believe the Taylor spatial frame is a very powerful and accurate surgical modality with a relatively short learning curve for the correction for most difficult foot deformities.

The use of the Taylor spatial frame in adolescent Blount's disease: is fibular osteotomy necessary?

BACKGROUND: The standard treatment of adolescent Blount disease includes proximal tibial osteotomy and osteotomy of the fibula. Some believe that the fibula should also be fixed to prevent migration and subluxation. The purpose of the current study was to examine the results of treatment of patients with adolescent tibia vara treated by tibial osteotomy and Taylor spatial frame (TSF) without fibular osteotomy. METHODS: Correction of deformities was performed on eight patients (ten tibias) with adolescent Blount disease using TSF. The fibula was not osteotomized in any patient and was not fixed in the last five patients. RESULTS: All patients had precise anatomical correction of deformities and no problems related to the fibula occurred during or after correction. CONCLUSION: Based on our experience we believe that placement of the origin at the level of the proximal tibial fibular joint in conjunction with external fixation eliminates the need for fibular osteotomy and the potential morbidity of this procedure in patients with mild to moderate tibia vara.

Neonatal incidence of hip dysplasia: ten years of experience.

UNLABELLED: The advantages of sonographic examination are well known, but its main disadvantage is that it might lead to overdiagnosis, which might cause overtreatment. Variations in the incidence of developmental dysplasia of the hip are well known. We ascertained the incidence of neonatal sonographic developmental dysplasia of the hip without considering the development of those joints during followup. All 45,497 neonates (90,994 hips) born in our institute between January 1992 and December 2001 were examined clinically and sonographically during the first 48 hours of life. Sonography was performed according to Graf's method, which considers mild hip sonographic abnormalities as Type IIa. We evaluated the different severity type incidence pattern and its influence on the total incidence during and between the investigated years. According to our study, sonographic Type IIa has major effects on the incidence of overall developmental dysplasia of the hip with a correlation coefficient of 0.95, whereas more severe sonographic abnormalities show relatively stable incidence patterns. LEVEL OF EVIDENCE: Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of Graf's ultrasound class III and IV hips using Pavlik's method.

UNLABELLED: When Pavlik introduced his method of treating congenital dislocation of the hip, he emphasized reducing the rate of osteonecrosis. Graf's method of sonographic evaluation afforded earlier accurate diagnosis and subsequent treatment of developmental dysplasia of the hip. To ascertain whether treatment duration, gender, age at diagnosis, clinical stability, and/or treatment onset correlate with the risk of osteonecrosis in Graf Type III or IV hips, we clinically and sonographically screened 18,067 neonates (36,134 hips) for developmental dysplasia of the hip over a 4-year period; 151 had Graf Type III or IV hips, and 78 of these were treated by us and had known outcomes. Of these 78 hips, 65 (0.18%) had Graf Type III and 13 (0.036%) had Graf Type IV hips. Sixteen of the 65 Type III hips (25%) reduced spontaneously. Using Pavlik's method, reduction was achieved in 46 of 65 (88.5%) Type III hips and eight of 13 Type IV hips. None of the hips treated exclusively by Pavlik's method developed osteonecrosis. Thus, the method achieves one of Pavlik's original goals of decreasing osteonecrosis incidence to close to zero. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.