Outcome of Open Reduction Alone or with Concomitant Bony Procedures for Developmental Dysplasia of the Hip (DDH).

Introduction: Developmental dysplasia of the hip (DDH) is commonly managed in a tertiary centre and regularly involves surgical treatment. The aim of this study is to determine the surgical outcome of DDH patient treated with either open reduction alone or combined with bony procedures in our institution. Methods: Medical records of DDH patients treated surgically were reviewed. Patients were divided into two groups: Group A: underwent open reduction (OR) only; and Group B: underwent open reduction with additional bony procedures (ORB), such as pelvic or femoral osteotomy. Modified McKay classification was used to evaluate the clinical outcome, and Severin classification for the radiological outcome. Presence of avascular necrosis and other post-operative complications were recorded. Results: A total of 66 patients (76 hips) were reviewed with the mean age of 11.9 ± 4.8 years. Mean duration of follow up was 8.6 ± 4.7 years (ranged 2 to 23 years). From our sample, 50/66 patients (75.8%) achieved satisfactory clinical outcome, whereas 48/66 patients (72.7%) had satisfactory radiological outcome. A higher proportion of patients achieved satisfactory outcomes in the OR group compared to the ORB group (p < 0.05), but no difference was seen in terms of radiological outcome (p = 0.80). Overall, 23 hips (34.8%) developed radiographic evidence of avascular necrosis (AVN). Nineteen hips had undergone ORB, although they were mainly (63.2%) Grade I AVN. Incidence of AVN was comparable in both groups (p = 0.63), but presence of AVN led to a higher proportion of unsatisfactory clinical and radiological outcome (p < 0.05). Other complications included redislocation/subluxation (13.6%) and bleeding (0.1%). Conclusions: Good overall outcome of DDH surgery was achieved in our centre. The OR group may produce a better clinical outcome, but with similar radiological results and AVN rate with the ORB group. The presence of AVN is associated with unsatisfactory clinical and radiological outcomes.

Knee measurements among children with normal alignment, physiologic and pathologic bowing aged 0-3 years old: a systematic review.

Distinguishing physiologic and pathologic genu varus is challenging among children below age 3. They can be assessed by measuring intercondylar distance (ICD), clinical tibiofemoral angle (cTFA) or radiologic TFA (rTFA). We aim to determine the knee measurement values among three groups of children. Medline (1946-) and EMBase (1947-) were searched until 31 July 2020 using a search strategy. Studies with original data which reported knee measurements among children with normal alignment, physiologic and pathologic bowing between the ages of 0-3 years were included. In total 1897 studies were identified, and 16 studies included after title and abstract screening. These studies involved 1335 patients with normal alignment, 286 with physiologic and 184 with pathologic bowing. Five studies provided data on ICD, seven on cTFA and eight on rTFA which were pooled for meta-analyses. Normal children had neither measurable ICD nor demonstrable varus on cTFA after 19 months old. The mean (95% confidence interval) ICD for children with pathologic genu varus at 18 months was 4.41 (4.19-4.63). The rTFA for children with pathologic compared to the physiologic bowing by age groups was; 11-20 months: 24.74°(23.22°-26.26°) vs. 19.44°(17.05°-21.84°), 21-30 months: 20.35°(18.13°-22.56°) vs. 14.72°(12.32°-17.12°) and 12-36 months: 32.60°(26.40°-38.80°) vs. 19.14°(17.78°-20.50°). Children above the age of 18 months with genu varus should be closely monitored clinically using ICD or cTFA. An ICD of more than 4 cm may warrant further investigation for pathologic cause. rTFA has limited use in the detection of pathologic varus.

A rare case of diplopodia and syndactyly: anatomical and surgical considerations.

Diplopodia is a rare congenital disorder that has not been extensively discussed in textbooks, and case reports appear to be the main source of information. Although the exact cause of diplopodia remains unknown, the presence of extra digits as well as metatarsals and tarsals allows it to be differentiated from pedal polydactyly. Syndactyly refers to the congenital fusion of the digits. Concomitant bilateral syndactyly and diplopodia is extremely unusual, and in this report we describe a case of right diplopodia and left polydactyly combined with bilateral manual syndactyly in a 15-year-old girl who was ultimately treated with through-the-knee amputation. Radiological examination of the right leg revealed tibial hypoplasia and the right foot displayed 8 digits with corresponding metatarsals and tarsals, whereas the left leg revealed 2 extra digits on the medial aspect of the foot with corresponding metatarsal and tarsal bones. Anatomical dissection of the right foot revealed that it was divided into halves consisting of 8 toes with corresponding metatarsals and tarsals, as well as tibial hypoplasia and absence of the great toe. Diplopodia associated with tibial hypoplasia and syndactyly can be treated surgically, and the present case report details the clinical, radiological, and anatomical elements of this rare deformity.

Congenital Constriction Band With Lymphedema in a Neonate: A 17-Year Follow-Up After Single Stage Excision and Z-Plasty.

Congenital constriction band syndrome is a rare condition that presents with constriction bands affecting different types of extremities. Timely surgical intervention for moderate and severe stages of this condition can be performed either in a single stage or multiple stages. We report the case of a neonate who presented with a congenital constriction band and had excision of the constriction band and z-plasty reconstruction. The surgery was done in a single stage. This case highlights the outcome and safety of this single-stage surgery with Z-plasty reconstruction. At 17 years of age, he has a functional lower limb and excels in archery.

Missed proximal radioulnar joint translocation with ulnar nerve entrapment: an unusual injury in a child.

Traumatic elbow dislocation in a child is rare, and it is usually associated with fractures. Simultaneous proximal radioulnar joint (PRUJ) translocation with ulnar nerve palsy is even rarer. We report an unusual case of a missed PRUJ translocation with ulnar nerve entrapment in a 10-year-old child. The key to diagnosing the translocation is the position of the proximal radius, which lies medial to the ulna. This was treated by open reduction and release of the entrapped nerve. The ulnar nerve palsy recovered fully at the 1-year follow-up. Although PRUJ translocation with ulnar nerve entrapment is a rare injury, a successful outcome is possible with timely open reduction and release of the ulnar nerve.

Early Surgery Is Feasible for a Very Large Congenital Infantile Fibrosarcoma Associated With Life Threatening Coagulopathy: A Case Report and Literature Review.

Background: Congenital infantile fibrosarcoma (CIF) is a rare malignant soft tissue tumor that predominantly occurs in children under 1 year of age. CIF is frequently misdiagnosed with other conditions like hemangioma of infancy, infantile fibromatosis, or kaposiform hemangioendothelioma. Disseminated intravascular coagulopathy (DIVC) is rarely reported to be associated with CIF. Case presentation: We describe an infant who presented with a large mass over the right arm. She was initially treated conservatively as hemangioma but was later confirmed by tissue histopathological examination to have CIF as the mass rapidly increased in size. She developed massive intra-tumoral bleed with DIVC whilst receiving neoadjuvant chemotherapy requiring multiple blood products transfusion. An urgent near-total resection of the tumor was performed in view of life threatening bleeding despite multiple blood transfusions. Post-operatively, she received further adjuvant chemotherapy. Subsequently, she remained in complete remission 32 months off-treatment and has full function of the affected limb. Conclusions: CIF is an important condition to be considered in infant who has large mass over the extremity. DIVC could be associated with large CIF and when it occurs can be life-threatening. Whenever feasible early surgery should be performed in very young patients with large CIF to prevent mortality from bleeding.

Tibia vara and slipped upper femoral epiphysis: is there an association?

Tibia vara and slipped upper femoral epiphysis (SUFE) share a common risk factor, but their relationship is unclear. In both conditions, the patients are usually obese. To the best of our knowledge, there have been only two previous reports in the literature that have described the occurrence of tibia vara and SUFE in three patients. We report a child who was treated for bilateral tibia vara at the age of 3 years and subsequently developed a SUFE at the age of 13 years.

Successful closed reduction after adductor tenotomy in a 14-year-old boy with chronic hip dislocation in Down syndrome.

Dislocation or subluxation of the hip is considered as the most common hip problem in patients with Down syndrome. Recommended treatment of chronic dislocation treatment is open reduction combined with femoral and/or pelvis osteotomies. We report a Down syndrome child with chronic hip dislocation who was successfully treated with adductor tenotomy and closed reduction, which has not been reported previously.

Clostridium perfringens surgical site infection after osteotomy for knee deformity correction in a non-immunocompromised child.

BACKGROUND: Clostridium perfringens myonecrosis following an elective surgical procedure in a previously healthy child is a rare incident. METHODS: Case report and literature review. RESULTS: A two-year old boy admitted for elective bilateral osteotomies of tibiae was detected to be febrile at day one post-operatively with crepitus felt at his left ankle. An emergency wound debridement was performed followed by a course of antibiotics. Clostridium perfringens was isolated from tissue culture. His wound was later covered with a split-thickness skin graft. CONCLUSION: Clostridium perfringens infection following a surgical procedure in a healthy child is rare. A high index of suspicion is important to recognize this debilitating infection.

Through-knee amputation for a patient with proximal femur focal deficiency and tibial hemimelia: surgical anatomy and clinical implications.

Tibial hemimelia is a rare anomaly of unknown etiology. This condition can occur sporadically or may have a familial inheritance. It is characterized by deficiency of the tibia with a relatively intact fibula. The anomaly may be unilateral or bilateral. We report a case of a 2-year-old girl who presented with right lower limb deformity since birth. She was diagnosed with proximal femur focal deficiency with absence of the ipsilateral tibia. She presented with a shorter right lower limb and a deformed foot. She was treated with a through-knee amputation. Anatomical dissection of the amputated limb was carried out to verify the anomalies. The dissection showed that the distal phalanx of the great toe was trifid. The anatomical and clinical significance of this interesting case is discussed.

Nerve injuries in supracondylar fractures of the humerus in children: is nerve exploration indicated?

A retrospective study of nerve injuries with displaced supracondylar fractures of the humerus in children younger than 12 years of age, treated in Hospital Universiti Kebangsaan Malaysia. Our objectives were to determine the incidence of primary and iatrogenic nerve injuries in supracondylar humerus fractures Gartland types II and III and to determine the outcome of nerve recovery. A total of 272 patients with displaced supracondylar humerus fractures who required admission to Hospital Universiti Kebangsaan Malaysia from January 2000 to December 2007 were reviewed. There were 182 boys (67%) and 90 girls (33%). The mean age was 6.0 years, ranging from 1 to 12 years. Of 272 supracondylar fractures, 79 were type II and 193 were type III. Fifty-one (19%) patients had closed reduction, 160 (59%) had closed reduction and percutaneous crossed Kirschner (K) wires, and 61 (22%) had open reduction and crossed K-wires. Associated nerve injuries involving the median, radial, and ulnar nerves were observed in 48 (18%) patients. Nerve injuries were observed in nine (3%) patients upon admission. Thirty-nine (14%) patients developed nerve injuries following treatment. Of these 39 patients, 34 had ulnar, three had radial, and two had median nerve injuries. Nerve exploration was performed in five patients (in four patients following debridement of open fracture and in one because of unacceptable postoperative radiographs, and they subsequently underwent open reduction and exploration). Except for these five patients, the K-wires were not removed earlier nor were the nerves surgically explored in others. The nerve injuries resolved clinically on an average time of 3.5 months (range from 3 weeks to 8 months). Our study found complete resolution of all patients with nerve injuries confirmed by clinical assessment. On the basis of our study, we believe that there is no indication to remove the K-wires immediately or to explore the nerve surgically following a mini-open technique, which reduces the risk of penetrating a nerve during pinning.

Congenital pseudoarthrosis of the tibia: healing by lengthening over a rod without compression of the nonunion. A preliminary report.

This preliminary report is on two patients with congenital pseudoarthrosis of the tibia who had a persistent nonunion following intramedullary rodding and bone grafting. We do not advocate repeated surgery to achieve union. When limb length discrepancy becomes greater than 5 cm, we proceeded with an Ilizarov procedure with the primary aim of equalizing limb length rather than achieving union. Healing of the pseudoarthrosis occurred in both patients after lengthening over the intramedullary rod without compression of the nonunion site. We believe that union occurs because of hyperaemia during the lengthening. This approach minimizes the repeated surgeries that are usually needed and thus ensures a more normal childhood without frequent hospitalizations.

NOMID: the radiographic and MRI features and review of literature.

Neonatal onset multisystem inflammatory disease (NOMID) is a rare autoinflammatory disorder, which manifests early in infancy. We describe a case of a 10-year-old boy who has been unwell since infancy. He presented with urticarial rash, intermittent fever and hepatosplenomegaly followed by progressive arthropathy. His joint symptoms started at two years of age, which progressively involved multiple joints, resulting in bone and joint deformities. A series of joint radiographs demonstrated bizarre enlarging physeal mass with heterogenous calcification. Magnetic resonance imaging (MRI) of the involved right ankle and knee showed characteristic thickened and calcified physeal lesions, which enhanced post-gadolinium. This debilitating disease is also known to involve the central nervous system and eyes. This case report aims to highlight the conventional radiographic and magnetic resonance imaging (MRI) findings of this physeal abnormality in NOMID syndrome.

Hypertrophic nonunion of the ulna in a child: treatment with an elastic stable intramedullary nail without bone graft.

Nonunion following diaphyseal forearm fracture is an uncommon complication in children. Compression plate fixation with bone grafting has been the standard method to treat this complication. We report a case of hypertrophic nonunion of the ulna in a child who was treated surgically using an elastic stable intramedullary nail (ESIN) without bone grafting. The nonunion healed 4 months after surgery.

Giant cell tumor of the tendon sheath in the knee of an 11-year-old girl.

Giant cell tumors are commonly found over the flexor tendon sheath of the hand and wrist. However, giant cell tumors in the knee joint are rare, especially in children. We report an interesting case of an 11-year-old girl who presented with a painful lump on her right knee that enlarged over time. Clinically, she had fullness over the anterolateral part of her knee. Magnetic resonance imaging revealed an encapsulated mass inferior to the patella. The tumor measured 3 x 3.5 x 1.5 cm. Histopathological findings confirmed that it was a tenosynovial giant cell tumor. Because of initial mild symptoms, there was a delay of 2 years from the initial symptoms until tumor excision. Her follow-up period was 35 months, and her health to date is excellent with no recurrence. We believe that reporting this rare case will help clinicians update their knowledge on possible causes of lumps in the knee, and avoid diagnostic delay. It could also prove to be beneficial in arriving at a diagnosis in future cases.

An elbow dislocation in a child with missed medial epicondyle fracture and late ulnar nerve palsy.

Elbow dislocations associated with a medial epicondyle fracture and ulnar nerve palsy are uncommon injuries. We present the case of an 11-year-old girl with an elbow dislocation treated by closed manual reduction. The medial epicondyle fracture was missed initially until she developed an ulnar nerve palsy 2 months later. Intraoperatively we discovered the bony epicondyle piercing the joint capsule and compressing the ulnar nerve. Removal of the bony fragment relieved her symptoms and she returned to normal activities at 1 year follow-up. We would like to highlight this rare occurrence and present the detailed history and management of this case.