Knee orthopedic problems in newborns and infancy: a review.

PURPOSE OF REVIEW: We present the reader with insight on the most common disorders of the knee in newborns and infants. Knee issues in this population may confuse the first contact physicians due to certain peculiarities of the immature immune system, small size and underdevelopment of joint anatomy. Data presented here are recent and significant, and something to bear in mind when caring for children of this age. RECENT FINDINGS: With the advent of new diagnostic methods, a shift in the causative agent of pediatric knee infections has been noted. Minimally invasive methods such as arthrocentesis and arthroscopy are successfully employed in treatment of knee problems in newborns and infants. A trial of conservative therapy in congenital patellar instability can give good results, and obviate the need for surgery in some cases. Various syndromes that affect the knee have specific characteristics that need to be recognized early to avoid problems in the future. SUMMARY: Although rare, knee problems in infants can and do occur. Their cause varies significantly and good outcomes require a multidisciplinary approach. Early diagnosis, referral and initiation of treatment protocols can significantly influence the fate of the joint and with it the patients' functional status for life.

The Effect of Spinopelvic Parameters on the Development of Proximal Junctional Kyphosis in Early Onset: Mean 4.5-Year Follow-up.

BACKGROUND: Proximal junctional kyphosis (PJK) is a major complication after posterior spinal surgery. It is diagnosed radiographically based on a proximal junctional angle (PJA) and clinically when proximal extension is required. We hypothesized that abnormal spinopelvic alignment will increase the risk of PJK in children with early-onset scoliosis (EOS). METHODS: A retrospective study of 135 children with EOS from 2 registries, who were treated with distraction-based implants. Etiologies included 54 congenital, 10 neuromuscular, 37 syndromic, 32 idiopathic, and 2 unknown. A total of 89 rib-based and 46 spine-based surgeries were performed at a mean age of 5.3±2.83 years. On sagittal radiographs, spinopelvic parameters were measured preoperatively and at last follow-up: scoliosis angle (Cobb method, CA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope and PJA. Radiographic PJK was defined as PJA≥10 degrees and PJA≥10 degrees greater than preoperative measurement. The requirement for the proximal extension of the upper instrumented vertebrae was considered a proximal junctional failure (PJF). Analysis of risk factors for the development of PJK and PJF was performed. RESULTS: At final follow-up (mean: 4.5±2.6 y), CA decreased (P<0.005), LL (P=0.029), and PI (P<0.005) increased, whereas PI-LL (pelvic incidence minus lumbar lordosis) did not change (P=0.706). Overall, 38% of children developed radiographic PJK and 18% developed PJF. Preoperative TK>50 degrees was a risk factor for the development of radiographic PJK (relative risk: 1.67, P=0.04). Children with high postoperative CA [hazard ratio (HR): 1.03, P=0.015], postoperative PT≥30 degrees (HR: 2.77, P=0.043), PI-LL>20 degrees (HR: 2.92, P=0.034), as well as greater preoperative to postoperative changes in PT (HR: 1.05, P=0.004), PI (HR: 1.06, P=0.0004) and PI-LL (HR: 1.03, P=0.013) were more likely to develop PJF. Children with rib-based constructs were less likely to develop radiographic PJK compared with children with spine-based distraction constructs (31% vs. 54%, respectively, P=0.038). CONCLUSIONS: In EOS patients undergoing growth-friendly surgery for EOS, preoperative TK>50 degrees was associated with increased risk for radiographic PJK. Postoperative PI-LL>20 degrees, PT≥30 degrees, and overcorrection of PT and PI-LL increased risk for PJF. Rib-based distraction construct decreased the risk for radiographic PJK in contrast with the spine-based constructs. LEVEL OF EVIDENCE: Level III.

Does timing of surgery influence the long-term results of foot polydactyly treatment?

BACKGROUND: There is an evident lack of research on timing of polydactyly surgery and its effects on treatment results. METHODS: Retrospective comparative study on foot polydactyly patients treated at our department from 1995 to 2009. Patients were divided into 2 groups, group A - under the age of 5 at surgery, and group B - 5 years and older. RESULTS: There were 24 patients (8 male, 16 female), 30 feet. Median age at surgery was 1 year (range, 9 months-4.5 years) for group A, and 8.5 years (range, 6-37 years) for group B. Median follow-up was 16.2 years (range, 7-21 years). There were 16 postaxial and 8 preaxial cases. At the last follow-up 12 patients' feet were "excellent" and 12 "good". No significant differences were identified between the two groups at final follow-up. CONCLUSIONS: Timing of surgery for foot polydactyly is not crucial for final results.

Localized pigmented villonodular synovitis of the ankle: Expect the unexpected.

BACKGROUND: We present the technique, results and discuss arthroscopic treatment of the localized form of pigmented villonodular synovitis (LPVNS) of the ankle. METHODS: Medical records of five patients diagnosed and treated for ankle LPVNS with a minimum five-year followup were retrospectively reviewed. All patients were treated arthroscopically, altered synovial tissue was resected and a sample of tissue was sent for pathohistological examination for the definitive diagnosis. RESULTS: No recurrence was noted at a mean followup of 6.5 years, both clinically and by MRI at one year postoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and an improvement was noted from an average score of 65.6 prior to treatment to 94.6 at final followup. CONCLUSION: Considering the results of this case series, and the absence of complications, arthroscopy is a viable option for treating LPVNS of the ankle.

[Characteristics of anesthesia in patients with osteogenesis imperfecta undergoing orthopedic surgical procedures]. / Osobitosti anestezije kod ortopedskih zahvata u bolesnika s osteogenesis imperfect.

The aim is to show our experience in anesthesia of patients with osteogenesis imperfecta (OI) who have undergone orthopedic surgical procedures. This is a retrospective analysis of OI patients treated at our Department from 1980 to 2012. We analyzed demographics, comorbidities, preoperative characteristics, anesthesia types, anesthetics and intraoperative and postoperative complications. In the given period, 26 OI patients were treated, using 103 surgeries, and 103 anesthesia procedures. Most procedures, a total of 68, were used in children aged 0-10 years. According to the diagnosis, OI type III was mostly encountered. The rating of the American Society of Anesthesiologist (ASA) physical status was II in most cases, a total of 99. General anesthesia was used in 89 cases, and regional anesthesia in 14. Fourteen intraoperative complications were seen, mostly difficult intubation, and six postoperative cardiovascular instability cases. With careful preparation, and knowledge of pitfalls, anesthesia in these patients should be a safe procedure.

Osteochondritis dissecans of the first metatarsophalangeal joint: arthroscopy and microfracture technique.

Osteochondritis dissecans (OCD) is a localized disorder of the joint surface by which a segment of subchondral bone and its overlying cartilage become fragmented. Arthroscopic treatment of OCD of the first metatarsophalangeal joint consisted mainly of debridement and loose body removal. The microfracture technique for the treatment of OCD of the first metatarsophalangeal joint is presented for the first time. The technique has been shown to be a safe and technically uncomplicated first-line treatment.

Arthroscopic treatment of localized and diffuse pigmented villonodular synovitis of the knee.

Pigmented villonodular synovitis (PVNS) is a rare proliferative synovial disorder of uncertain etiology. Two forms of this disorder, a localized (LPVNS) and diffuse (DPVNS) form, are well differentiated. The therapy of choice for LPVNS is arthroscopic partial synovectomy with excision of the lesion. Total synovectomy, whether done arthroscopically or through an open arthrotomy, is the recommended treatment for DPVNS. During an eight-year period 13 patients, six male and seven female, average age 28 years (range, 16 to 60 years) were treated for PVNS of the knee with arthroscopic synovectomy. Average follow-up was 84 months (range, 28 to 127 months). Four patients were affected by localized PVNS and were subjected to partial arthroscopic synovectomy (two to three portals) with a complete lesion excision. The remaining nine patients presented with the diffuse form of PVNS and all of them underwent total arthroscopic synovectomy (five portals). The diagnosis was confirmed by synovial biopsy. Each patient was evaluated before treatment and at final follow-up. Results were assessed clinically, radiographically and subjectively and were rated as excellent, good, fair, or poor. No complications or recurrences were noted in the LPVNS group, and all four patients were rated as excellent. In the DPVNS group, eight patients were rated as excellent and one patient was rated as fair and it was the patient who suffered the only recurrence in our case series. No relevant complications were encountered. No cases of infection, joint stiffness or neurovascular lesions were seen. Arthroscopy has become the golden standard in treatment of LPVNS, and can undoubtedly give results that are as good as with open synovectomy when treating DPVNS, if performed by an experienced arthroscopic surgeon.

Frontal and sagittal imbalance in patients with adolescent idiopathic deformity.

The human spinal column underwent many significant changes over the 4.5 million years of our ancestral bipedalism. The main change, however, came with acquiring multiple curvatures in the sagittal plane. This alteration seems to have exposed a weakness in our body's keystone and made us susceptible to thus far unbeknown problems of the spine because it has been noted that idiopathic scoliosis has not been observed in other primates. Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine causing an imbalance of the trunk as it increases in magnitude. A scoliotic curve comprises three components, the coronal, sagittal, and axial so that each curve can affect the global balance of the body differently. Patients with significant scoliotic deformities often find themselves at a biomechanical disadvantage when it comes to energy expenditure and keeping an upright stance. The pioneers of scoliosis research recognized the need for describing and quantifying deformity to better understand it, so they first translated clinical measurements to radiographs and built from there. The development of concepts like defining a curve by its end vertebrae and measuring its magnitude, assessing global spinal balance, describing the stable zone, and pinpointing the stable vertebra all followed suit. The importance of sagittal balance and restoring sagittal parameters during treatment was emphasized. In a quest to bring order to chaos, some tried to classify various scoliotic curve types. These classifications helped steer treatment decisions but were found lacking in many aspects. So far, a widely accepted three-dimensional classification of scoliosis still does not exist. This review aims to provide the reader with an overview of the development of balance and imbalance concepts in scoliosis.

Superior Extension of Upper Instrumented Vertebrae in Distraction-based Surgery: A Surrogate for Clinically Significant Proximal Junctional Kyphosis.

BACKGROUND: Proximal junctional kyphosis (PJK) is a reported complication of distraction-based growth-friendly surgery for early-onset scoliosis (EOS). A potential consequence of PJK is revision surgery with superior extension of the upper instrument vertebrae (UIV). The purpose of this study was to determine the risk of radiographic and clinically significant PJK during growth-friendly surgery. METHODS: This is a retrospective review of children treated with distraction-based growth-friendly surgeries from two EOS registries with minimum two-year follow-up. PJK is defined as clinically significant in this study if surgery with superior extension of the UIV was performed. RESULTS: Of 419 total patients, there was a 20% risk of developing clinically significant PJK (24% rib vs. 15% spine-based anchors, p = .03). These patients had a mean preoperative age of 5.6 years (5.2-year rib vs. 6.0-year spine, p < .001), scoliosis of 73° (69° rib vs. 77° spine, p < .001), and kyphosis of 51° (47° rib vs. 56° spine, p < .01). Regression analysis demonstrated that these differences in age, scoliosis, and kyphosis between anchor type did not account for a significant proportion of the measured variance. CONCLUSIONS: There was a 20% risk of developing clinically significant PJK, with a slightly higher risk for patients treated with rib-based proximal anchors (24%) than for those patients treated with spine-based proximal anchors (15%). LEVEL OF EVIDENCE: Level III.

Paper #42: Spinopelvic alignment affects Health-related Quality of Life (HRQoL) for Patients with Early Onset Scoliosis.

Recent studies in the adult scoliosis population have shown effects of spinopelvic parameters on HRQoL outcomes. In this retrospective cohort study of 75 EOS patients treated with growth-friendly surgery, spinopelvic parameters affected HRQoL (EOSQ-24). Pre-operative PI>60° increased the risk for poor pain outcomes, pre- and post-operative LL>60° increased the risk for poor satisfaction, post-operative PI-LL mismatch of O >20° and post-operative PJK increased the risk of Fatigue.

Epidemiology of musculoskeletal tumors in a national referral orthopedic department. A study of 3482 cases.

AIM OF THE STUDY: Musculoskeletal tumors are relatively rare, and their geographic distribution varies greatly around the world. In this study, we present the incidence, age distribution and localization of musculoskeletal tumors diagnosed and/or treated at a tertiary referral orthopedic department, catering to an entire Southeastern European country. METHODS: This was a retrospective study of prospectively collected data, in which all patients diagnosed and/or treated for musculoskeletal tumors at our Department in the period of 30 years (1981-2010) were included. RESULTS: Data of a total of 3482 patients with musculoskeletal tumors were collected. Average age of patients was 33.5 years (range, 2 months-88 years), with even distribution according to sex. Malignant tumors were seen in 20.7% of patients, more often in men (56.9%). Most common malignant tumors were osteosarcoma (estimated incidence: 1.68/million/year), chondrosarcoma (0.79/million/year) and Ewing sarcoma (0.76/million/year). Benign tumors and tumor-like lesions were found in 79.3% of patients, with slight female predominance. Most common benign bone lesions were osteochondroma (5.81/million/year), simple bone cyst (2.13/million/year), and enchondroma (2.05/million/year). CONCLUSION: This report represents a first of its kind in our region, and gives representative results to be compared to other middle and south European countries. Further nationwide studies are needed to improve strategies in bone tumor diagnosis and treatment.