New Single-stage Double Osteotomy for Late-presenting Infantile Tibia Vara: A Comprehensive Approach.

BACKGROUND: Successful surgical treatment of late-presenting infantile tibia vara (ITV) patient requires the correction of oblique deformities. The purpose of this study was to report on a new comprehensive approach to correct and prevent recurrence of these deformities with a single procedure. METHODS: Medical records of 23 consecutive children (7 to 18 y) with advanced ITV (29 knees) were retrospectively reviewed after a mean of 7.3 years postoperatively (range, 2 to 22 y). Indications for the corrective surgery were any child 7 year or older with a varus mechanical axis angle ≥10 degrees or a varus anatomic axis angle ≥11 degrees and a medial tibial angle (MTA) slope <60 degrees. The deformities were corrected with a dome-shaped osteotomy proximal to the tibial tubercle with a midline vertical extension to the subchondral region of the joint and a lateral hemi-epiphysiodesis. RESULTS: At latest follow-up, means and medians of each tibial radiographic axis measurement improved significantly from preoperative values (P<0.001): mechanical axis angle from 23 degrees to 4 degrees varus, anatomic axis angle from 25 degrees varus to 1 degree valgus, MTA downward slope from 30 to 78 degrees, posterior MTA from 59 to 80 degrees. In total, 79% and 74% had good to excellent results based on radiographic criteria and clinical questionnaire for satisfaction, pain and function, respectively. Two abnormal medial tibial plateau types were described. CONCLUSIONS: This is the first study to use a single-stage double osteotomy performed proximal to the tibial tubercle for the late-presenting ITV for children 7 years of age or older. In addition to the effective correction of the 4 major tibial deformities, a lateral proximal tibial hemi-epiphysiodesis minimizes recurrence of tibia vara. A contralateral proximal tibial epiphysiodesis is recommended for treated skeletally immature patients with unilateral disease. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Pedicle screw instrumentation and spinal deformities: have we gone too far?

INTRODUCTION: Placement of pedicle screws within the thoracic and lumbar spine has become the "state of the art" for the treatment of spinal deformities. Newly trained surgeons are often trained only with the placement of pedicle screws within the thoracic and lumbar spine and not with hooks or other means of fixation. However, if the benefits of pedicle screw instrumentation in terms of correction ability cannot be questioned on some issues pertaining to their safety, their rationale for all situations as well as their long-term adverse consequence and or early or late complications start to arise. MATERIALS AND METHODS: We therefore present four case examples that illustrate the advantages, questions and complications inherent to pedicle screw instrumentation in spinal deformities. These four cases serve as discussion supported by a review of the literature. The literature search was performed to include pedicle screws associated risks, costs and complications. Articles focusing on instrumentation of the thoracic and lumbar spine for the treatment of adult and pediatric scoliosis were reviewed. RESULTS: Pedicle screw instrumentation in the treatment of spinal deformity is here to stay, however a fair number of issues have come up since their widespread use that started 10 years ago: these include their misplacement with the inherent risks to the vascular or neurologic structures, the rate of misplaced pedicle screw not per number of screws inserted, but per patient operated, the number of screws really necessary to achieve a satisfactory outcome while maintaining costs, their contraindications in some very challenging deformities where the risks clearly outweigh their advantage compared to hooks. At last, the use of pedicle screw instrumentation has driven many centers in increasing the safety of such procedures using intraoperative spinal cord monitoring as well as improved imaging technologies. CONCLUSION: To answer our provocative title "Pedicle screw instrumentation have we gone too far?" Definitively we can answer that for some spinal deformities instrumented with all-pedicle-screw instrumentation, we have observed cases where the surgeons have gone way too far; in other cases, where such instrumentation was used in a comprehensive and rational manner, the answer to "Have we gone too far" is no, and such use of pedicle screw has improved outcome with minimum complications.

Increasing incidence of slipped capital femoral epiphysis in Trinidad and Tobago: A 50-year review.

Slipped Capital Femoral Epiphysis (SCFE) is a physeal disorder of the proximal femur. Misdiagnosis and late treatment are associated with poorer outcomes. The epidemiology and delays in treatment of the disease between 1968 and 2018 were investigated in North Trinidad. The number of cases presenting annually has increased over the decades and the incidence between 2008-2018 was 2.2 cases per 100 000 per year. Almost 70% of cases were above the 95th percentile for body weight. Delay in treatment from onset of symptoms was 278 ± 258 days. Awareness of the risk factors and clinical presentation of SCFE may facilitate early diagnosis and treatment, and prevent severe hip disability in adulthood.

Talectomy by Medial Surgical Approach for Congenital Vertical Talus in Arthrogryposis Multiplex Congenita.

Arthrogryposis multiplex congenita involves stiff contracture of joints and weak atrophic muscles presenting at birth. The two most common forms are amyoplasia and distal arthrogryposis. Amyoplasia affects all 4 extremities: internally rotated shoulders, extended fixed elbows, flexed fixed wrists, extended fixed knees, clubfeet, and decreased muscle volume. Distal arthrogryposis is a group of syndromes with a genetic basis. The distal joints are contracted. Clubfeet and congenital vertical talus are the most common foot deformities. A 10-year-old boy presented with distal arthrogryposis with bilateral congenital tali. He reported having deformed and painful feet and difficulty wearing shoes. His rocker-bottom foot deformities caused him to walk with a heel to heel gait. He also had stiff extended knees. His previous foot surgeries included failed open reduction and pin fixation of the talonavicular joints with Achilles tendon lengthening and capsulotomies. The boy underwent bilateral talectomies and releases of contracted joint capsules and lengthening of multiple extrinsic tendons through separate incisions. The talectomy of each foot was performed via a novel medial surgical approach. At 2-year follow-up, he had normal-appearing plantar grade feet. He had a painless gait, could ambulate independently, and was considered to have an excellent result. This is the first detailed report of performing a talectomy via a medial approach for bilateral congenital tali in a patient with arthrogryposis multiplex congenita. [Orthopedics. 2020; 43(6):e623-e626.].