Treatment of Refractory Congenital Pseudoarthrosis of Tibia with Contralateral Vascularized Fibular Bone Graft and Anatomic Distal Tibial Locking Plate: A Case Series and Literature Review.

BACKGROUND: Congenital pseudoarthrosis of the tibia (CPT) remains a challenge for physicians. Several treatment options have been proposed, but the standard of care remains inconclusive. In this study, we present three patients for whom the failure of prior treatments was managed with a contralateral vascularized fibular bone graft (VFG) and an anatomic distal tibial locking plate. METHODS: Between 2017 and 2021, three patients were referred for failed treatment of CPT. All patients had undergone multiple prior surgeries, including tumor excision and fixation with ring external fixators, plates, and screws. We performed radical tumor resection and reconstruction of bone defects with a VFG. The construct was fixed with an anatomic locking plate, and the patients were followed up for a mean of 45.7 months. RESULTS: All three patients were able to obtain graft union at 19.3 weeks. At the final follow-up, all grafts achieved bony hypertrophy without evidence of bone resorption or local tumor recurrence. There was a mean leg length difference of 8.5 cm preoperatively, compared with 6.3 cm postoperatively. The average lower leg angulation was 7.4 degrees and the average ankle range of motion was 58.3 degrees. The mean VAS score was 0 and the mean AOFAS score was 88.3. No significant complications were noted. CONCLUSIONS: Implantation of a VFG and an anatomic distal tibia locking plate can be considered an option for treatment-refractory CPT. Patients can expect to achieve bone consolidation, ambulate as tolerated, and have a low complication rate.

Posteromedial dislocation of the elbow with lateral condyle fracture in children.

Posteromedial dislocation of the elbow with lateral condyle fracture is a rare injury, and only a few cases have been reported in the literature. We report 3 children who had posteromedial dislocation of the elbow with Milch type II lateral condylar fracture of the distal humerus. Major complications included malunion, nonunion of the fracture, heterotophic calcification and elbow subluxation. From our experience and a review of the literature, open anatomical reduction and internal fixation of the lateral condyle fracture is the mainstay of treatment for these children. Poor reduction of the lateral condyle fracture results in incongruity of the joint surface and leads to poor results.

Slotted acetabular augmentation in the treatment of painful residual dysplastic hips in adolescents and young adults.

BACKGROUND/PURPOSE: This study retrospectively evaluated the benefits and prognostic factors of slotted acetabular augmentation (SAA) used for treating painful residual or neglected dysplastic hips in adolescents and young adults. METHODS: Sixteen hips in 15 patients underwent SAA at an average age of 14.4 years. The radiologic and functional outcomes were reviewed after an average follow-up of 6.6 years. RESULTS: All the patients obtained marked alleviation of pain (p<0.05). Harris hip score (HHS) was improved from 74.7 to 92.7 on average (p<0.05). Postoperative center-edge angle, Sharp's angle, c/b ratio and femoral head coverage showed significant improvement (p<0.01). Among the radiographic parameters, only the postoperative measurement of the femoral head coverage was significantly correlated with improvement of HHS (p<0.05). Detectable progression of osteoarthritis, from grade III to IV, was found in one patient 12 years after surgery. None of the hips required conversion to joint replacement. There were no surgical complications. Three-dimensional computed tomography showed that the grafts remained intact and provided congruent coverage at the latest follow-up, and none of them required arthroplasty. CONCLUSION: The major benefit of SAA was to alleviate hip pain by increasing load-bearing area. This benefit was not sensitive to preoperative radiographic parameters. There were no postoperative complications. Compared with other complex reconstructive acetabuloplasty procedures, SAA is a simple, safe and effective pain-reducing procedure for symptomatic dysplastic hips in adolescents and young adults.

Successful treatment of congenital pseudarthrosis of the tibia with long segment fibular allografting in a young child.

Congenital pseudarthrosis of the tibia (CPT) in young children with large bone defect after surgical resection can be difficult to reconstruct. Structural allograft may be a useful alternative in such cases but data are limited. We report a girl 1 year and 10 months of age with CPT successfully treated with en bloc resection of there current extensive pseudarthrosis, intramedullary rod placement, and long-segment intercalary allografting with supplemental autograft of the bony defect. At 6 years of follow-up, radiographs showed equal leg lengths, with good incorporation into the host bone. This method is technically simple and less time-consuming. It may be considered as an alternative method to the other more complicated procedures, such as microvascular fibula graft or the Ilizarov technique, in such a young child.

Chronic posttraumatic anterior dislocation of the radial head in children: thirteen cases treated by open reduction, ulnar osteotomy, and annular ligament reconstruction through a Boyd incision.

OBJECTIVE: To report the results of open reduction, ulnar osteotomy, and annular ligament reconstruction all through a Boyd incision for chronic radial head dislocations in children. DESIGN: Retrospective review. SETTING: Tertiary pediatric orthopaedic care unit at a general hospital in Taichung, Taiwan. PATIENTS/PARTICIPANTS: From 1986 to 2003, 13 children, aged 4 to 13 (mean, 8.3) years, who had a chronic traumatic anterior dislocation of the radial head were treated at our institute. These patients were seen at our hospital 2 to 36 (mean, 8.2) months after injury. INTERVENTION: Open reduction of the radial head, ulnar osteotomy, then rigid fixation with plate/screws, and annular ligament reconstruction with forearm fascia, all performed through a Boyd incision. MAIN OUTCOME MEASUREMENTS: Forearm radiographs for reduction and osteotomy site union, physical examinations for elbow mobility, and Kim's elbow performance scores for overall elbow function. Evaluations were done at a special follow-up clinic for this study by a pediatric orthopaedic surgeon who was not involved in the patients' previous care. RESULTS: Patient follow-up averaged 7.8 (range, 1-16.9) years after surgery. Twelve of our cases had successful radial head reductions, satisfactory elbow mobility, and excellent functional outcome. One case had a redislocation, was retreated, and had a fair result. Other complications included 1 patient with transient posterior interosseous nerve palsy, and 1 delayed union of an ulnar osteotomy site, which healed without further intervention at 1 year with an excellent result. CONCLUSION: This surgical procedure provides a high success rate with a low level of complications for chronic radial head dislocations in children.

Traumatic Separation of the Distal Ulnar Physis in Children: A New Classification for Displaced Volar-Flexion Injuries.

OBJECTIVES: To propose a new fracture classification according to the direction of epiphysis displacement and to compare clinical findings and surgical outcomes between these subtypes. DESIGN: Retrospective study. SETTING: A tertiary referral hospital. PATIENTS: Twelve adolescents (mean age, 13.4 ± 1.3 years) who experienced separation of the distal ulnar physis were identified from the pediatric trauma database. INTERVENTION: Closed reduction was attempted for all injuries. If a satisfactory alignment could not be achieved, an open reduction was performed. MAIN OUTCOME MEASUREMENTS: The clinical outcome was evaluated with Mikic's criteria (union, alignment, length, distal radioulnar joint subluxation, limitations of elbow/wrist function, and degree of supination/pronation). The impacts of fracture patterns and locations of wrist abrasions on treatment decisions and clinical outcomes were tested with Fisher exact tests (unadjusted) and logistic regression analyses (adjusted for age and gender) with the bootstrap method. Five orthopedic surgeons used the new classification, and the reproducibility was tested with multirater kappa. RESULTS: The injury patterns included 6 dorsally-tilted distal ulnas (type 1) and 6 volarly-tilted distal ulnas [type 2-A (n = 1), type 2-B (n = 3), and type 2-C (n = 2)]. All type 1 fractures were successfully treated with closed reduction. Five of 6 cases with type 2 injuries failed closed reduction because of entrapment of the extensor carpi ulnaris tendon in the fracture site. Eleven of the patients' outcomes were excellent. One patient with a type 2-C injury experienced ulnar growth arrest. The multirater kappa for the new classification equals to 0.94, and P < 0.001. CONCLUSIONS: A majority of volar-flexion injuries require surgery to reduce the entrapped soft tissue. This new classification is easy to understand with a good interrater reproducibility. It is useful in identifying the injury mechanism and correlated with the likelihood of open reduction. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bifocal cryptococcal osteomyelitis: management of a patient with concurrent femur and rib infections.

A case of Cryptococcus neoformans osteomyelitis involving both the femur and rib is reported. A 50-year-old male presented with a 1-month history of a persistently painful right hip. Radiography revealed an osteolytic area in the subcapital region of the right femoral neck and trochanteric region, and magnetic resonance imaging (MRI) revealed an intramedullary lesion in the peritrochanteric region. A Tc99m whole body bone scan showed significantly increased uptake in the posterior aspect of the right 7th rib as well as the right femoral region. Hemiarthroplasty with a bipolar prosthesis was performed. Because a permeative osteolytic lesion was identified intraoperatively, surgical resection was also performed. A culture from intraoperative specimens yielded C. neoformans. The rib infection was not treated surgically. Intravenous fluconazole was administered postoperatively. The patient became seronegative for cryptococcal antigen with no further illness over the next five years.