Percutaneous screw fixation promotes healing of lateral condyle nonunion in children.

BACKGROUND: This retrospective study examined whether pediatric lateral condyle nonunions could be successfully managed by percutaneous screw fixation. We report the outcome of this minimally invasive technique avoiding open reduction and bone grafting associated with the risk of avascular necrosis (AVN), infection, and stiffness. METHODS: The hospital radiology database was searched between 1998 and 2008. This identified 16 consecutive patients aged 2 to 10 years, with lateral condyle nonunions treated with percutaneous screw fixation. We assessed clinical and radiographic outcomes from presentation to final follow-up. Potential risk factors for recalcitrant nonunion were identified. Categorical variables are presented as proportions and percentages. Continuous variables were assessed for normality with the d'Agostino-Pearson test. Normally distributed variables are presented as means with 1 SD. Non-normally distributed data are presented as medians with interquartile range. RESULTS: Outcome was defined as successful if radiologic and clinical union was achieved. Twelve patients (75%) united after surgery, at a mean of 16.2 weeks (±6.74). Four (25%) failed to unite. The failures presented with nonunion later (median of 225.5 wk from initial injury). This was significantly different (P=0.039) from presentation in the successful group (median time 15.7 wk).Median age at injury was 5.1 years (range, 3.2 to 7.2) in the successful and 2.8 years (range, 2.1 to 4.7) in the unsuccessful group (P=0.18). Overall, mean time from nonunion diagnosis to percutaneous surgery was 5.2 weeks (±4.11). Forty-four percent had implant removal once union was achieved and no cases of AVN were reported. CONCLUSIONS: We demonstrate this technique to be successful in nonunions addressed within 16 weeks from initial injury to diagnosis. Our 4 failures occurred in nonunions diagnosed >31 weeks from the injury (31, 68, 383, 427 wk). All had been managed nonoperatively as their primary treatment plan.Percutaneous fixation is feasible and safe. Patients not achieving union were diagnosed after a greater delay. There was a trend toward successfully treated patients being younger. There were no cases of AVN, infection, or elbow stiffness. LEVEL OF EVIDENCE: Level 4.

Femoral varus derotation osteotomy for the treatment of habitual subluxation and dislocation of the pediatric hip in trisomy 21: a 10-year experience.

BACKGROUND: Habitual hip subluxation and dislocation are potentially disabling features of the trisomy 21 syndrome. We describe outcomes after a femoral varus derotation osteotomy to achieve and maintain hip stability and community ambulation. METHODS: All individuals with trisomy 21, who underwent hip surgery at our institution between 1998 and 2008, were searched using the hospital databases. The clinical notes and radiographs were reviewed from presentation to final follow-up. Nine children (16 hips) aged below 10 years, were identified. All had a femoral varus derotation osteotomy with a target femoral neck-shaft angle (NSA) of 105 degrees and external rotation of < 20 degrees of the distal fragment. All were performed by the senior author. RESULTS: Mean age at first known hip dislocation was 4.6 years (range, 4 to 5.2 y), mean age at surgery was 6.1 years (range, 5.2 to 7.0 y), and mean follow-up was 5.4 years (range, 3.8 to 7.1 y). Mean NSA fell postoperatively to 106.0 degrees (range, 103.1 to 110.2 degrees) from 166.7 degrees (range, 162.2 to 171.1 degrees). In 2 hips, intraoperative instability remained, requiring immediate periacetabular osteotomy and capsulorraphy.Postoperatively, all patients demonstrated an asymptomatic waddling gait, which persisted in 1 individual. Fourteen hips developed peritrochanteric varus deformities with a mean center of rotation and angulation of 21 degrees (range, 16 to 25 degrees). Two hips (12.5%) sustained implant-related fractures 4 and 8 years postoperatively. One hip (6.3%) developed arthritis and none had redislocated at latest follow-up. CONCLUSIONS: Sequelae from recurrent subluxation or dislocation of hips in trisomy 21 may require surgery to prevent eventual disability.We recommend a varus producing proximal femoral osteotomy correcting the NSA to approximately 105 degrees. This should be performed before the age of 7 years or a widened or V-shape teardrop develops. After 2 implant-related fractures, we recommend implant removal once the osteotomy has healed and the hip stabilized.In our experience, this approach is effective in maintaining hip stability. LEVEL OF EVIDENCE: A level 4 study, looking at a specific patient population undergoing a particular procedure.

Locked volar plating for unstable distal radial fractures: clinical and radiological outcomes.

We studied 40 patients treated with locked volar plates for unstable distal radial fractures. Outcome was assessed at a mean of 59 weeks, both radiologically and functionally using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, range of motion and grip strength. The complication rate in our series was 48%. In 11 cases, screw penetration into the radiocarpal joint occurred as a consequence of postoperative collapse. Of these, 25% had malunited and 12.5% ruptured their extensor pollicus longus (EPL) tendon. Functionally, when compared with the contralateral side, 74% of extension, 67% of flexion, 91% of pronation and supination and 81% of grip strength were regained. The mean DASH score was 23. Although locked volar plates can achieve good results in the management of unstable distal radial fractures, there remains a high major complication rate. They should be used with caution particularly in fractures with significant metaphyseal comminution.

Arthrographically defined subchondral defects in Perthes' disease.

Since the original 1910 description of Perthes' disease, the aetiology and pathophysiology of this condition have remained elusive, and the treatment controversial. We found during arthrography that it has been possible to demonstrate a fluid-filled space between the ossified epiphysis of the femoral head and its overlying articular cartilage. This finding has not previously been documented in the literature, and we believe this mechanically vulnerable region may be subject to mechanical distortion, acting as a significant contributor to the evolving femoral head deformity seen in Perthes' disease. If this is so, treating this lesion could prevent further femoral head deformation.