Is Using a Ring External Fixator in the Treatment of Congenital Pseudarthrosis of the Tibia Associated With Better Results or Using a Locking Plate?

BACKGROUND: Congenital pseudarthrosis of the tibia (CPT) is a rare disease. CPT is often unilateral and occurs between the middle and distal third of the tibia. Concurrent involvement of the fibula is present in more than half of cases. histologic studies indicate the presence of fibrous hamartoma tissue and a sick periosteum, which leads to recalcitrant bone fracture and, eventually, pseudoarthrosis. Although there are various surgical techniques, we intend to compare the 2 methods of external fixation versus internal plating. METHODS: Demographic data were collected from 26 patients with frank pseudoarthrosis. After exclusion criteria, patients were compared in groups A (12 patients) and B (11 patients). Resection of hamartoma and sclerotic bone, intramedullary rodding and autologous bone, and periosteal grafting were performed for all patients. In group A, we used a ring external fixator for compression and rotational stability, but in group B, a locking plate was used for these purposes. RESULTS: Plating takes less time to use during surgery. In group A, the primary bony union was obtained in 67% of patients, while in group B, 82% of patients had a primary union. Meanwhile, the average time till the final union in group A was 6 months, while in group B, this time was 3.5 months. Positive union mass was obtained in 58% of the patients in group A and 82% of group B. In addition, plating prevented ankle valgus deformity in group B. CONCLUSIONS: Permanent intramedullary rodding is a surgical requirement for correction of deformity and refracture prevention, but additional stability can be achieved with the use of a ring external fixator or internal plate. Cross union and positive union mass are 2 important factors in the treatment of pseudoarthrosis; these results are achieved to a greater extent and in a shorter period of time using the plate. LEVEL OF EVIDENCE: level IV - case series.

Outcomes of the Pin and Plate Technique in Complex Fractures and Nonunions of Distal Humerus.

Objectives: This study investigates outcomes and complications of the pin and plate fixation technique, which was suggested for distal humerus fractures. It also reports the results of its application in nonunions for the first time. Methods: Forty-nine fracture and 17 nonunion cases who underwent surgery using the technique and were followed for at least 18 months were assessed through the range of motion (ROM), Quick Disabilities of the Arm, Shoulder, and Hand Score (Quick-DASH), Mayo Elbow Performance Score (MEPS), four-category verbal rating scale (VRS-4), and complications. Results: At the last follow-up, the mean scores of flexion, extension deficit, supination, and pronation ranges in fracture cases were 116.7, 22.9, 90.0, and 90.0 degrees, respectively. These values in nonunion cases were 112.2, 26.4, 86.7, and 85.5 degrees, respectively. The average ROM in fracture cases was 93.8, while it was 85.8 degrees in nonunion cases. The mean Quick-DASH in fracture and nonunion patients were 25.2 and 31.1, respectively. According to the MEPS, 77.5% of fracture and 64.7% of nonunion patients had excellent and good results. In fracture cases, the mean scores of VRS-4 at rest, light activity, and hard activity were 1.3, 1.8, and 2.3, respectively. These values in nonunion cases were 1.8, 2.2, and 2.5, respectively. The most common complications were device prominence and ulnar neuropathy. Conclusion: An acceptable union rate and proper elbow function can be expected by using this technique. Owing to the promising results of this study, further high-quality studies are recommended. Hereby this technique is called Persian Fixation.

Congenital hypoplastic thumbs treated by staged nonvascularized MTP joint transfer for absent MCP joints and abductor digiti minimi tendon transfer for opposition: a case series study.

BACKGROUND: We developed a 2-stage, MTP (metatarsophalangeal) joint- plus ADM (abductor digiti minimi) tendon-transfer, procedure for treatment of hypoplastic thumb. This method is intended to achieve both structural and functional goals of reconstruction. Structurally, it preserves a five-digit hand with minimal donor site complications. Functionally, it provides a functioning opposable thumb. CASE PRESENTATION: The case series included 7 patients with type IV hypoplastic thumb. At the first stage non-vascularized joint (not bone) was transplanted. In the second stage abductor digiti minimi tendon was transferred. Patients were followed for a median 5-yr period (range: 37-79 months). Functional outcome was assessed using a modified Percival assessment tool. Participants aged 17 to 36 months at the time of surgery with (2 male, 4 female). All patients were able to grasp large and small objects after the procedure. The thumb tip could actively move to touch the tips of index (2 patients) middle, ring, and little fingers (all patients) in an ulnar ward sequence and vice versa. All patients attained the ability to do lateral, palmar, and tripod pinch. As for donor site complications, none of the patients were found to have difficulty walking or keeping their balance. CONCLUSIONS: An alternative surgical procedure was developed to reconstruct a hypoplastic thumb. We obtained a good functional and cosmetic outcome with few donor site complications. Future studies will be needed to determine the long-term outcomes, to refine the selection criteria and to examine the necessity of additional procedure at the older ages.

Extensive Deep Tissue Involvement in Nicolau Syndrome and Below-Knee Amputation: A Case Report and Literature Review.

Nicolau syndrome (NS) is a rare cutaneous drug reaction in response to injections administered via any route. Based on the available studies in the medical literature, NS presents as skin and subcutaneous fat necrosis, and typically, it does not cause severe complications such as acute limb ischemia or death. In this study, we report the case of a 6-year-old boy who received an intramuscular injection of benzathine penicillin G for the treatment of bacterial pharyngitis, and subsequently developed a severe case of NS, which eventually led to below-knee amputation of the right lower limb. Although a few approaches have been suggested for the management of NS, they might not be effective under certain circumstances. Early detection, close monitoring, and consistent interventions, such as surgical fasciotomy and debridement procedures, might be necessary in severe cases of NS.

Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes.

BACKGROUND: Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation. METHODS: From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery. RESULTS: The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations. CONCLUSION: Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.

Clinical, radiological, pedobarographic, and quality of life outcomes of the Ponseti treatment for clubfoot: a prospective study.

BACKGROUND: Talipes equinovarus, also known as clubfoot, is a congenital anomaly that affects one newborn per 1000 live births. Its standard treatment strategy is Ponseti casting management. This study aims to report the long-term outcomes of the Ponseti treatment in Iran. METHODS: A prospective cohort study was enrolled to evaluate clinical outcomes, radiological results, pedobarographic measurements, and quality of life after the Ponseti treatment in patients with clubfoot who were followed for at least five years. RESULTS: In this study, 25 clubfeet of 18 patients were included. Significant reductions in Pirani, Dimeglio, and CAP scores, improved ankle dorsiflexion, and acceptable pedobarographic indices were observed in this study. From the radiological evaluation indices, the calcaneal pitch and lateral talus-first metatarsal angles were significantly reduced. After five years of treatment, patients' quality of life was favorable, which was better in females. This study showed that the results of the Ponseti treatment remained acceptable after five years. CONCLUSIONS: The Ponseti management for clubfoot in the long term appears to maintain significant improvements. However, the recurrence rate - albeit without disruption to daily activities - cannot be ignored.

Prognosis of Congenital Pseudarthrosis of the Tibia: Effect of Site of Tibial Pseudarthrososis and Fibular Involvement.

BACKGROUND: Congenital pseudarthrosis of the tibia is a rare condition that has long been one of the most challenging concerns in pediatric orthopedic surgery. When the fracture occurs, a recalcitrant nonunion is expected. This is why successful treatment means maintaining a long-term union. In this study, we aimed to assess the therapeutic outcomes for the middle and distal third fractures of the tibia and to explore whether the treatment of concurrent fibular pseudoarthrosis affects the outcome. METHODS: We studied 12 patients with congenital pseudarthrosis of the tibia (Crawford type 4) from 2014 to 2019. A combination approach including intramedullary rod, Ilizarov apparatus, corticocancellous bone graft, and periosteal graft was used. In the initial surgery, we did not fix the ankle and subtalar joints. RESULTS: As a result, the union was achieved in 67% of the cases after the index surgery. All of the cases with primary nonunion were related to the concurrent fibular and distal third tibial pseudarthrosis. In addition, ignoring the treatment of fibular pseudarthrosis in the index surgery led to ankle valgus deformity both in the middle and in the distal third tibial pseudarthrosis. We finally achieved a 100% union rate in all cases, with no subsequent refracture. CONCLUSIONS: Surgery at an early age was associated with favorable results and minimized deformity. In concurrent fibular and distal third tibial pseudarthrosis, it is recommended to transfix the ankle and subtalar joints to create a cross-union with fibula so that the intense union can be confidently obtained with more cross-section to prevent ankle valgus deformity. LEVEL OF EVIDENCE: Level IV-case series.

The path to minimizing instability in developmental dysplasia of the hip: is Capsulorrhaphy a necessity or a futile habit?

BACKGROUND: To evaluate and quantify the intraoperative effect of capsulorrhaphy on the deep seating of femoral head within the acetabulum as measured by medial joint space, a surrogate measure of acetabular-head contact. METHODS: In order to determine the exact effect of capsulorrhaphy, we prospectively scrutinized a consecutive sample of 18 patients with unilateral dysplastic hips aging > 18 months and followed them for a period of at least 12 months. The procedure of open reduction is described in detail. Two pediatric orthopedists carried out the operations from August 2014 to January 2019 at a tertiary pediatric hospital. Intraoperatively, AP radiographs of the pelvis were obtained before and after capsulorrhaphy. The distance between the inferomedial edge of the proximal femoral metaphysis and the lateral edge of the obturator foramen was recorded. To determine if there were differences in medial joint space due to capsulorrhaphy, a generalized linear model was run on the study sample. All patients were followed for at least 12 months to determine the rate of re-dislocation. RESULTS: Mean age (±standard deviation) of the participants was 37.5 (±24.7) months. All cases underwent Salter osteotomy, 5 cases needed femoral shortening (27.8%) and none needed derotational osteotomy. Capsulorrhaphy lead to a statistically significant decrease in the mean medial joint space from 1.59 cm before (95% CI: 1.12-2.05) to 0.76 cm after (95% CI: 0.50-1.02) the capsulorrhaphy (P < 0.001). When we took the effect of age into account the corresponding figures were 1.47 (95% CI: 1.22-1.75) and 0.67 (95% CI: 0.39-0.94), respectively (P < 0.001). After follow up periods of 1 to 5.5 years, none of the patients experienced instability or re-dislocation. CONCLUSIONS: Capsulorrhaphy, independently, of age was associated with a 1-cm decrease in the mean medial hip joint space and a more deeply seated femoral head. Furthermore, this study presents a successful experience with capsulorrhaphy to prevent hip instability.

Anterior Distal Hemiepiphysiodesis of Tibia for Treatment of Recurrent Equinus Deformity Due to Flat-Top Talus in Surgically Treated Clubfoot.

Treatment of persistent or recurrent equinus after repeated surgical releases can be challenging in patients with clubfoot. Anterior distal tibial epiphysiodesis has recently been used in patients with recurrent progressive equinus deformity, with inconsistent outcomes. Herein, we used this technique in a carefully selected subgroup (8 children, 9 feet) of patients with a severe equinus deformity and a flat-top talus. The patients were followed up with radiological and clinical measures for 12 to 18 months. The mean angle of the ankle improved significantly (25.5°, p < .0001). The mean anterior distal tibial angle decreased from 86.3° to 69° (p < .0001). Plantigrade foot was obtained in all patients, except 1 with arthrogryposis. When applied to carefully selected patients, anterior distal hemiepiphysiodesis of the tibia is an effective method for management of recurrent equinus deformity.

Use of the Ponseti method in the Iranian population.

BACKGROUND: The most common congenital orthopaedic condition requiring treatment is clubfoot. The Ponseti method, which has improved the recurrence rate, is at present the most attractive method of treatment in the north of America. The purpose of this study was to evaluate the outcome of this method in an Iranian population and look for characteristics that may affect the treatment process. METHODS: A total of 78 patients (129 feet) were treated by precisely adhering to the technique originally introduced by Ponseti. Relapse was defined as any return of each of 4 clubfoot components according to the Dimeglio-Bensahel system. The mean follow-up period was 24.7 months and relapse was analyzed with respect to severity of primary disorder, number of casts, compliance with postcorrection bracing and stretching exercise, and educational level of parents. RESULTS: At the end of the follow-up, 24 (18.6%) clubfeet experienced relapse as defined. The mean time to relapse was 13.7 months, 30 feet had brace noncompliance, and stretching was not done for 35 feet. Significant association was detected between recurrence and severity of clubfoot, number of casts for complete correction, and bracing and stretching exercise noncompliance. CONCLUSIONS: The Ponseti method is a successful treatment protocol for idiopathic clubfoot. Its success rate will increase with use of abduction orthosis after complete correction and also by performing regular stretching exercises. LEVEL OF EVIDENCE: Therapeutic level II.

Musculoskeletal injuries associated with earthquake. A report of injuries of Iran's December 26, 2003 Bam earthquake casualties managed in tertiary referral centers.

This is a descriptive analysis, performed on victims of Iran's December 26, 2003 Bam earthquake that were referred to tertiary referral trauma management centre in Tehran. Two hundred and ten patients were included in this study. Associated musculoskeletal injuries and renal function of the patients were recorded. The mean time under rubble was 1.9 h in our patients with a mean rescue to first medical aid time of 13.5 h. We had 19 cases of compartment syndrome and 6.7% of patients had impaired renal function. The incidence of compartment syndrome had a direct relation to the time under rubble and the incidence of renal failure was directly related to rescue to first medical aid time. Axial skeleton fractures, amongst them the lateral compression type pelvic fractures, were particularly common. Fracture associated neural injuries were also common. Institution of renal protective protocols from the very first hours after injury more conservative approaches to treatment of fractures in these crush trauma patients are strongly recommended.