Does Orientation of the Femoral Head Affect Acetabular Development? An Experimental Study in Lamb.

BACKGROUND: Derotational osteotomy of the proximal femur has proved to be effective in the treatment of residual acetabular dysplasia. However, the reason why this osteotomy is effective remains debatable. The purpose of this study is to investigate if an alteration of femoral head orientation affects acetabular growth. METHODS: A proximal femoral osteotomy was performed in 21 lambs aged 3 months: 5 varus osteotomies (110 degrees), 4 valgus osteotomies (150 degrees), and 12 derotation osteotomies. Results were compared with a control group (5 animals). Osteotomy was fixed with a screw-plate device. Version was controlled intraoperatively with K-wires. Animals were killed 3 months after surgical procedure. A morphometric study of both proximal femur and acetabulum was performed, including deepness, volume and diameters of the acetabulum, neck-shaft angle and femoral version. RESULTS: The average neck-shaft angle for the normal, anteversion, and retroversion groups was 129 degrees, whereas it was 110 degrees for the varus group and 149 degrees for the valgus group. The average femoral version for the normal, valgus, and varus groups was 21 degrees of anteversion, whereas it was 38 degrees of anteversion for the so-called anteversion group and 17 degrees of retroversion for the retroversion group. Nor the neck-shaft angle, nor the femoral version correlated with the acetabular anteroposterior diameter (P=0.698, 0.6, respectively), the acetabular inferosuperior diameter (P=0.083, 0.451, respectively) or the acetabular deepness (P=0.14, 0.371, respectively). The neck-shaft angle correlated significantly with acetabular volume (P=0.023), so that the lower the neck-shaft angle, the higher the acetabular volume (r=-0.453). The femoral version did not correlated with acetabular volume (P=0.381). CONCLUSIONS: Decreasing the neck-shaft angle provokes an increase in acetabular volume, whereas changes in femoral version do not affect the acetabular growth. Extra-articular osteotomies that alter femoral orientation affect intra-articular gross morphology. LEVEL OF EVIDENCE: Level II-therapeutic study.

Long-term Functional Results of Neurological Complications of Pediatric Humeral Supracondylar Fractures.

PURPOSE: It has been reported that most neurological injuries after sustaining a supracondylar fracture will usually resolve spontaneously in the first months; however, studies are lacking regarding the influence of these injuries in the upper limb functionality in the long-term follow-up. The aim of this study is to report the long-term functional outcome of neurological complications associated to pediatric supracondylar fractures. METHODS: Medical records of 448 children who sustained a supracondylar humeral fracture were reviewed. Patients with a concomitant neurological injury were included. Clinical evaluation included grip and pinch strength and a thorough examination of sensibility. Clinical outcomes were described according to the Mayo Elbow Performance Score and Flynn criteria. Patients completed the quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) questionnaire. RESULTS: There were 29 patients with a supracondylar humeral fracture and a neurological injury (6.5%). The median nerve was injured in 13 patients, the radial nerve in 14 patients and the ulnar nerve in 9 patients. Of them, 16 patients returned for clinical evaluation. The mean age at the time of fracture was 7.5±1.9 years and at revision 16±5.3 years. The average follow-up was 8.6±4.8 years (3.4 to 17.4 y). There were no differences in terms of grip or pinch strength. Seven patients referred paresthesias, 6 of them in the ulnar nerve's territory. The average score was 4±3 (median, 4) for the QuickDASH questionnaire and 96±7 for the Mayo Elbow Performance Score. According to Flynn criteria, results were satisfactory in 10 cases. DISCUSSION: Functional results were excellent in the majority of patients. Almost half of the patients referred paresthesias, mostly in the ulnar nerve territory, that were not limiting normal daily activity. At final follow-up, although 100% of the radial nerve injuries and 87.5% of the median nerve injuries were fully recovered, only 25% of the ulnar nerve injuries were. LEVEL OF EVIDENCE: Level IV-prognostic study.

C sign: talocalcaneal coalition or flatfoot deformity?

BACKGROUND: C sign is used to alert the physician of the possible presence of talocalcaneal coalition (TCC), so that advanced imaging can be ordered. The purpose of this study was to know the prevalence of the C sign among patients with TCC and its relationship to the presence of a TCC or to hindfoot alignment. METHODS: Retrospective reviews of the presence of C sign in radiographs of 88 feet with TCC (proved by computed tomography scan or surgical findings) and 260 flexible flatfeet were conducted. C sign was classified as complete and interrupted (types A, B, and C). The interobserver variability of the C sign was studied. Seven radiographic parameters were measured to analyze the relationship of these measurements with the presence or absence of the C sign. RESULTS: C sign was present in 68 feet (77%) with TCC: 14.5% complete and 62.5% interrupted (26% type A, 19.5% type B, and 17% type C). C sign was present in 116 flatfeet (45%), all of them interrupted (0.4% type A, 5.5% type B, and 39% type C). The talo-first metatarsal angle, the talohorizontal angle, the calcaneal pitch, the calcaneo-fifth metatarsal angle, and the naviculocuboid overlap presented a more pathologic value when a C sign was present. The κ-value for the presence of a C sign was 0.663. CONCLUSIONS: The so-called true C sign (complete or interrupted type A) indicates the presence of a TCC and it is not related to flatfoot deformity. However, it is only present in 41% of the cases. The interrupted C sign is much more likely to be related to flatfoot deformity than to the presence of a TCC, specifically when a type C is found. LEVEL OF EVIDENCE: Diagnostic Study level I.

Selective epiphysiodesis of the triradiate cartilage for treatment of residual experimental acetabular dysplasia.

BACKGROUND: The purpose of the study is to evaluate the effect of a selective epiphysiodesis of the ilioischial limb of the triradiate cartilage (TC) in an experimental dysplastic hip. MATERIALS AND METHODS: A hip dysplasia was obtained in 23 New Zealand rabbits 3 weeks old by immobilizing the knee in extension with a K-wire, in 4 groups: (1) control group; (2) K-wire maintained until sacrifice; (3) K-wire removed 1 week later without epiphysiodesis; and (4) K-wire removed 1 week later with selective epiphysiodesis of the ilioischial limb of the TC. Radiographic evaluation was performed previous to knee immobilization, after K-wire removal and after sacrifice. Acetabular index (AI), Sharp's angle, ACM angle, acetabular floor thickness ratio (AFTR) were measured and presence of dysplasia, subluxation, or dislocation was noted. The acetabular version, the acetabular sector angles, and the pelvis rotation were obtained using CT evaluation. A morphology score was developed and a morphometric study of both proximal femur and acetabulum was performed. RESULTS: No differences between groups in the radiographic assessment before immobilization or K-wire removal were found. All cases in group 2 showed dysplasia, subluxation, or dislocation of the hip. The radiographic assessment of group 4, compared with group 3, showed a lower AI (P=0.027), Sharp's angle (P=0.005), ACM angle (0.049), and AFTR (P=0.017). No differences between groups 1 and 4 regarding AI (P=0.08), Sharp's angle (P=0.484), and AFTR (P=0.639) were obtained. The morphology score was lower in group 4 than in groups 2 and 3. Group 4 showed a deeper acetabulum than group 2 (P=0.008) and group 3 (P=0.033), while it was similar to group 1 (P=0.364). CONCLUSIONS: A selective epiphysiodesis of the ilioischial limb of the TC in a dysplastic hip normalized the radiographic measurements of the acetabulum and the acetabular deepness, and it improved the previous gross morphology of the capsule, labrum, and ligamentum teres in rabbits. LEVEL OF EVIDENCE: Level II-therapeutic study.

Comparison of the calcaneo-cuboid-cuneiform osteotomies and the calcaneal lengthening osteotomy in the surgical treatment of symptomatic flexible flatfoot.

BACKGROUND: Surgery is indicated in symptomatic flatfoot when conservative treatment fails to relieve the symptoms. Osteotomies appear to be the best choice for these painful feet. The purpose of this study was to compare the clinical and radiographic outcome of the calcaneo-cuboid-cuneiform osteotomies (triple C) and the calcaneal-lengthening osteotomy in the treatment of children with symptomatic flexible flatfoot. METHODS: The surgeries were performed by senior surgeons who preferred either triple C or calcaneal lengthening. The results were graded by an orthopaedic surgeon uninvolved with the cases. The clinical and radiographic outcome was evaluated in 30 feet (21 patients) with a triple C osteotomy and 33 feet (21 patients) with a calcaneal-lengthening osteotomy. We used the American College of Foot and Ankle Surgeons (ACFAS) score (flatfoot module) for clinical assessment, which contains a subjective and objective test. We measured and compared 12 parameters on the anteroposterior and lateral weight-bearing radiographs. The effect of additional procedures (Kidner procedure, medial reefing of the talonavicular capsule, tendo-Achilles lengthening, peroneous brevis lengthening and, in the calcaneal-lengthening group, a medial cuneiform osteotomy) on the clinical and radiographic result was also evaluated. RESULTS: Average age at the time of surgery was similar (triple C: 11.2 ± 3 y, calcaneal lengthening: 11.6 ± 2.5 y, P = 0.51). Average follow-up was 2.7 ± 2.2 years in the triple C group and 5.3 ± 4 years in the calcaneal-lengthening group. There were no significant differences in the clinical outcome measured by the ACFAS subjective test in the calcaneal-lengthening group (P = 0.003). There were no significant differences in the ACFAS score, both the subjective test (triple C: 43.3 ± 6.1, calcaneal lengthening: 44.7 ± 7.6, P = 0.52) and the ACFAS objective test (triple C: 28.6 ± 2, calcaneal lengthening: 25.9 ± 7, P = 0.13). We found significant differences in 2 of the 12 radiographic measurements: anteroposterior talo-first metatarsal angle (triple C: 15.5 ± 11.1, calcaneal lengthening: 7.4 ± 7.3, P = 0.001) and talonavicular coverage (triple C: 28 ± 14.7, calcaneal lengthening: 13.7 ± 12.4, P<0.001). None of the additional procedures improved the clinical outcome. There were 3 (10%) complications in the triple C group and 6 (18%) complications in the calcaneal-lengthening group. Also, calcaneocuboid subluxation was present in 17 (51.5%) feet of the calcaneal-lengthening group. CONCLUSIONS: Both techniques obtain good clinical and radiographic results in the treatment of symptomatic idiopathic flexible flatfoot in a pediatric population. The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus but it is associated with more frequent and more severe complications. Additional soft-tissue procedures have not proven to improve clinical or radiographic results. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Flexible flatfoot: differences in the relative alignment of each segment of the foot between symptomatic and asymptomatic patients.

BACKGROUND: Flexible flatfoot is a physiological variation of normality that does not need correction unless it becomes symptomatic. It remains unclear why some flexible flatfeet become symptomatic. Operations for symptomatic flatfoot correct the theoretical deformities with the intent of relieving symptoms. Using radiographic measurements, we analyzed the relative alignment of each segment of the foot in symptomatic and asymptomatic flexible flatfoot. METHODS: One hundred and thirty-five patients with idiopathic flexible flatfoot were identified restrospectively and divided into 3 groups: (a) 45 asymptomatic; (b) 45 symptomatic with conservative treatment; and (c) 45 symptomatic with surgical treatment. Standing anteroposterior and lateral radiographs of the foot were analyzed. Thirteen measurements were calculated to describe the alignment of the hindfoot, midfoot, and forefoot. Multivariate analysis of variance and Bonferroni post hoc comparisons were used for statistical analysis. RESULTS: Age and sex were similar in the 3 groups. Significant differences among the 3 groups were found in 8 measures. However, differences between asymptomatic (a) and symptomatic (b) flatfeet were found in just 2 measures: talonavicular coverage, with a large effect size (0.59); and lateral calcaneo-fifth metatarsal angle, with a small effect size (0.10). CONCLUSIONS: There were no differences, between symptomatic (a) and asymptomatic (b) flexible flatfeet, in the measures that describe the alignment of the hindfoot, the longitudinal arch, the lateral column length or the pronation/supination of the forefoot. However, the lateral displacement of the navicular, measured by the anteroposterior talonavicular coverage, seems to be related to the onset of symptoms among patients with flexible flatfeet.

Developmental dysplasia of the hip: update of management.

The term 'developmental dysplasia of the hip' (DDH) includes a wide spectrum of hip alterations: neonatal instability; acetabular dysplasia; hip subluxation; and true dislocation of the hip.DDH alters hip biomechanics, overloading the articular cartilage and leading to early osteoarthritis. DDH is the main cause of total hip replacement in young people (about 21% to 29%).Development of the acetabular cavity is determined by the presence of a concentrically reduced femoral head. Hip subluxation or dislocation in a child will cause an inadequate development of the acetabulum during the remaining growth.Clinical screening (instability manoeuvres) should be done universally as a part of the physical examination of the newborn. After two or three months of life, limited hip abduction is the most important clinical sign.Selective ultrasound screening should be performed in any child with abnormal physical examination or in those with high-risk factors (breech presentation and positive family history). Universal ultrasound screening has not demonstrated its utility in diminishing the incidence of late dysplasia.Almost 90% of patients with mild hip instability at birth are resolved spontaneously within the first eight weeks and 96% of pathologic changes observed in echography are resolved spontaneously within the first six weeks of life. However, an Ortolani-positive hip requires immediate treatment.When the hip is dislocated or subluxated, a concentric and stable reduction without forceful abduction needs to be obtained by closed or open means. Pavlik harness is usually the first line of treatment under the age of six months.Hip arthrogram is useful for guiding the decision of performing a closed or open reduction when needed.Acetabular dysplasia improves in the majority due to the stimulus provoked by hip reduction. The best parameter to predict persistent acetabular dysplasia at maturity is the evolution of the acetabular index.Pelvic or femoral osteotomies should be performed when residual acetabular dysplasia is present or in older children when a spontaneous correction after hip reduction is not expected.Avascular necrosis is the most serious complication and is related to: an excessive abduction of the hip; a force closed reduction when obstacles for reduction are present; a maintained dislocated hip within the harness or spica cast; and a surgical open reduction. Cite this article: EFORT Open Rev 2019;4:548-556. DOI: 10.1302/2058-5241.4.180019.

Management of supracondylar fractures of the humerus in children.

Supracondylar fractures of the humerus are the most frequent fractures of the paediatric elbow, with a peak incidence at the ages of five to eight years.Extension-type fractures represent 97% to 99% of cases. Posteromedial displacement of the distal fragment is the most frequent; however, the radial and median nerves are equally affected. Flexion-type fractures are more commonly associated with ulnar nerve injuries.Concomitant upper-limb fractures should always be excluded. To manage the vascular status, distal pulse and hand perfusion should be monitored. Compartment syndrome should always be borne in mind, especially when skin puckering, severe ecchymosis/swelling, vascular alterations or concomitant forearm fractures are present.Gartland's classification shows high intra- and inter-observer reliability. Type I is treated with casting. Surgical treatment is the standard for almost all displaced fractures. Type IV fractures can only be diagnosed intra-operatively.Closed reduction and percutaneous pinning is the gold standard surgical treatment. Open reduction via the anterior approach is indicated for open fractures, absence of the distal vascular flow for > 10 to 15 minutes after closed reduction, and failed closed reduction.Lateral entry pins provide stable fixation, avoiding the risk of iatrogenic ulnar nerve injury.About 10% to 20% of displaced supracondylar fractures present with alterations in vascular status. In most cases, fracture reduction restores perfusion.Neural injuries occur in 6.5% to 19% of cases involving displaced fractures. Most of them are neurapraxias and it is not routinely indicated to explore the nerve surgically. Cite this article: EFORT Open Rev 2018;3:526-540. DOI: 10.1302/2058-5241.3.170049.

Results of the Pavlik harness when treating Ortolani-positive hips: predictors of failure and arthrographic findings.

BACKGROUND: Predictors of failure of the Pavlik harness in reducing and stabilizing an Ortolani-positive hip remain 'unclear'. The purpose of this study is to investigate the success of the Pavlik harness when treating Ortolani-positive hips, to look for predictors of failure of the harness and to analyze the arthrographic findings among these failures. MATERIALS AND METHODS: The medical records of 39 consecutive patients with an Ortolani-positive hip treated initially with a Pavlik harness were reviewed. Data regarding birth order, problems during pregnancy, presentation at birth, delivery, family history of DDH, gender, side involved, bilaterality, onset of treatment, problems related to use of the harness, and time until the harness reduced and stabilized the hip or was abandoned because of a failure were recorded. The presence of plagiocephaly, torticollis or foot deformity was also noted. We looked for predictors of failure among these aspects and report the arthrographic findings of the failures. RESULTS: The mean age when the harness was started was 16.7 days. The mean time until success or failure of the harness in reducing and stabilize the hip was 18.5 days. There were 8 (20.5 %) failures. Multigravida (p = 0.026) and foot deformity (p = 0.023) were associated with failure of the harness. On the other hand, problems during pregnancy (p = 1), presentation at birth (p = 0.078), c-section (p = 0.394), family history of DDH (p = 1), gender (0.313), torticollis (p = 1), bilaterality (p = 1) and onset of treatment (p = 0.485) were not associated. Arthrographic abnormalities were found in all failures. CONCLUSION: The Pavlik harness failed to reduce and stabilize the hip in 20.5 % of the newborns with an Ortolani-positive hip. Multigravida and foot deformity were statistically associated with failure of the harness. An anatomical obstacle for reduction was found in all hips with a harness failure. A more teratological than mechanical hip dislocation could be the reason for failure of the Pavlik harness. LEVEL OF EVIDENCE: IV, Retrospective case series.

Natural history of unreduced Gartland type-II supracondylar fractures of the humerus in children: a two to thirteen-year follow-up study.

BACKGROUND: The preferred treatment of type-II supracondylar humeral fractures remains controversial. The purpose of this study was to evaluate the long-term clinical and radiographic outcome of type-II supracondylar humeral fractures in children treated with immobilization in a splint without reduction. METHODS: The medical records of forty-six consecutive patients who sustained a supracondylar Gartland type-II fracture of the humerus treated with immobilization in a splint were reviewed. Age at the time of fracture, sex, side involved, dominant extremity, duration of immobilization, and complications were recorded. Radiographic assessment included the Baumann angle, carrying angle, and lateral humerocapitellar angle. Patients returned for clinical evaluation, and the Mayo Elbow Performance Score and the criteria of Flynn et al. were recorded. Patients completed the QuickDASH, an abbreviated form of the Disabilities of the Arm, Shoulder and Hand questionnaire, to measure disability. RESULTS: The average age (and standard deviation) at the time of fracture was 5.5 ± 2.6 years. The average duration of follow-up was 6.6 ± 2.8 years. The initial lateral humerocapitellar angle was a mean of 12.8° ± 9.8°, the mean Baumann angle was 12° ± 5.7°, and the mean radiographic carrying angle was 9° ± 11.3°. There were significant differences between injured and uninjured elbows at the time of follow-up with regard to flexion (mean, 137.9° ± 9.1° for injured and 144.8° ± 7.1° for uninjured elbows; p < 0.001), extension (mean, 13.2° ± 5.9° for injured and 7.4° ± 5.1° for uninjured elbows; p < 0.001), clinical carrying angle (mean, 9° ± 8.1° for injured and 12.1° ± 4.9° for uninjured elbows; p = 0.003), radiographic carrying angle (mean, 8.9° ± 8.1° for injured and 14.2° ± 5.5° for uninjured elbows; p < 0.001), and lateral humerocapitellar angle (mean, 30.5° ± 11° for injured and 41.9° ± 9.9° for uninjured elbows; p < 0.001). The mean score was 10 ± 15.3 points for the QuickDASH questionnaire, 4.7 ± 12.2 points for the QuickDASH-sports questionnaire, and 95.6 ± 10.5 for the Mayo Elbow Performance Score. According to the Flynn criteria, results were satisfactory in 80.4% of the patients. CONCLUSIONS: Patients with a type-II supracondylar fracture of the humerus treated conservatively had a mild cubitus varus deformity and a mild increase in elbow extension, although functional results were excellent in the majority of patients.

Injuries associated with femoral shaft fractures with special emphasis on occult injuries.

BACKGROUND: Fractures of the femoral shaft are mostly the result of high-energy accidents that also cause multiple trauma injuries, in particular ipsilateral knee and hip injuries. The purpose of this study was to investigate the incidence of injuries associated with femoral shaft fractures and how many of them were undetected. METHODS: We studied 148 patients (150 femoral shaft fractures) with an average age of 52 (range: 18-97). Femoral shaft fractures were treated with antegrade intramedullary nailing in 118 cases (78.7%), and with open reduction and internal fixation in 32 cases (21.3%). Unlocked reamed intramedullary nailing was performed in Winquist type I and type II fractures, while statically locked unreamed intramedullary nailing was carried out in Winquist type III and type IV fractures. RESULTS: There were 70 patients with associated injuries (46.4%). The associated injuries went undetected in 18 out of 70 patients (25.5%). Six femoral nonunions (4%) occurred in patients under 70 years of age (high-energy accidents) treated by open reduction and internal fixation. CONCLUSION: Injuries associated with femoral shaft fractures were very frequent (46.4%) in our series, with 25.5% undetected. Open reduction and internal fixation was a poor prognostic factor of nonunion in these fractures.

Enteroparásitosis en niños con síndrome diarreico agudo de la ciudad de Valdivia, X Región, Chile con especial referencia a Cryptosporidium sp / Enteroparasitoses in children with severe diarrheal syndrome of Valdivia (X Region), Chile: with special reference to Cryptosporidium sp

Se comunica los resultados de un estudio coproparasitológico en 100 niños de la ciudad de Valdivia que presentaban síndrome diarreico agudo. El análisis se realiza mediante la técnica de MTM y PAF, tiñéndose además un frotis por la técnica de Ziehl-Neelsen para el diagnóstico de Cryptosporidium. El 45% de los niños estaba infectado por parásitos y/o comensales intestinales. El grupo más afectado fue el de los escolares con un 85% de infección, los lactantes presentaron un 27,3% de infección. Constatándose asociación estadísticamente significativa entre la variable infección por parásitos y/o comensales con la edad del hospedador. Se encontró una prevalencia de 5% de cryptosporidiosis entre los niños estudiados, los más afectados fueron los lactantes. En relación a las condiciones de saneamiento básico, se encontró asociación estadística entre el número de niños infectados por parásitos y/o comensales, con la disposición de excretas y con la potabilidad del agua. Se concluye que es imprescindible la implementación de técnicas de diagnóstico para Cryptosporidium como examen de rutina en todo menor de tres años con síndrome diarreico agudo

Absorción intestinal en escolares asintomáticos portadores de Giardia lamblia / Intestinal absorption in asymptomatic school children with Giardia lamblia

En 14 escolares con edades entre 6,2 y 13,6 años, portadores asintomáticos de Giardia lamblia se hicieron evaluaciones antropométricas y mediciones de hematocrito, hemoglobinemia, proteinemia total, albuminemia, carotinemia basal y prueba de absorción de vitamina A y D-xilosa, antes y después de recibir tratamiento antiparasitario con Tinidazol y Mebendazol. Se demonstraron aumentos significativos en pliegue cutáneo tricipital, hematocrito, hemoglobinemia y proteinemia. La xilosemia fue de 38,8 + ou - 8,9 y de 57,5 + ou - 10,8 mg% (p <0,005) antes y después del tratamiento respectivamente. Las concentraciones de vitamina A después de sobrecarga oral fueron 66,5 + ou - 26,0 y 213,0 + ou - 113,0 microng% (p <0,005) y el delta vitamina A de 32,7 + ou - 25,3 y de 152,7 + ou - 115,8 microng% (p <0,005) para las etapas previa y posterior al tratamiento respectivamente. Se concluye que en escolares asintomáticos, portadores de Giardia lamblia, podría incrementar la absorción intestinal luego de erradicar al parásito