RESUMO
BACKGROUND: The induced membrane technique is now widely used for pediatric diaphyseal bone loss due to various etiologies. Although consolidation rates remain satisfactory, complications, and healing delays may occur requiring additional procedures. We studied a series of induced membrane bone reconstructions in which the second stage included an embedded endomembranous non vascularized fibular shaft, in addition to iliac bone grafts. The purpose of this study was to analyze the results in terms of bone consolidation and complications. METHODS: This is a retrospective comparative and multicentric study of 32 children with large bone loss treated with the induced membrane reconstruction technique. Patients were divided into 2 groups according to the graft used during the second stage. The first group (G1) of 16 patients had a nonvascularized fibula embedded inside the membrane in addition with the corticocancellous grafts from the iliac crest. The second group (G2) of 16 patients underwent reconstruction using the original technique, with iliac crest graft only. RESULTS: The 2 groups were similar in terms of etiologies of bone loss and follow-up (mean: 44 mo for G1 and 49 mo for G2). Mean bone losses were 15.4 cm (range: 2 to 25; SD: 5.6) for G1 and 10.6 cm (range: 3 to 19; SD: 5.2) for G2. In the first group, all patients healed primarily, with a mean time of 5.9 months (range: 4 to 8; SD: 1.6). In the second group, 2 of 16 patients did not healed; for the others 14, healing mean time was 6.9 months (range: 3 to 12; SD: 2.7). The short-term and long-term complications rates were 38% to 19% for G1 and 50% to 31% for G2, respectively. Regarding the donor site, the fibulas reconstructed spontaneously with a mean time of 4.8 months (range: 3 to 6; SD: 1.2). CONCLUSIONS: The integration of a nonvascularized fibula during the second stage of the induced membrane technique appears to improve the consolidation rate in the pediatric population. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.
Assuntos
Transplante Ósseo , Fíbula , Ílio , Humanos , Criança , Estudos Retrospectivos , Transplante Ósseo/métodos , Masculino , Feminino , Ílio/transplante , Fíbula/transplante , Adolescente , Seguimentos , Pré-Escolar , Resultado do Tratamento , Procedimentos de Cirurgia Plástica/métodos , Diáfises/cirurgiaRESUMO
BACKGROUND: Spasticity of the elbow flexors causes a dynamic and/or static elbow flexion deformity. This position interferes with the functional use of the hand, is aesthetically unpleasant and can cause problems with hygiene and comfort. A lengthening procedure of elbow flexor muscles can improve elbow posture and range of motion. However, causal spasticity is not addressed directly. Selective neurectomy of the musculocutaneous nerve has a direct effect on underlying spasticity but is not sufficient when contracture is present. In this study, we examine the long-term results of a combined surgical approach: a release procedure of the elbow flexors and selective neurectomy of the musculocutaneous nerve. METHODS: A retrospective study of 14 patients with spastic flexion deformity of the elbow was performed. After a mean follow-up of 52.6 months (SD 33, range 12 to 113), the results of the combined surgical approach were evaluated. Spontaneous position of the elbow and active and passive range of motion were assesses using goniometry. Spasticity was assessed using the Modified Ashworth Scale. Function of the affected upper limb before and after surgery was assessed by the House functional classification. Patient and caretaker's satisfaction were assessed using a visual analogue scale. RESULTS: The mean decrease of passive elbow extension deficit was 34 degrees (SD 21.3, P <0.05). Active elbow extension increased with a mean of 41 degrees (SD 16.5, P <0.05). Spontaneous position elbow flexion decreased by a mean of 40 degrees (SD 21.1, P <0.05).The Modified Ashworth score decreased significantly ( P <0.05) from 3.27 (range 1 to 4) preoperatively to 0.64 (range 0 to 4) postoperatively.The difference between the House score preoperatively and postoperatively was not significant ( P =0.180). Mean patient satisfaction was 8.2/10 (SD 2.7, range 2 to 10) and mean caregiver satisfaction was 7.1/10 (SD 2.7, range 1 to 10). CONCLUSION: A combined surgical approach to elbow flexion deformity in the form of a lengthening procedure and selective neurectomy of the elbow flexors result in a significant and sustained improvement of the spontaneous position, active and passive elbow extension and elbow flexor spasticity and high patient and caregiver satisfaction. LEVEL OF EVIDENCE: Case series, level IV.
Assuntos
Articulação do Cotovelo , Espasticidade Muscular , Nervo Musculocutâneo , Amplitude de Movimento Articular , Humanos , Criança , Estudos Retrospectivos , Adolescente , Espasticidade Muscular/cirurgia , Feminino , Masculino , Articulação do Cotovelo/cirurgia , Articulação do Cotovelo/fisiopatologia , Seguimentos , Nervo Musculocutâneo/cirurgia , Resultado do Tratamento , Satisfação do Paciente , Pré-EscolarRESUMO
Management of the upper limb in children with cerebral palsy is often complex and must be carried out by a team experienced in this field. Several clinical parameters must be taken into consideration, such as higher functions, visual problems, overall upper limb function, motor control, sensitivity, presence of hemineglect or synkinesis, limb position at rest and during walking. And last but not least, a complete analysis of the upper limb is required. It is only after this exhaustive assessment - which often includes occupational therapy, physiotherapy and in some cases, video and electromyography evaluations - that a treatment indication can be discussed with the patient's family. Other than baseline treatment consisting of rehabilitation, occupational therapy and bracing, botulinum toxin injections could be an option, targeting specific muscle groups. Surgical treatments, which are often indicated in severe forms with contractures, are proposed after the patient's case is presented at a multidisciplinary meeting. These include selective neurotomy, muscle-tendon release, transfer or lengthening, and procedures on bone and joints (osteotomy, arthrodesis). LEVEL OF EVIDENCE: Expert opinion.
Assuntos
Toxinas Botulínicas Tipo A , Paralisia Cerebral , Fármacos Neuromusculares , Criança , Humanos , Toxinas Botulínicas Tipo A/uso terapêutico , Fármacos Neuromusculares/uso terapêutico , Paralisia Cerebral/complicações , Paralisia Cerebral/terapia , Espasticidade Muscular , Extremidade SuperiorRESUMO
In the management of brachial plexus birth palsies, the quality of the roots eligible for reconstruction is thought to be a key issue. The aim of the present study was to evaluate the correlations between pathological root examination and motor recovery after brachial plexus reconstructions. Quantitative histopathological analysis of intraneural fibrosis was conducted on 72 nerve transections (40 roots, 18 trunks and 14 suprascapular nerves) in 20 patients. Clinical recovery of targeted muscles after surgery was assessed by standardized functional scores. After a mean follow-up of 32 months, patients with a lower fibrosis rate for the suprascapular nerve had greater global Mallet scores (r = -0.57; p = 0.042) as well as a greater active shoulder flexion (r = -0.66; p = 0.015). Correlations were also found between C6 root and upper trunk fibrosis rate and some of the subsections of the Mallet score, active movement scale for the biceps and active elbow flexion. These results seem to confirm the relevance of intraoperative pathological evaluation of the roots and nerves after neuroma resection to optimally define the reconstruction strategy.Level of evidence: IV.
RESUMO
In children suffering from brachial plexus birth injuries (BPBI), one major difficulty concerns intraoperative selection of the roots to be used for reconstruction. Between November 2018 and August 2020, surgical qualitative evaluations and pathological quantitative analyses were conducted on 52 roots and 29 distal neural stumps (trunks, divisions, cords, and nerves distal to the neuroma) in 17 patients who underwent brachial plexus reconstruction. For each root, surgeons rated stump quality as "good", "fair" or "avulsed". Neural sections were then sent to pathology to determine percentage intraneural fibrosis under microscopy. Mean root intraneural fibrosis rates were 30.5% (SD 24.9; range, 0-80%), 46.3% (SD 32.6; range, 0-90%) and 24.6% (SD 23.5; range, 0-80%) in the "good quality", "fair quality" and "avulsed" groups, respectively, with no significant differences between groups. In distal neural stumps, the mean intraneural fibrosis rate was 30.9% (SD 24.7). These findings raise the question of conducting frozen section biopsy of neural stumps after neuroma resection to determine surgical reconstruction strategy.
Assuntos
Traumatismos do Nascimento , Neuropatias do Plexo Braquial , Plexo Braquial , Transferência de Nervo , Neuroma , Traumatismos do Nascimento/cirurgia , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/cirurgia , Criança , Humanos , Neuroma/cirurgiaRESUMO
From 1998 to 2014, we performed primary brachial plexus repair in 260 children with neonatal brachial plexus palsy. Thirty-three presented with a C5-8 palsy and 24 were reviewed for this study. The surgical strategy was to focus on repairing the upper trunk. Secondary surgical procedures were performed in 21 patients, mainly for shoulder external rotation deficit or weak wrist extension. After a mean follow-up of 9.7 years (range 3 to 19), the median Mallet score for the shoulder was 9.5 and the mean Raimondi score for the hand was 3.3. Median active movement scale was 5, 7 and 5.5 for the deltoid, biceps and triceps, respectively. We conclude that primary C5-8 brachial plexus reconstruction provides restoration of elbow flexion and most patients have a sensitive and functional hand. We also found that secondary surgery to improve shoulder and wrist function is often necessary, which should initially be explained to the family.Level of evidence: IV.
Assuntos
Neuropatias do Plexo Braquial , Plexo Braquial , Paralisia do Plexo Braquial Neonatal , Transferência de Nervo , Neuropatias do Plexo Braquial/cirurgia , Criança , Humanos , Recém-Nascido , Amplitude de Movimento Articular , Resultado do Tratamento , Articulação do PunhoRESUMO
The objective of this study was to evaluate the results after selective pronator teres (PT) neurectomy in children with spastic hemiplegia. Patients with PT spasticity without contracture and an active supination improvement after PT botulinum toxin injection were included. Hand function and deformities were evaluated with the House score, Gschwind and Tonkin pronation deformity classification and Zancolli's classification. Twenty-two patients (mean age 11.6 years) were included in this study. The average follow-up was 32.6 months. All but one patient improved their supination with a preoperative mean active supination of 5° (range -80-70°) and postoperative of 48° (range 10-90°). Active pronation was always maintained at the last follow-up. PT selective neurectomy appears to improve active and passive forearm supination and should be included in a global strategy of treatments to improve upper limb function in children with cerebral palsy. LEVEL OF EVIDENCE: IV.
Assuntos
Paralisia Cerebral/fisiopatologia , Denervação , Antebraço/cirurgia , Espasticidade Muscular/cirurgia , Músculo Esquelético/inervação , Adolescente , Criança , Feminino , Seguimentos , Antebraço/fisiopatologia , Hemiplegia/fisiopatologia , Humanos , Masculino , Espasticidade Muscular/fisiopatologia , Músculo Esquelético/cirurgia , Pronação/fisiologia , Estudos Retrospectivos , Supinação/fisiologiaRESUMO
Congenital muscle hypertrophy of the upper limb is a very rare condition with unknown aetiology. This descriptive observational and retrospective series included eight children followed by a multidisciplinary team from 2005 to 2017. The diagnosis was based on a cluster of clinical and radiological characteristics after elimination of differential diagnoses. Patients were categorized according to: anomalies of the wrist, anomalies of long fingers of intrinsic or extrinsic origin; and anomalies of the thumb with or without first web space contracture. Treatment begins in young children with hand orthoses to limit muscle contraction and joint malposition. The purpose of surgical treatment was to release contractures and to restore muscle balance through, in the main, finger intrinsic releases and first web releases. At the 2-year follow-up, we found that limited surgical procedures improved finger, thumb and wrist positions. We conclude that muscle hypertrophy is the main cause of deformity and that selective releases of contracted musculo-tendinous units and skin lengthening are effective. LEVEL OF EVIDENCE: IV.
Assuntos
Hipertrofia/congênito , Músculo Esquelético/patologia , Músculo Esquelético/cirurgia , Deformidades Congênitas das Extremidades Superiores/cirurgia , Adolescente , Criança , Pré-Escolar , Contratura/cirurgia , Feminino , Humanos , Hipertrofia/diagnóstico por imagem , Hipertrofia/cirurgia , Imageamento por Ressonância Magnética , Masculino , Músculo Esquelético/diagnóstico por imagem , Procedimentos Ortopédicos , Radiografia , Estudos Retrospectivos , Deformidades Congênitas das Extremidades Superiores/diagnóstico por imagemRESUMO
PURPOSE: Obstetric brachial plexus palsy (OBPP) may result in a severe impairment of upper limb function, especially when major motor functions do not recover with or without early microsurgical reconstruction. Various methods to restore elbow flexion have been described. The aim of this study was to report the results after pectoralis minor transfer for elbow flexion restoration in late OBPP. METHODS: Nineteen patients were included. Mean age at surgery was six years (range, 2.3-12.8). The mean follow-up period was four years (range, 1-15). Shoulder function was evaluated by the Mallet classification and hand function by the Raimondi scale. We used the "active movement scale" (AMS) to evaluate elbow flexion function. RESULTS: Eighteen of the 19 patients had improvement in their elbow active flexion. There was significant improvement in biceps muscle power according to the BMRC grading system, from an average grading of 1.7 (range, 1-3) pre-operatively to 3 (range, 1-4) post-operatively (P < 0.05). The average active elbow flexion was significantly improved from a mean of 81° (range, 0-120; SD = 44) pre-operatively, most of them gravity eliminated, to a mean of 111° (range, 0-140; SD = 33) post-operatively (P < 0.05). According to the AMS, 12 patients (63%) had a good result, 4 (21%) a fair result and 5 (26%) a poor result. Poor results were significantly correlated with a low pre-operative AMS score (P < 0.05). CONCLUSIONS: The pectoral minor transfer can be a reliable technique for elbow flexion improvement in late OBPP by strengthening an already existing but inadequate active flexion. LEVEL OF EVIDENCE: IV.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Articulação do Cotovelo/cirurgia , Músculos Peitorais/transplante , Transferência Tendinosa/métodos , Plexo Braquial , Criança , Pré-Escolar , Cotovelo , Articulação do Cotovelo/fisiopatologia , Feminino , Humanos , Masculino , Gravidez , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Transferência Tendinosa/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Resection of primary malignant tumors often creates large bony defects. In children, this creates reconstructive challenges, and many options have been described for limb salvage in this setting. Studies have supported the use of an induced-membrane technique after placement of a cement spacer to aid in restoration of bone anatomy. QUESTIONS/PURPOSES: We asked: (1) What complications are associated with the induced-membrane technique? (2) How often is bone healing achieved after resection greater than 15 cm using this technique? (3) What is the functional outcome of patients treated with this technique? METHODS: We performed a retrospective evaluation of eight patients with a mean age of 13.3 years (range, 11-17 years) treated for a malignant bone tumor between 2002 and 2012 at our centers. The primary malignant tumors involved the proximal humerus, femur, and tibia. All patients were treated using the induced-membrane technique after a resection with mean bone loss of 18 cm (range, 16-23 cm). The general indication for using the induced-membrane technique during this time was a large diaphyseal defect after resection of the tumor. In addition to using cancellous graft as with the original technique, in the current patients an autogenous nonvascularized fibula was used to enhance stability. The patients were assessed at the last followup using the Musculoskeletal Tumor Society (MSTS) scoring system. Mean followup was 47.1 months (range, 24-120 months), and none of the patients were lost to followup before 2 years. RESULTS: A total of four unplanned reoperations were performed in these eight patients. A fracture of the reconstruction occurred in three patients and all were treated successfully, two with surgery and one with immobilization. Bone fusion was obtained in all patients within 4 to 8 months (mean, 5.6 months) after the reconstruction. The mean healing index was 0.31 month/cm of reconstruction (range, 0.23-0.5 month/cm). At last followup, the mean MSTS score was 74% (range, 67%-80%). CONCLUSIONS: Our findings suggest that the modified induced-membrane technique is a reasonable alternative to other limb reconstruction techniques for bone tumors in children and has the advantage of not requiring a bone bank or an expensive metal prosthesis. Although more patients will be needed to substantiate our findings, it has become a standard part of our arsenal in the treatment of large bone defects after resection of pediatric primitive bone tumors. LEVEL OF EVIDENCE: Level IV, therapeutic study.
Assuntos
Neoplasias Ósseas/cirurgia , Transplante Ósseo/métodos , Neoplasias Femorais/cirurgia , Fíbula/transplante , Úmero/cirurgia , Osteotomia , Procedimentos de Cirurgia Plástica/métodos , Tíbia/cirurgia , Adolescente , Fatores Etários , Autoenxertos , Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/patologia , Remodelação Óssea , Transplante Ósseo/efeitos adversos , Criança , Feminino , Neoplasias Femorais/diagnóstico por imagem , Neoplasias Femorais/patologia , Consolidação da Fratura , Humanos , Úmero/diagnóstico por imagem , Úmero/patologia , Salvamento de Membro , Imageamento por Ressonância Magnética , Masculino , Osteotomia/efeitos adversos , Procedimentos de Cirurgia Plástica/efeitos adversos , Estudos Retrospectivos , Tíbia/diagnóstico por imagem , Tíbia/patologia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Acetabular fractures are rare in children and can be complicated by premature fusion of the triradiate cartilage resulting in secondary acetabular dysplasia. Early recognition and treatment of a physeal bar in this location can be difficult. The purpose of this case report was to investigate whether early intervention could restore acetabular growth and prevent secondary acetabular dysplasia as measured on plain radiographs. CASE DESCRIPTION: We report a series of three patients (3, 4, and 5 years old) who underwent physeal bridge resection and methylmethacrylate or fat interposition through an extended Pfannenstiel approach. The mean followup was 6 years. After resection of the osseous bridge the physis initially remained open with evident acetabular growth in all three patients. In one patient, the bridge reformed 6 years after the procedure. All patients had a slight increase in the thickness of the acetabular wall relative to the contralateral side but no radiographic evidence of acetabular dysplasia. LITERATURE REVIEW: To our knowledge, there are only two reports of physeal arrest resection of triradiate cartilage with one successful result. CLINICAL RELEVANCE: Posttraumatic, partial physeal arrest of the triradiate cartilage may be treated with resection of the bone bridge resection through an extended Pfannenstiel approach. The potential benefits of this treatment must be weighed against the risks.
Assuntos
Acetábulo/cirurgia , Cartilagem Articular/cirurgia , Fraturas Ósseas/cirurgia , Luxação do Quadril/prevenção & controle , Acetábulo/diagnóstico por imagem , Acetábulo/crescimento & desenvolvimento , Acetábulo/lesões , Cimentos Ósseos/uso terapêutico , Cartilagem Articular/diagnóstico por imagem , Cartilagem Articular/crescimento & desenvolvimento , Cartilagem Articular/lesões , Pré-Escolar , Epífises/diagnóstico por imagem , Epífises/crescimento & desenvolvimento , Epífises/lesões , Epífises/cirurgia , Feminino , Fraturas Ósseas/complicações , Fraturas Ósseas/diagnóstico por imagem , Luxação do Quadril/etiologia , Humanos , Masculino , Metilmetacrilato/uso terapêutico , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
The hand is a commonly inljured location of a child. Fractures are the most frequent lesions with two specific locations. In the young child, the fracture is usually a crush injury, such as occurs when a hand gets caught in a door, with lesion of the distal phalanx. Soft tissue associated injuries are the main problem in this location. In the older child, the fracture is usually secondary to recreational sports, with lesion on the proximal phalanx of the second and fifth digits. Dislocations or sprains are less common. A metacarpophalangeal joint dislocation is more likely to be irreducible secondary to volar plate entrapment. Open reduction is often necessary Most hand injuries in children are treated nonoperatively with a favorable outcome. The treating physician should however identify those cinical situations that require surgery, as complications are most commonly due to a failure to identify and treat an injury requiring an operation acutely. These injuries include intra-articular fractures, displaced phalangeal neck fractures and malrotated fractures. Malrotation or intra articular malunion have no remodeling capacity.
Assuntos
Traumatismos da Mão/diagnóstico , Traumatismos da Mão/terapia , Criança , HumanosRESUMO
Segmental defects of the tibia are challenging therapeutic problems for both the physician and the patient. These defects may be caused by severe trauma, infection, tumors and congenital processes. Several different techniques have been described for treatment of these defects including the Papineau technique, allograft reconstruction, bone transport using the Ilizarov frame, free vascularized fibular graft, tibiofibular synostosis and medial transport of the fibula with Tuli's technique, use of the Ilizarov frame and Huntington's procedure. All of these techniques have their specific advantages as well as disadvantages. Some of these techniques are used rarely i.e. the Papineau technique. The procedure of choice for most large tibial defects is bone transport with Ilizarov's technique; but in some cases the tibial remnant is inadequate for lengthening and we must use alternative treatments. In the three aforementioned techniques, the fibula is transferred with peroneal and anterior tibial muscles on a pedicle of peroneal vessels. This transfer retains a biological component of vital bone that allows for a shorter time for consolidation, increased remodeling potential and resistance to infection. It also has better long-term mechanical properties. Hypertrophy of the centralized fibula is described as attaining twice its original diameter or twice the size of the contralateral tibia. Hypertrophy has been seen in nearly all cases of the fibular centralization. Maximum hypertrophy is seen in children and besides patient age, is related to bony union and weight bearing. The reported time for hypertrophy of fibula varies from one to four years. No significant change in the diameter of the fibula was observed after five years. Fracture of tibialized fibula was not reported in many studies of fibular centralization with different techniques. In the reviewed articles, there were no cases of valgus deformity of the ankle. Either the patients were satisfied with the final results despite appearance of the lower extremity and the presence of some angular deformities, although in most cases, the deformities were mild. In this review we conclude that tibialisation of the fibula in selected cases is a reasonable alternative for the treatment of massive tibial defects.
RESUMO
PURPOSE: The purpose of this study is to describe the kinematic changes in children with cerebral palsy (CP) after treatments performed on the forearm, wrist or thumb, with specific attention to the changes around the trunk, shoulder and elbow kinematics. METHODS: With the use of a specific kinematic protocol, we first described the upper limb kinematics in a group of 27 hemiplegic patients during two simple daily tasks. Eight of these children were treated with botulinum toxin (Botox(®), Allergan) injection or surgery and were, thereafter, evaluated with another kinematic analysis in order to compare the pre- and post-therapeutic condition. The target muscles were the pronator teres, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, flexor pollicis longus and the adductor pollicis. RESULTS: Significant kinematic changes were found after treatment. Patients increased forearm supination (P < 0.05) and wrist extension (P < 0.05) during both tasks. Patients also decreased trunk flexion/extension range of motion (ROM) (P < 0.05), improved elbow ROM (P < 0.05) and improved internal shoulder rotation (P < 0.05). CONCLUSIONS: Dynamic shoulder or elbow limitations in children with mild hemiplegia involvement could be related to a compensatory movement strategy and/or co-contractions. As these proximal kinematics anomalies are improved after treatments performed at the forearm, wrist and thumb, they should not be treated first but should be reconsidered after the treatment of more distal problems.