Problems, Complications, and Factors Predisposing to Failure of Fassier-Duval Rodding in Children With Osteogenesis Imperfecta: A Double-center Study.

BACKGROUND: Although Fassier-Duval (FD) rods have been used for almost 2 decades, knowledge of factors predisposing to their failure is limited. Thus, the purpose of this study was to: (1) present the most common complications of FD rodding, (2) present tips on how to avoid or overcome them, and (3) identify factors predisposing to treatment failure. METHODS: Fifty-eight rod segments in 19 patients with osteogenesis imperfecta (mainly type III) underwent analysis with a median follow-up (FU) time of 4.4 years. We assessed the total number of complications clinically and radiographically. Next, the possible predisposing factors leading to failure were assessed using the Mann-Whitney U test. In addition, we evaluated the cutoff age for the increased rate of complications using the Youden index. A P<0.05 was considered significant. RESULTS: The total number of complications reached 44.8%. The most common complications included: migration of the male or female implant (45.7% and 25.7% out of the total number of complications, respectively), bone fracture with bending of the rod (8.6%), and rotational deformities (8.6%). Significant differences in patients' ages at the time of surgery were found between the group with and without complications (P=0.04), while sex, segment treated, preceding surgeries, length of FU, FD rod diameter, and length of bisphosphonate treatment were not significant. The Youden index showed that the risk of complications rose significantly in patients treated when younger than 5.5 years of age (P<0.05). CONCLUSIONS: This series displays the effectiveness and utility of FD rods at a median FU of over 4 years. Complication rates were comparable with the existing literature, with a notable increase in the number of side effects observed in younger patients (below the age of 5). LEVEL OF EVIDENCE: Level IV-therapeutic study.

Limitations in Use of Elastic Stable Intramedullary Nailing (ESIN) in Children with Disorders of Bone Mineralization.

BACKGROUND: Elastic intramedullary nails (ESIN) have been the treatment of choice in many long bone fractures in children for more than 20 years. The introduction of ESIN has drastically reduced tissue traumatization during fracture fixation procedures and decreased the risk of growth cartilage damage, as well as allowing for preservation of the natural biology of closed fracture healing. The objective of the present report is to draw attention to a small group of patients with bone mineralization disorders, who consequently demonstrate decreased mechanical resistance of the skeletal system, in whom indications for using ESIN fixation are limited. MATERIAL AND METHODS: The study group consisted of 6 patients who met the criteria for using ESIN fixation, but did not demonstrate a satisfactory outcome. The inclusion criteria included age below 18 years, appropriate ESIN nail insertion technique with correct calculation of nail diameter (2/5 of the medullary canal diameter), body mass < 50 kg and achieving appropriate prebending that is the prerequisite of three-point intramedullary support. The patients' medical records and radiographs were analyzed and they were invited for clinical and radiological follow-up examinations. RESULTS: All six patients demonstrated a gradually increasing bending deformity of the long bone axis. Additionally, in three patients, there was intrusion of terminal parts of the nails into the bone. In one patient with bone fibrous dysplasia, the proximal epiphysis was perforated by the flattened ends of the nails. In all patients, the removal of the ESIN fixation was followed by single or double-level corrective osteotomies and Rush pin fixation. CONCLUSION: In cases of long bone fractures in children with metabolic bone disorders in whom the bone structure is weakened and the bones themselves are easily deformed, more rigid intramedullary fixation with Rush or Fassier-Duval type nails as primary osteosynthesis should be considered.

Chronic recurrent multifocal osteomyelitis (CRMO) in children - single-centre clinical observations and experience.

BACKGROUND: CRMO is characterized by chronic bone pain of recurrent nature. The onset is usually at the beginning of the second decade of life. Bony lesions may be visible on radiographs, although sometimes a CT or MRI scan is necessary to visualise them. The aim of study was analyse symptoms, diagnostic difficulties and results of accessory investigations in patients suffering from CRMO. MATERIAL AND METHODS: Medical records of 42 patients with CRMO were analysed to assess: age at onset of the disease, symptoms reported, location of lesions and abnormalities in laboratory and imaging studies. RESULTS: The medical records of 42 children, including 16 boys (38%) and 26 girls (62%), were analysed. The median age at onset was 10.5 years. The first symptom was bone pain in 34 patients (81%), with the remaining 8 (19%) presenting with widened bone contour in the absence of pain. Initially, only 5 (12%) subjects had multiple foci, whereas the vast majority (88%) presented with a single lesion. During exacerbations, osteocalcin levels were significantly elevated, increasing to a mean of 34 ng/ml (max. 68, min.14.6) against a reference upper limit of 13.7 ng/ml. Diagnostic difficulties and complications were found in 18 children. CONCLUSIONS: 1. Familiarity with CRMO in orthopaedic clinical practice is indispensable in differential diagnosis with other bone diseases, including those suggestive of malignancy. 2. Correctly diagnosed CRMO is managed conservatively as a treatment of choice.

Dysplasia epiphysealis hemimelica - diagnostics and treatment in pediatric patients.

BACKGROUND: Dysplasia epiphysealis hemimelica, also known as Trevor-Fairbanks disease, is a rare developmental disorder The objective of this article is to present own observations and experience in treating patients with dysplasia epiphysealis hemimelica. MATERIAL AND METHODS: Six children with dysplasia epiphysealis hemimelica were treated in years 1990-2007. The mean age of observation was 8.5 years (from 3 to 19 years). Analysis of medical and radiological documentation of patients was performed to collect data on symptoms, disease location, management and outcomes. RESULTS: The main symptoms reported by patients included limited range of motion of the affected joints with pain (66%) and deformed joint outline (34%). Four patients were subjected to surgical treatment while conservative treatment was applied in the other two. Lated complications were observed in two patients after surgical intervention (50%). In patients undergoing conservative treatment, one positive outcome and one negative outcome involving complete hip ankylosis, were observed. CONCLUSIONS: Correct diagnosis is very important as it may save the patient from unnecessary surgery and, if the surgery is necessary, it may help in performing it correctly. In patients presenting with joint pains, joint deformations, and tuberous lesions in joints possibility of dysplasia epiphysealis hemimelica should be taken into account. The treatment should start with conservative treatment, particularly physical therapy applied in the region of pain. If pain, joint deformation or limited range of motion of the affected joint persist, surgical treatment consisting of complete excision of the lesion should be taken into account.

Stress fractures in children.

BACKGROUND: Presentation of own experiences, observations and results of treatment of patients with stress fractures treated in the Department of Paediatric Orthopaedics. The authors present an algorithm of diagnosing and treatment of stress fractures. MATERIAL AND METHODS: Over the period 1998 - 2010, 38 patients were hospitalised (40 fractures) with the final diagnosis of stress fracture. Personal patients' data, case histories and management preceding the diagnosis of the disease, diagnostic and therapeutic methods, as well as the results of treatment were collected on the basis of medical documentation. Standard diagnostic procedure consisted of: clinical and radiological examination, laboratory tests as well as computed tomography (CT). In 11 cases, the procedure included also scintigraphy and in two children MRI scan was performed. RESULTS: Complete healing of fractures was finally achieved in all patients CONCLUSIONS: In case of suspected stress fracture, it is necessary to perform a series of radiograms, which should present the picture of bone rebuilding and incorporation of the periosteal callus. If plain radiograph is inconclusive we should consider MRI , CT or scintigraphy scan. The results of laboratory tests should not show any abnormalities. In case of confirmed stress fracture nonweight-bearing of the affected extremity is recommended as well as introducing of close clinical-radiological monitoring. The results of MRI examination should be interpreted very cautiously, be cause it can be misleading. The observation strategy ("wait and see") should be implemented. However, the lack of the regression of pain sensation, bone rebuilding features and incorporation of periosteal callus or the appearance of visible bone destruction (lysis) should raise questions and present an indication for taking biopsy of the laesion.

[Ischial tuberosity fractures in children]. / Zlamania guza kulszowego u dzieci.

BACKGROUND: Ischial tuberosity fractures in children are a form of avulsion fractures caused by the strong thigh muscles of the back group (ischiotibial muscles). OBJECTIVE: Presentation of observations covering the diagnostic difficulties, treatment and follow-up of ischial tuberosity fractures in children. MATERIAL AND METHODS: 6 children (one girl and five boys), average age at the time of injury - 13.6 years (12-15.5 years). An analysis of medical and radiological documentation of patients. RESULTS: Two patients with chronic pain were suspected of ischial bone tumor, one was suspected of Perthes disease, and only 3 were sent to the Traumatology Department immediately after the football injury. All patients were treated conservatively. Complete healing of fractures was finally achieved in all patients - (fibrous union in two cases) and finally, after an average period of 9 months, the pain subsided. CONCLUSIONS: There is a discussion in medical literature about the difficulties in the diagnosis of ischial tuberosity fractures, which were primarily unrecognized. Radiological picture of significant bone rebuilding may suggest neoplastic lesions. In the literature dominates the attitude of conservative treatment. Only in cases of large displacement of fracture and chronic ailments caused by pressure on the sciatic nerve, surgery should be considered.