Subtalar Arthroereisis for Flexible Flatfoot in Children-Clinical, Radiographic and Pedobarographic Outcome Comparing Three Different Methods.

Subtalar arthroereises (STA) is a minimally invasive and reversible surgery to correct symptomatic flexible flatfoot (FFF) in children. Various techniques were described either applying expandable sinus tarsi implants or lateral calcaneus stop screws. Studies comparing the outcome of STA with different devices are rare. This retrospective single-center cohort study analyzes the results of STA using three different implants. 113 STA were performed in 73 consecutive patients (28 females). Mean age at surgery was 10.8 years (range 5-16). Mean follow-up was 29.0 months (range 1-111). In 21 feet the non-absorbable Kalix® endorthesis and in 56 feet the absorbable Giannini endorthesis were applied. Subtalar extraarticular screw arthroereises (SESA) was conducted in 36 feet. Clinical, radiographic and pedobarographic parameters were analyzed. No intraoperative complications were observed. All three procedures achieved comparable improvements of the clinical, radiographic and pedobarographic parameters. The mean foot function index (FFI) improved from 36.4 (range 12-63) to 22.8 (range 2-55). The mean preoperative calcaneal inclination angle and the lateral talocalcaneal angle improved from 9.5° (range 0-22) and 42.3° (range 21-62) to 12.8° (range 0-26) and 37.6° (range 15-56), respectively. Pedobarographically determined values of the arch index, the medial midfoot contact area and the medial forefoot peak pressure decreased. In contrast to SESA (1/36, 3%), a higher incidence of implant-related complications was observed using Kalix® (6/21, 29%) and Giannini (10/56, 8%) sinus tarsi implants. Peroneal muscle contractures only occurred in the SESA group (4/36, 11%). Premature removal due to treatment-related complications was necessary in 6/21 Kalix® implants (29%), 4/56 Giannini implants (7%) and 4/36 SESA implants (11%). Implant choice for treatment of painful FFF in children with STA seems to play a subordinate role. Clinical, radiographic and pedobarographic outcomes are comparable between the applied implants. Surgeons and patients should be aware of the different spectrum of implant-related complications. Treatment can be reliably monitored by radiation-free pedobarography providing dynamic information about the deformity.

Deformity correction and extremity lengthening in the lower leg: comparison of clinical outcomes with two external surgical procedures.

OBJECTIVE: Distraction osteogenesis is a method of stimulating the growth of new bone tissue in order to lengthen the extremities or bridge resected bone defects. In addition to the now-established intramedullary procedures, two different fixator systems are in use. The present study investigated the classical Ilizarov ring fixator (IRF) and a hexapod to assess the precision of lower-leg lengthening and complications classified using the Paley criteria for problems, obstacles, and complications. The study also examined the follow-up results in functional tests to assess outcomes in terms of range of motion in adjacent joints, daily activities, and quality of life. PATIENTS AND METHODS: A total of 43 patients (53 segments) who were treated over a period of 16 years were re-assessed. In 33 segments, treatment was carried out with the hexapod Taylor Spatial Frame (TSF); the conventional IRF was used in 20 segments. The patients' mean age was 13.5 years (range 2-54 years). The follow-up examinations were carried out 2-15 years postoperatively and comprised measurement of a current leg axis view with the patient standing, calculation of a knee score, activity scores, ankle joint scores, and assessment of motor function and sensory function using appropriate scores in the lower leg and foot. The post-treatment health-related quality of life was assessed using the Short-Form Health Survey-36 questionnaire. RESULTS: Using the Paley criteria, far fewer problems occurred in the TSF group in comparison with the IRF (TSF 12.1%, IRF 50%). In the problems category, significant differences were observed with regard to axial deviation (TSF 0%, IRF 36.8%) and pin infections (TSF 9.1%, IRF 40%). Comparison of the obstacles and complications did not identify any significant differences between the two groups. Analysis of the scores for the knee, activity, and motor function/sensory function also did not show any marked discrepancies, apart from a major difference in mobility in the upper and lower ankle joints with poorer findings in the TSF group. CONCLUSIONS: During treatment, the TSF ring fixator leads to fewer problems, fewer secondary axial translations, and fewer pin infections. However, with temporary transfixation of the ankle joints, the TSF system is also associated with postoperative deterioration in mobility in the upper and lower ankle joint.

Publication rate of abstracts presented at European Paediatric Orthopaedic Society Annual Meetings, 2006 to 2008.

BACKGROUND: The quality of the abstracts presented at a conference reflects the scientific work and level of activity of the scientific association concerned. The aim of the present study was to determine the rate of publications of podium presentations and posters at the conferences of the European Paediatric Orthopaedic Society (EPOS) from 2006 to 2008 and to identify factors that favor publication in peer-reviewed journals. The results are compared with those of other international societies. METHODS: All 646 abstracts (including podiums, posters, and e-posters) presented at the EPOS conferences were investigated using the PubMed database to identify any corresponding published articles in the journals listed in the database. A period of 5 years before and after the relevant conference was used for the PubMed search. Factors influencing publication and the quality of the study, such as the type of presentation and the level of evidence, were also investigated. RESULTS: A publication rate of 36.7% was observed, corresponding to 237 publications of 646 abstracts. The period to publication showed a mean of 13.88 ± 1.34 months. It was found that abstracts of podium presentations were published significantly more often than poster abstracts (P<0.001). Experimental studies, with a publication rate of 50.9%, showed better results than clinical studies (36.0%). Overall, the articles were published in 61 different journals, with the largest number (n=50) appearing in the Journal of Pediatric Orthopaedics. In addition, the present study shows that abstracts with a higher level of evidence were associated with a higher publication rate. CONCLUSIONS: At 36.7%, the rate of publication of EPOS abstracts is within the range reached by other specialist orthopaedics societies, such as the German Society of Orthopaedics and Trauma Surgery (36%) and the British Orthopaedic Association (36%). However, it is lower than the publication rate of the Pediatric Orthopaedic Society of North America (POSNA), at 50%. The high percentage of unpublished conference abstracts (63%), which did not go through a peer-reviewed process, casts doubts upon the practice of utilizing the citation of abstracts based purely on conference abstracts. LEVEL OF EVIDENCE: Statistical study.

Lower limb lengthening in patients with disproportionate short stature with achondroplasia: a systematic review of the last 20 years.

Parents of children suffering from disproportionate short stature due to achondroplasia may wish to have surgical leg lengthening carried out for the child. The aim is not to increase height, but rather to achieve physiological proportions in the body. In a systematic review of the literature on the topic dating from the last 20 years, the surgical approaches used for this purpose were analyzed in accordance with the Preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria. Twelve studies show that to date, involvement of the child in decision-making at the start of treatment has been expected and that it is recommended from the age of 12. In highly heterogeneous patient groups, with varying factors involved and different techniques being used, lengthening (often by more than 10 cm) is described. High complication rates are reported, with many setbacks often requiring repeat surgery. Using PALEY'S multiplier method, the expected standing height, sitting height, and leg length can be predicted and an individualized treatment approach can be planned and operative procedures could be started in early childhood as PERETTI suggests. As the patients are unable to be involved in decision-making as young children, these data may provide a basis for offering differentiated advice to parents, who usually consult a pediatric orthopedist at a very early stage in the child's life.

Reconstruction of forearm deformity by distraction osteogenesis in children with relative shortening of the ulna due to multiple cartilaginous exostosis.

BACKGROUND: In patients with multiple cartilaginous exostosis, distal ulnar osteochondromas frequently cause forearm deformities, with relative ulnar shortening, wrist joint deviation, and varus bowing. Progressive deformation often leads to pain, functional impairment, and cosmetic problems. Surgical ulnar lengthening is necessary to restore the carpal balance. The results of fixator-controlled ulnar lengthening were investigated in this study, using appropriate clinical and radiologic parameters and focusing on medium-term functional and structural outcomes. METHODS: Twelve children (3 boys, 9 girls; mean age 9.8 y) with multiple cartilaginous exostosis-induced ulnar shortening treated with fixator-controlled ulnar callotasis were evaluated retrospectively based on clinical and radiographic examinations preoperatively, after fixator removal, and at a follow-up investigation. Subjective symptoms and objective joint function were assessed clinically, whereas the extent of ulnar shortening, radial articular angle, carpal slip, and radial head dislocation were determined radiographically. RESULTS: The average follow-up period was 24.6 months. The mean ulnar shortening and radial articular angle improved significantly, from 14.3 mm or 38.7 degrees preoperatively to 1.7 mm or 25.6 degrees after fixator removal and showed a slight but significant increase to 5.2 mm or 30.1 degrees at the follow-up. Carpal slip and radial head dislocation remained unchanged. With the exception of radial abduction, no notable functional advancement was observed. One unintended ulnar overlengthening with a subsequent ulnocarpal impaction syndrome, one premature callus consolidation, and two fixator dislocations were noted. CONCLUSIONS: In agreement with literature reports, carpal balance can be restored over the medium term. However, mild recurrences of ulnar shortening and radial malformation were observed during further development. To prevent deformity progression in immature patients, surgery should be carried out early. The optimal timing of surgery needs to be calculated precisely to take advantage of the high remodeling potential and an acceptable degree of recurrent deformity. Ulnar lengthening is necessary, but overcorrection is inadvisable due to possible ulnocarpal impaction syndrome. As significant remodeling effects on the radius were observed, simultaneous radial correction procedures are not recommended a priori.

The postoperative patella height: a comparison of additive and subtractive high tibial osteotomy in correcting the genu varum.

INTRODUCTION: Intraligamentary correctional operations like a high tibial osteotomy were performed in genua valga to prevent later medial gonarthrosis especially in younger patients. An unwanted effect of this method seems to be the inferiorization of the patella. This is feared because of the complications in case of subsequent alloarthroplasty. Besides the classical Coventry method as a subtractive osteotomy the hemicallotasis has been established as a sustainable additive procedure. This means a gradual open wedge correction using an external fixateur. OBJECTIVE: The aim of this study was to determine the position of the patella pre- and postoperatively and in follow-ups with subtractive versus additive intraligamentary high tibial osteotomies on the basis of five radiological parameters. It was expected that an additive osteotomy leads to an inferiorized patella position whereas a subtractive osteotomy leads postoperative to a higher position of the tibia. METHOD: Between 1990 and 2001, 54 patients (61 legs) had undergone an operation due to a genu varum either by the subtractive osteotomy (n = 30) according to Coventry's method or the additive gradually hemicallotasis (n = 31) with an external fixator. RESULTS: In coherence with the Coventry's osteotomy a significant inferiorization of the postoperative patella position with all five radiological parameters was observed, the hemicallotasis showed no operation-related significant alteration of the patella height. Instancing the Insall-Salvati Index there were four (12.9%) preoperative and three (9.7%) postoperative patella baja positions detected. Along with the subtractive osteotomy there were 5 preoperative patellae baja (16.7%) and 11 postoperative patellae baja (36.7%) positions. Furthermore a significant interrelation was noticed between the extent of the correctional angle and the postoperative alteration of the patella. CONCLUSION: The results are surprising, contrary was expected. First this can be explained by its gradual, additive correctional property in contrast to the spontaneous correction by the conventional method according to Coventry, second by the postoperative treatment, which allows an early mobilization and active remedial gymnastics, provided an impact resistant osteosynthesis by a fixateur externe is given. In the case of the additive hemicallotasis an intraligamentary osteotomy is recommended. Technically expensive step cuts in order to osteotomize below the tuberositas tibiae are not necessary. Due to the low quota of complications and the small operative expense the continuous distraction is preferential to ad hoc correction. A postoperative patella baja position has not to be afraid in hemicallotasis.

Estimation of patient dose and associated radiogenic risks from limb lengthening.

UNLABELLED: Limb-lengthening procedures include a series of radiographic examinations to follow the lengthening process and callus formation. We quantified ionizing radiation exposure during lengthening treatment and estimated the risks associated with this exposure in 53 patients undergoing lengthening procedures. Field size and tube voltage of all radiographs and fluoroscopy time during surgery were recorded. According to conversion factor tables of organ doses, the cumulative organ dose was estimated. Location of lengthening, age, complications during lengthening procedure, range of lengthening, healing index, and other factors affecting the duration of the lengthening procedures were analyzed. Average lengthening was 4.8 cm (range, 3.0-12.5 cm). The average cumulative organ dose for a straight lengthening procedure was 3.1 mSv (range, 0.2-12.5 mSv). The average organ dose per centimeter of lengthening was 0.7 mSv/cm (range, 0.03-5.9 mSv/cm). Doses for patients with tibial lengthening (0.3 mSv/cm) were less than doses for patients with femoral lengthening (1.1 mSv/cm). Age, complications, range of lengthening, and healing index did not influence the dosage of radiation per centimeter lengthening. We judge the average patient's exposure during a limb-lengthening procedure as tolerable, but femur lengthening results in a higher cumulative organ dose. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.