Correction of arthrogrypotic clubfoot with a modified Ponseti technique.

Surgical releases for arthrogrypotic clubfeet have high recurrence rates, require further surgery, and result in short, painful feet. We asked whether a modified Ponseti technique could achieve plantigrade, braceable feet. Ten patients (mean age, 16.2 months; range, 3-40 months), with 19 arthrogrypotic clubfeet, underwent an initial percutaneous Achilles tenotomy to unlock the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. A second percutaneous Achilles tenotomy was performed in 53%. Mean number of casts was 7.7 (range, 4-12). From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5 (ranges, 12-18 and 2-9, respectively), Catterall scores (as modified by Pirani and colleagues) from 4.8 to 0.9 (ranges, 1.5-6.0 and 0.0-2.0), and maximum passive dorsiflexion from -45 degrees (range, -75 degrees to -20 degrees ) to 10 degrees (range, 0 degrees to 40 degrees ). Ankle-foot orthoses maintained correction. At the minimum followup of 13 months (mean, 38.5 months; range, 13-70 months), the mean maximum dorsiflexion was 5 degrees (range, -20 degrees to 20 degrees ), two patients had posterior releases and no patient's ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be corrected without extensive surgery during infancy or early childhood. Limited surgery may be required as the children age.

Articulated hip distraction: a treatment option for femoral head avascular necrosis in adolescence.

PURPOSE: To describe the clinical outcomes of adolescent patients treated with articulated hip distraction (AHD) for avascular necrosis (AVN) of the femoral head. Outcomes were examined in order to better understand the usefulness of and indications for performing hip arthrodiastasis in this patient population. METHODS: : Retrospective review was performed on 31 hips with femoral head AVN treated with AHD. Mean age at treatment was 14.7 years. Preoperative and follow-up pain and physical limitations, as well as follow-up range of motion, were assessed. RESULTS: Follow-up assessment was obtained at 18.7 years. Time of follow-up was 57.4 months after distraction. The etiologies of AVN were the following: 10 slipped capital femoral epiphysis (SCFE), 5 idiopathic AVN, 3 with hip dysplasia, and 12 others. There was a significant difference in pain preoperatively and postoperatively (P<0.001), most patients (78.6%, n=22) had less pain after the treatment. Multivariate regression model demonstrated that patients with SCFE were likely to have less improvement in pain than patients with other etiologies (odds ratio, 22.7; P=0.035). All patients had activity limitations before the treatment; at the postoperative assessment, half of our patients (n=14) reported no limitations in their regular daily activities. Eight patients had minor complications with the fixator. At follow-up, 5 patients (17.2%) converted to total hip replacement or arthrodesis. Survival rates were 90.6% at 5 years, 77.7% at 10 years, and 38.8% at 15 years. CONCLUSIONS: Hip distraction arthroplasty in adolescent patients with symptomatic AVN reduces the amount of pain and limitation in daily activities at a follow-up of 4.7 years. Arthrodiastasis is not the final solution to AVN. With longer follow-up, patient's symptoms increases. Patients with AVN secondary to SCFE do not seem to benefit from this procedure as much as other patients do. Articulated hip distraction is a safe and appropriate procedure to perform in these patients. The procedure might be able to delay definitive surgical procedures at an early age, restoring function and improving the patient's quality of life.

Femoral deformity correction in children and young adults using Taylor Spatial Frame.

UNLABELLED: The Taylor spatial frame (TSF) has been used commonly in children and young adults. Its use in the tibia is more extensively studied and applied than in the femur. We asked whether normal alignment can be achieved with accuracy during correction of femoral deformities while avoiding major complications in children and young adults. We retrospectively reviewed the clinical and radiographic records of 20 patients (22 limbs), ages 5.9 to 24.6 years, who underwent a TSF for femoral deformity. Etiology included a number of diagnoses of the pediatric age. Minimum followup was 4.5 months (mean, 15.7 months; range, 4.5-35 months). The mean time in frame was 6.2 months (range, 2.6-19 months). Frontal and sagittal plane deformities were corrected to within normal values. A mean limb lengthening of 4.9 cm (range, 1.5-9 cm) was performed in eight femora in seven of which the limb length discrepancy was a secondary concern. External fixation index in the lengthening subgroup was 2.2 months/cm. The 15 complications in 13 limbs included pin tract infection, knee stiffness, delayed union, skin irritation, and posterior knee subluxation. No complications occurred in nine limbs. Computer-assisted femoral deformity correction with six-axis deformity analysis and the TSF is an accurate and safe technique in children and young adults. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Is there a correlation between the change in the interscrew angle of the eight-plate and the delta joint orientation angles?

OBJECTIVES: It is known that the screws of the eight-plate hemiepiphysiodesis construct diverge as growth occurs through the physis. Our objective was to investigate whether there is a correlation between the amount of change of the joint orientation angle (JOA) and that of the interscrew angle (ISA) of the eight-plate hemiepiphysiodesis construct before and after correction. PATIENTS AND METHODS: After the institutional review board approval, medical charts and X-rays of all patients operated for either genu valgum or genu varum with eight-plate hemiepiphysiodesis were analyzed retrospectively. All consecutive patients at various ages with miscellaneous diagnoses were included. JOA and ISA were measured before and after correction. After review of the X-rays, statistical analyses were performed which included Pearson correlation coefficient and regression analyses. RESULTS: There were 53 segments of 30 patients included in the study. Eighteen were males, and 12 were females. Mean age at surgery was 9.1 (range 3-17). Mean follow-up time was 21.5 (range, 7-46) months. The diagnoses were diverse. A strong correlation was found between the delta JOA (d-JOA) and delta ISA (d-ISA) of the eight-plate hemiepiphysiodesis construct (r = 0.759 (0.615-0.854, 95%CI), p < 0.001). This correlation was independent of the age and gender of the patient. CONCLUSIONS: There is a strong correlation between the d-ISA and the d-JOA. The d-ISA follows the d-JOA at a predictable amount through formulas which regression analysis yielded. This study confirms the clinical observation of the diverging angle between the screws is in correlation with the correction of the JOA. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Neonatal physeal separation of distal humerus during cesarean section.

Diagnosing physeal separation of the distal humerus in a newborn can be challenging. Skeletal immaturity and absence of secondary ossification centers make radiographic diagnosis difficult for inexperienced providers. This fracture is seen in the setting of complicated deliveries with excessive traction and rotation applied to the forearm. We report a case of physeal separation of the distal humerus in a newborn as a complication of cesarean section and describe the intervention used and the short-term results.

Gait analysis in adults with severe hip dysplasia before and after total hip arthroplasty.

Anatomical reconstruction of high riding hips by total hip arthroplasty (THA) and subtrochanteric shortening osteotomy aims to normalise gait pattern and improve functional hip scores. We present the medium-term clinical results of a group of patients with high riding dislocated hips in whom a cementless THA and subtrochanteric shortening osteotomy had been performed. We compared them with their preoperative status, with patients who had undergone a cementless THA for primary osteoarthritis, and also with a group of healthy gender and age-matched controls. Prospective computerized, three-dimensional gait analyses were performed in 8 female patients with uni-/ or bilateral severe developmental dysplasia of the hip (Group I). Gait analysis was performed preoperatively and at a mean of 12.5 months postoperatively. A group of 8 individuals who received cementless hip replacement for primary osteoarthritis (Group II), and a control group of 8 able-bodied individuals (Group III) were recruited for comparison. Patients in Group I improved and approached the values of Group II. However both were behind Group III. Limb length discrepancy was reduced from a mean of 4.3 cm (range, 1 - 8 cm) to a mean of 0.8 cm (range, 0 - 2 cm) at the latest follow-up. Pain was reliably relieved and activities of daily living were improved in patients with high riding developmental dysplasia of the hip, but they were still behind the normal population average. Nevertheless, the results can be as satisfactory as those in patients who undergo a THA for primary osteoarthritis.

A new perspective on management of open calcaneus fractures.

The treatment protocol of closed calcaneal fractures has been described in the literature extensively. However, treatment of open calcaneal fractures has not been discussed in detail. Various treatment alternatives have been suggested including external fixator, primary subtalar distraction arthrodesis, and partial calcanectomy according to the type of fracture. We have retrospectively reviewed 36 adult patients with 39 open calcaneal fractures who were treated with our new philosophy. Average follow-up time was 9.29 years (range, 1.25-28 years). The American Orthopaedic Foot and Ankle Society (AOFAS) scoring system was used in functional evaluation. The average score was 77.9 (range, 67-92). All of the patients had limited subtalar movement. We propose an algorithm for the management of open calcaneus fractures, although treatment largely depends on the physical status of the patient, type of the fracture, localisation of the open wound and the surgeon's choice.

Thumb polydactyly with radius hypoplasia--a case report.

Triplication of the thumb is a rare condition described only in several case reports. Radial longitudinal deficiency is a relatively more common entity. These 2 congenital abnormalities generally do not occur within the same extremity. We present a patient with a combination of 3 thumbs (triplication of the thumb) and hypoplastic radius in the same limb.

Implantation of vancomycin microspheres in blend with human/rabbit bone grafts to infected bone defects.

In orthopaedic applications, allografts are used for restoration of bone defects. In order to combine the effects of bone repair and to prevent the infection, antibiotic-impregnated bone grafts are under current investigation with promising early results. In this study, to preserve the stability of antibiotics and to provide appropriate release profiles for 4-6 weeks, antibiotic-loaded microspheres were administered in combination with allografts and vancomycin was the antibiotic loaded to microspheres. Particle size, surface characteristics, loading capacity and in vitro release characteristics of the microspheres with and without allografts were determined. In vivo studies were performed on rabbits and antibiotic amount was determined by a fluorescence polarization immunoassay (FPIA) method from synovial fluid sample aspirated. According to the results, although the in vitro study demonstrated effective antibiotic release of vancomycin from antibiotic-impregnated allografts for 5 weeks, in vivo conditions led to an early instability of the antibiotic (in powder form) and contrary to the high initial loading dose an effective release could not be obtained from the allografts after the first week. Following these studies, it was determined that antibiotic release over a minimum inhibitory concentration (MIC) for 6 weeks was realized from vancomycin-loaded microspheres which were implanted in a blend with allografts in bone defects. In conclusion, preservation of the antibiotic in microspheres maintained the bioactivity and provided the controlled antibiotic release, thus implantation of microspheres in a blend with allografts seemed to be a promising carrier system for the orthopaedic applications.

Late spinal cord compression caused by pulled-out thoracic pedicle screws: a case report.

STUDY DESIGN: A case report. OBJECTIVES: To report a late neurologic compromise caused by pulling-out of thoracic pedicle screws. SUMMARY OF BACKGROUND DATA: Although screw misplacement is quite common, only few neurologic injuries have been reported because of penetration of the medial wall of pedicles in the thoracic spine. To our knowledge, neurologic compromise caused by pulling-out of the screws has not been reported to date. METHODS: A 6-year-old girl with congenital muscle fiber type disproportion was posteriorly instrumented (T3 to L4) for severe kyphosis. Later, she had a junctional kyphosis over the top of the instrument. Her instrumentation was lengthened to T2 by using transpedicular screws. During the follow-up period, T2 screws were pulled-out and intruded into the canal, causing neurologic compromise. The presenting symptoms, imaging studies, and related literature are reviewed in this report. RESULTS: Patient's neurologic symptoms subsided after removal of the pedicle screws intruded into the spinal canal. CONCLUSIONS: Pulling-out of transpedicular screws inserted at T1 or T2 where the pedicles are oriented more medially may cause late neurologic compromise caused by intrusion of triangulated screws into the spinal canal.