Implant-related fractures in children: a 15-year review.

BACKGROUND: To our knowledge, there are no comprehensive clinical studies of implant-related fractures in children. Our goal was to identify the incidence, skeletal location, and associated diagnoses of implant-related fractures. METHODS: We reviewed our institutional database to identify cases of implant insertion (7584 cases) in patients less than 18 years old from January 1, 1995 through December 31, 2009. We calculated the overall incidence of these fractures and stratified the incidence by skeletal location and preoperative diagnoses. Fisher exact test was used to ascertain differences in fracture incidence. Risk ratios were calculated when appropriate. Significance was set at P<0.05. RESULTS: There were 25 cases of implant-related fractures: 22 in the femur, 2 in the tibia, and 1 in the radius. The overall incidence of implant-related fracture was 0.33%; the incidence by skeletal location was: femur, 0.89%; tibia, 0.1%; and radius, 0.14%. Associated diagnoses were cerebral palsy (9 cases), hip dysplasia (3 cases), spina bifida (2 cases), and avascular necrosis (1 case); 10 cases were associated with "other diagnoses," which included various skeletal syndromes (5 cases) and traumatic fractures (5 cases). The incidences of implant-related fractures by diagnoses were: cerebral palsy, 1.1%; hip dysplasia, 1.1%; spina bifida, 1.3%; and avascular necrosis, 0.35%. The incidence of implant-related fracture in the "other diagnoses" group was 0.16%, and the incidence of fracture in otherwise healthy patients was 0.084%. The femur was 15.2 times more likely to fracture than other bones (P<0.001). Diagnoses of cerebral palsy, hip dysplasia, spina bifida, and avascular necrosis were 6.1 times more likely to be associated with implant-related fractures than the "other diagnoses" (P<0.001). The mean time to fracture in the study was 2.8 years. The overall implant removal rate at our institution was 24.3%, and it varied significantly by patient diagnosis (P<0.01). CONCLUSIONS: Skeletal location and preoperative diagnosis should be factors of consideration in a surgeon's decision about removing implants to prevent implant-related fractures. LEVEL OF EVIDENCE: Prognostic Level III.

Pin size influences sagittal alignment in percutaneously pinned pediatric supracondylar humerus fractures.

BACKGROUND: No study examining pin constructs has adequately addressed pin size and its role in fracture fixation. Our goal was to review our experience with Wilkins-modified Gartland type-III pediatric supracondylar humerus fractures treated with closed reduction and percutaneous pinning to evaluate the effects of pin size within 2 different pin constructs on maintenance of reduction and on the risk of surgical complications. METHODS: We retrospectively reviewed the medical records of pediatric patients with Wilkins-modified Gartland type-III supracondylar humerus fractures that were closed reduced and percutaneously pinned at our institution from March 1999 through December 2008. We grouped those 159 patients by fracture stabilization method (lateral-entry-pin or crossed-pin constructs), by pin size ratio (ie, ratio of pin diameter to the humeral midshaft cortical thickness: small ≤0.9; large >0.9), and then by 4 combinations of pin construct and pin size ratio. For each group, we evaluated radiographs for immediate postoperative reduction (coronal and sagittal alignment), maintenance of reduction at last follow-up, and the number of surgical complications. We used the Student t test, χ² test, Mann-Whitney U test, and Wilcoxon Signed Rank test to examine for significance, which was set at P<0.05. RESULTS: Although we found no significant differences between the groups immediately after surgery, final follow-up sagittal alignment was significantly more likely to be maintained in the large pin size ratio group than in the small pin size ratio group. For 2 types of surgical complications, infection and nerve palsy, we found no statistically significant differences in these complications between the pin construct or pin size ratio groups. CONCLUSIONS: Large pin sizes improved radiographic sagittal alignment at final follow-up without an increased rate of infection or ulnar nerve palsy. LEVEL OF EVIDENCE: Level III Therapeutic Study.

Symposium on the musculoskeletal aspects of Marfan syndrome: meeting report and state of the science.

The National Marfan Foundation sponsored a symposium in August 2005 to review recent progress in the area of Marfan-related musculoskeletal research. Orthopaedic surgeons, molecular geneticists, medical geneticists, and pain specialists met to review a variety of topics. This report reviews and summarizes the proceedings of the symposium, with emphasis on future directions for study that were identified in the course of the meeting. Areas covered include clinical detection, diagnosis, growth, spine deformity, molecular mechanisms, dural ectasia, protrusio acetabuli, and pain in Marfan syndrome.

Protrusio acetabuli in Marfan syndrome: age-related prevalence and associated hip function.

BACKGROUND: Protrusio acetabuli is known to occur in patients with Marfan syndrome, but its prevalence, its effects on hip function, and its possible association with the subsequent development of degenerative hip disease have not been studied in a large population. Nevertheless, some clinicians have recommended prophylactic hip surgery for preadolescents with Marfan syndrome and protrusio acetabuli. METHODS: We performed a cross-sectional study of 173 patients (346 hips) with Marfan syndrome who were interviewed and examined for calculation of the Iowa hip score. Anteroposterior radiographs of the pelvis were made, and two radiographic indices of acetabular depth were measured: (1) the center-edge angle of Wiberg and (2) the acetabular-ilioischial distance. The presence of protrusio was defined with use of two extant definitions: (1) a center-edge angle of >50 degrees or (2) an acetabular-ilioischial distance of >/=3 mm in male patients or >/=6 mm in female patients. Linear regression analyses were performed between these radiographic indices of acetabular depth and patient age, Iowa hip scores, the magnitude of the radiographic joint space, and range of motion. RESULTS: The prevalence of protrusio acetabuli was 27% according to the center-edge angle criterion and 16% according to the acetabular-ilioischial distance criterion. The prevalence of protrusio increased until the age of twenty years and remained stable after the age of twenty years. Slight but significant negative correlations were detected between the two radiographic indices of acetabular depth and both the Iowa hip score and the summed range of motion (p < 0.02 for all). No significant relationship was found between the two radiographic indices and pain scores. In patients with Marfan syndrome who were more than forty years old, the Iowa hip scores for hips with protrusio were not significantly lower than those for hips without protrusio. CONCLUSIONS: In patients with Marfan syndrome, the prevalence of protrusio acetabuli increases during the first two decades of life and then plateaus in terms of both population-wide prevalence and radiographic severity. In this population, protrusio generally is not associated with severely problematic hip function but it is associated with slightly decreased range of motion of the hip. We concluded that prophylactic surgical intervention is not indicated for most patients with Marfan syndrome who have a radiographic diagnosis of protrusio.

The relation of joint laxity and trunk rotation.

A study was designed to evaluate the joint laxity during scoliosis screening, and to show if there is a relation of joint laxity values to the trunk rotation. One thousand, two hundred and seventy-three children (598 females, 675 males) with an average age of 10.4 years were screened with a scoliometer and forward bending for trunk rotations. Scapular and shoulder elevations, flexible pes planus were recorded and joint laxity was evaluated with the Beighton score. There was high inter-observer and intra-observer reliability for both scoliometer and Beighton scores. In 41 children (3.2%) with Beighton score 7 or higher, trunk rotation measurements were higher than for the rest of the children. Trunk rotation measurements of 7 degrees or higher were found in 30 children, who were more lax than the rest of the group and were invited for radiography, with a detection of curves between 11 and 18 degrees in 10 of them. The Beighton score is a practical and reliable method for defining joint laxity. Although the number of patients with scoliosis was limited, there are findings supporting the relation between joint laxity and scoliosis. Moreover, there was increased laxity in children with increased trunk rotations. Ligamentous laxity may be one of the causes changing the contour of the back.

Growth and maturation in Marfan syndrome.

Understanding the growth pattern in Marfan syndrome is important for prediction of expected growth, prevention of excessive growth by hormone therapy, timing of surgical epiphysiodesis for cessation of growth, and instituting brace treatment for scoliosis. In this study, we analyze growth patterns and generate growth charts for persons with Marfan syndrome. From the charts of 180 clinically diagnosed Marfan patients, longitudinal height and weight measurements were obtained. From this data, growth charts and growth velocity charts were generated for males and females. Skeletal maturation was studied by determining the Risser signs from the x-rays of 71 males and 56 females. From 22 female patients, age of menarche was available and retrieved either by reviewing the charts or contacting the patients. Mean length at birth was 53 +/- 4.4 cm for males and 52.5 +/- 3.5 cm for females. Mean final height was 191.3 +/- 9 cm for males and 175.4 +/- 8.2 cm for females. Mean birth weight was 3.51 +/- 0.74 kg for males and 3.48 +/- 0.68 kg for females. The puberty-associated peak in growth velocity was 2.4 years earlier than the gender-matched general population for males with Marfan syndrome and 2.2 years earlier for females. Age of menarche was 11.7 +/- 2 years of age, which is also early compared to the general population. This study suggests that the growth spurt and pubertal skeletal maturation occur early in Marfan syndrome. The growth curves generated should help more accurately predict adult stature, as well as monitor progression toward it.

Plain radiography of the lumbosacral spine in Marfan syndrome.

BACKGROUND CONTEXT: Marfan syndrome is a connective tissue disorder that results from a defect in the production of fibrillin. These patients tend to have several osseous anomalies of the lumbosacral spine. PURPOSE: This study examines the effectiveness of plain radiographic findings in predicting Marfan syndrome. STUDY DESIGN/SETTING: Case-control study. PATIENT SAMPLE: Fourteen height-matched controls and 33 patients with Marfan syndrome were obtained from our genetics clinic or through the National Marfan Foundation. OUTCOME MEASURES: Determined using measurements taken on plain radiographs. METHODS: Five measurements were acquired of the lumbosacral spine from the radiographs of both groups: interpedicular distance, scalloping value, sagittal canal diameter, vertebral body width and transverse process width. RESULTS: The following measurements were significantly larger in patients with Marfan syndrome: interpedicular distance at L1-L5 (p<.0001); sagittal diameters of the vertebral canal at L4-S2 (p<.01); transverse process to vertebral body width ratio at L2-L5 (p<.01). There was no significant difference in the scalloping values from L1-L5 between the patients with Marfan syndrome and the controls. A multivariate regression analysis generated the following criteria for plain film diagnosis of Marfan syndrome (two criteria need to be met for diagnosis): interpedicular distance at L5 greater than or equal to 36.0 mm, sagittal diameter at L5 greater than or equal to 13.5 mm or transverse process to vertebral width ratio at L3 greater than or equal to 2.25. CONCLUSION: Based on this criteria, patients can be diagnosed with Marfan syndrome with a high sensitivity (81.8%) but a low specificity (58.3%). Thus, plain radiography can be a useful means of screening patients with Marfan syndrome.

A new technique for creating an abdominal window in a hip spica cast.

Opening an abdominal window in a hip spica type of cast can be a troubling maneuver for both orthopaedic surgeon and patient. We present a simple device to create an abdominal window more easily.

Femoral-facial syndrome with hemifacial microsomia and hypoglossia.

We present a boy diagnosed as femoral-facial syndrome with total agenesis of right lower limb, agenesis of femur and fibula of left lower limb and micrognathia, long philtrum as facial features. Some additional features were described as hemifacial microsomia, preauricular tags and hypoglossia.

Lateral shelf acetabuloplasty in the treatment of Legg-Calvé-Perthes disease.

Although head containment is extremely important for the development of the acetabulum and femoral head, there are debates about conservative and surgical treatment. Shelf acetabuloplasty is an effective means of treatment as regards the coverage of the femoral head within the acetabulum, which is the most important issue for the normal development of the hip joint. Nineteen hips of 18 patients were evaluated radiographically using the acetabulum-head index of Heyman and Herndon and the center-edge angle for containment. It was shown that postoperatively both indices improve to increase the containment, thus demonstrating the effectiveness of shelf acetabuloplasty.

False profile radiography for the evaluation of Legg-Calvé-Perthes disease.

False profile radiography (FPR), as proposed by Lequesne and de Sèze, depicts the pathology on the anterolateral acetabular wall and femoral head. A study was conducted to find out the differences between normal anteroposterior radiography and FPR. Twenty-seven patients with Legg-Calvé-Perthes disease who had not been operated on previously and 50 recruits without any pathology were studied for the acetabulum-head index of Heyman-Herndon (HHI) and center-edge angles (CEs) in antero-posterior radiographs and VCA angles in FPR. The VCA angle is most useful to detect anterolateral coverage of the femoral head in lateral pillar C hips. FPR is an easy, reliable and cheap technique to evaluate the anterolateral parts of the femoral head, and the acetabulum.

[Short-term results of conservative treatment without reduction maneuver of the anterior sternoclavicular joint dislocation]. / Anterior sternoklaviküler eklem çikiklarinda redüksiyon manevrasi yapilmadan uygulanan konservatif tedavinin erken dönem sonuçlari.

BACKGROUND: To evaluate the results of the conservative treatment without a reduction maneuver in patients with anterior sternoclavicular joint (SCJ) dislocation. METHODS: Four cases with anterior dislocation of the SCJ were evaluated retrospectively. Three cases were unconscious and were followed in the intensive care unit. All of the cases were treated conservatively without any reduction maneuver, as they are either unconscious or refused the reduction in one case. Average follow-up period was 16 months (10-21 months). RESULTS: Good clinical results were achieved in three cases with only mild cosmetic problems, except one case with marked deformity. CONCLUSION: Good functional results may be achieved with conservative treatment of the anterior dislocation of the SCJ even without a reduction maneuver.

[Stress fracture of the fifth metatarsophalangeal sesamoid bone: a case report]. / Besinci metatarsofalengeal eklem sesamoidinin stres kirigi.

There is a paucity of published literature on the injuries of the lesser toe sesamoids of the foot. A fifty-six-year-old male patient without a major trauma history was diagnosed as having a stress fracture of the fifth metatarsophalangeal joint medial sesamoid bone. Conservative treatment was employed and the patient was followed-up for 25 months without any complaints. The sesamoid bone injury of the fifth toe should be included in the differential diagnosis of lateral forefoot pain.

Hamstring shortening in healthy adults.

Hamstring shortening (HS) causes changes in the posture and walking ability in spastic children, however, there are no studies defining the abnormalities in patellar alignment in individuals with HS.Twenty-five patients with a primary complaint of anterior knee pain, having HS detected at physical examination, and 11 healthy individuals without any HS or knee discomfort as a control group are included in this study. Serial x-rays of the spine, pelvis and knee are taken and knee x-rays are evaluated for the position of the patella in both groups.In patients with Knee Extension Deficit (KED) ≥ 60°, the Blackburne-Peel ratio is lower and the Insall-Salvati ratio is higher than the other groups, denoting a cephalic location of the patella (p < 0.05). There are no changes in the congruency and sulcus angles between the HS and control groups. Vertebral and pelvic changes correlate well with the literature, confirming that significant alterations occur after 60° of KED in adults.The extensor mechanism of the knee is affected and patella is located higher than normal in patients with severe HS, which may be a cause for knee discomfort. In the light of these findings, a routine knee extension deficit examination can be suggested in the initial evaluation of knee discomfort.

Improving clinical recognition of Marfan syndrome.

BACKGROUND: Marfan syndrome is a potentially fatal disorder with cardiovascular, skeletal, and other manifestations that may also be seen in individuals without Marfan syndrome, making diagnosis difficult. Our goals were (1) to examine the ways in which patients have been recognized as having Marfan syndrome, (2) to examine the prevalence of current diagnostic findings, and (3) to determine which physically evident features are most sensitive and specific for referral to confirm a diagnosis of Marfan syndrome. METHODS: Between 2005 and 2007, we prospectively studied 183 consecutive patients with identified Marfan syndrome (Marfan group) and 1257 orthopaedic patients and family members (non-Marfan group). For the Marfan group, we recorded age at the time of recognition and the methods by which the syndrome was recognized; we used Ghent criteria to identify physically and radiographically evident features. For the non-Marfan group, we examined for Ghent criteria that could be noted on the basis of a routine history, physical examination, or radiographs. We used means, odds ratios, and frequencies to analyze the diagnostic use of each finding (alpha = 0.05). RESULTS: According to the Ghent criteria, 27% of patients in the Marfan group (mean age at the time of diagnosis, 7.3 years) had major skeletal involvement whereas 19% had zero or one skeletal feature. The most common physical features were craniofacial characteristics, high-arched palate, positive thumb and wrist signs, and scoliosis. In the non-Marfan group, 83% had one skeletal feature, 13% had two skeletal features, and 4% had three skeletal features or more. The physical features with the highest diagnostic yield were craniofacial characteristics, thumb and wrist signs, pectus excavatum, and severe hindfoot valgus. CONCLUSIONS: Musculoskeletal clinicians should be aware of the diagnostic features of Marfan syndrome. Patients with three to four physically evident features, or two highly specific features (e.g., thumb and wrist signs, craniofacial features, dural ectasia, or protrusio), should be carefully reexamined and possibly referred for an echocardiogram or a genetics consultation. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Musculoskeletal findings of Loeys-Dietz syndrome.

BACKGROUND: Loeys-Dietz syndrome is a recently recognized multisystemic disorder caused by mutations in the genes encoding the transforming growth factor-beta receptor. It is characterized by aggressive aneurysm formation and vascular tortuosity. We report the musculoskeletal demographic, clinical, and imaging findings of this syndrome to aid in its diagnosis and treatment. METHODS: We retrospectively analyzed the demographic, clinical, and imaging data of sixty-five patients with Loeys-Dietz syndrome seen at one institution from May 2007 through December 2008. RESULTS: The patients had a mean age of twenty-one years, and thirty-six of the sixty-five patients were less than eighteen years old. Previous diagnoses for these patients included Marfan syndrome (sixteen patients) and Ehlers-Danlos syndrome (two patients). Spinal and foot abnormalities were the most clinically important skeletal findings. Eleven patients had talipes equinovarus, and nineteen patients had cervical anomalies and instability. Thirty patients had scoliosis (mean Cobb angle [and standard deviation], 30 degrees +/- 18 degrees ). Two patients had spondylolisthesis, and twenty-two of thirty-three who had computed tomography scans had dural ectasia. Thirty-five patients had pectus excavatum, and eight had pectus carinatum. Combined thumb and wrist signs were present in approximately one-fourth of the patients. Acetabular protrusion was present in approximately one-third of the patients and was usually mild. Fourteen patients had previous orthopaedic procedures, including scoliosis surgery, cervical stabilization, clubfoot correction, and hip arthroplasty. Features of Loeys-Dietz syndrome that are important clues to aid in making this diagnosis include bifid broad uvulas, hypertelorism, substantial joint laxity, and translucent skin. CONCLUSIONS: Patients with Loeys-Dietz syndrome commonly present to the orthopaedic surgeon with cervical malformations, spinal and foot deformities, and findings in the craniofacial and cutaneous systems. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Patterns of pediatric supracondylar humerus fractures.

PURPOSE: The Wilkins-modified Gartland classification of pediatric supracondylar humerus fractures does not consider coronal or sagittal obliquity. The purposes of our study were (1) to identify and describe fracture characteristics with unique properties and (2) to propose a fracture classification system that can be reproduced reliably. METHODS: We retrospectively studied 203 consecutive displaced pediatric extension-type supracondylar humerus fractures treated operatively from January 1998 to January 2003. Fracture characteristics (eg, coronal and sagittal obliquity, postoperative alignment), type of surgical treatment, outcome, and complications were assessed and analyzed statistically with Student t test and a receiver operating characteristic curve. Significance was defined as P < 0.05. We incorporated significant cutoff values for fracture obliquity into our classification scheme and tested the classification's interobserver and intraobserver reliability. RESULTS: We identified 4 coronal (typical transverse, medial oblique, lateral oblique, and high fractures) and 2 sagittal (low sagittal and high sagittal) subtypes with significantly different characteristics and outcome. Compared with fractures with coronal obliquity of less than 10 degrees, fractures with coronal obliquity of 10 degrees or greater were associated with significantly more comminution and rotational malunion. Compared with fractures with sagittal obliquity of less than 20 degrees, fractures with sagittal obliquity of 20 degrees or greater were associated with a significantly higher incidence of additional injuries and were more likely to result in extension malunion. Analysis of the interobserver and intraobserver reliability for our system identified correlation coefficients ranging from 0.772 to 0.907 and 0.860 to 0.899, respectively. CONCLUSIONS: Because pediatric extension-type supracondylar humerus fractures vary significantly in terms of characteristics, identification of sagittal oblique and coronal oblique angles may have an important role in surgical decision making and may impact outcomes.

Rib deformity in scoliosis.

Rib deformity in scoliosis is of interest because it may help in the diagnosis, and also, in some pronounced cases, it may need correction by costoplasty. There are, however, debates about its use in diagnosis, because some authors think that rib deformity is not closely related to either the magnitude or the extent of rotation of the curve. In order to define the relation between rib deformity and scoliosis, 11 patients were recruited who were to undergo scoliosis surgery and thoracoplasty, and anteroposterior (AP) T1-S1 standing radiographs, computerized tomography (CT) scans, and three-dimensional (3D) reconstructions were obtained. From the radiographs, the most rotated vertebra, the Cobb angle, the apex and the type of the curve were determined. From the CT scans and 3D reconstructions, the exact level of the rib deformity measured was matched with the corresponding vertebral level. In this way, the most rotated vertebra and the most prominent part of the rib cage deformity were identified. The most rotated vertebra was found to be at the same level in both radiographs and CT scans in only five patients. In the rest of the patients, CT scans showed it either one level higher or lower than it appeared on the radiograph. The most prominent part of the rib cage deformity was at the same level as the most rotated vertebra in two patients, and in the rest of the patients it was one, two or three vertebral levels lower. There was no association between the Cobb angle, vertebral rotation and rib deformity. A CT scan is necessary preoperatively in patients who will undergo a costoplasty, to determine the exact levels of the prominence. However, a scanogram or a 3D reconstruction is required for exactly matching the most prominent part of the rib cage deformity to the corresponding vertebral level.

The use of amniotic membrane in flexor tendon repair: an experimental model.

BACKGROUND: The objective of this study was to investigate the use of amniotic membrane as a long-term bioprosthesis in hand surgery. The role of the amniotic membrane was investigated in chickens with regard to the prevention of adhesion formation following tendon repair in zone II. METHODS: In the control group, the flexor tendon sheath was excised and the tendon repaired. In group II, both the flexor digitorum profundus tendon and its sheath were repaired. In group III, the repaired tendon was covered with amniotic membrane. Histological evaluation of the repaired tendons were done at 3, 6 and 12 weeks. RESULTS: Results of histologic examination demonstrated that use of the amniotic membrane significantly reduced the amount of adhesion compared with the other groups. Three months after implantation no remnants of amniotic membrane could be identified at the tendon repair site. CONCLUSIONS: Amniotic membrane is easily prepared, and because of its cost effectiveness, its use in the prevention and treatment of adhesions should always be kept in mind.

Evaluation of the muscles around the knee in rabbits whose anterior cruciate and/or medial collateral ligaments were dissected.

INTRODUCTION: The biological response of the muscles around the knee in chronic ligamentous instability was investigated in an animal study. MATERIALS AND METHODS: There were four groups of 6- to 9-month-old adult New Zealand albino rabbits (2500-3300 g). The animals were divided into groups according to the ligament that was surgically sectioned: group A anterior cruciate ligament (ACL), group B medial collateral ligament (MCL), group C both ACL and MCL, and group D served as the control group undergoing no surgical intervention. Three months after surgery, biopsy specimens of the vastus lateralis, rectus femoris, biceps femoris, extensor digitorum longus, and gastrocnemius muscles of the rabbits were obtained. Electron-microscopic cross-sections of the biopsy specimens were evaluated using the new predetermined atrophy parameters. RESULTS: Atrophy was found in the biopsy specimens of the quadriceps muscles in groups A and C (p<0.005). Unimportant changes were seen in the hamstrings, extensor digitorum longus, and gastrocnemius muscles (p>0.05). Only in the group undergoing MCL dissection were no changes observed in the muscles (p>0.05). CONCLUSION: It is concluded that ACL lesions affect the biomechanics of the knee negatively and this situation causes atrophy, especially in the quadriceps muscle. An MCL lesion alone does not cause an important problem in the surrounding musculature, probably because of its spontaneous healing capacity. New criteria for assessment of atrophy in the muscles employing electron-microscopic evaluation are suggested.