Use of inlet radiographs in the assessment of reduction after the surgical treatment of developmental dysplasia of the hip.

AIMS: This pilot study aimed to evaluate prospectively the use of inlet radiographs of the hip as an alternative method of the assessment of reduction after the surgical treatment of developmental dysplasia of the hip (DDH). PATIENTS AND METHODS: The children in this study underwent surgery between January 2013 and January 2015. All had inlet radiographs and CT scans post-operatively. Data were analysed by determining inter-observer reliability and intra-observer reproducibility, using the kappa value (K). Differences were settled by discussion between the two observers until a consensus was reached. The sensitivity and specificity of the radiographic and CT results were compared. A total of 26 radiographs were obtained from 23 children, with a mean age of 2.38 years (one to five). RESULTS: Similar high levels of intra- and inter-observer agreement were observed (K = 0.834, 95% confidence interval (CI)). There was a high agreement between the radiographic and CT results (K = 0.834, 5% CI), with excellent sensitivity and a specificity of 95.5%. CONCLUSION: These results suggest that inlet radiographs may be a reliable method of assessing the reduction of the hip after the surgical treatment of DDH. Cite this article: Bone Joint J 2017;99-B:697-701.

One-stage external iliac fixation device and bilateral fascial and groin flaps facilitate abdominal wall closure after posterior sagittal iliac osteotomy in cloacal exstrophy.

PURPOSE: Repairing abdominal wall defects after cloacal exstrophy reconstruction always poses a challenge. Our proposal for repair consists of bilateral posterior iliac osteotomy and external iliac fixation with Schanz pins, together with abdominoplasty through bilateral groin flaps of skin and muscular aponeuroses, in a single staged procedure. METHODS: 7 patients (5 male and 2 female; mean age 3.1 years) with cloacal exstrophy underwent reconstructive surgery at our institution. Cloacal exstrophy reconstruction was performed in 3 stages, whenever possible. In Stage 1, the intestinal tract is separated from the hemi-bladders; the small colon is tubularized (colorrhaphy) with an opening on the left flank. The hemi-bladders are joined and the pathology is converted into classic bladder exstrophy, followed by primary repair (cystorraphy). At this stage, closure of the abdominal wall is made by groin flap plasty, following bilateral posterior iliac osteotomy with an external iliac fixator. Stage 2 consists of bladder augmentation and the management of urinary continence. Stage 3 is genitoplasty. The aim of this study was to demonstrate our results for the first stage. RESULTS: After a mean follow-up of 7 years, closure of abdominal wall was found to be excellent and successful in all 7 patients. Their abdominal walls are strong and solid, with no retraction, fistula or eventration. CONCLUSION: The association, in a single stage, of a posterior osteotomy with an external iliac bone fixator and bilateral groin flaps for the closure of soft tissue defects of the abdominal wall in cloacal exstrophy appears to be a safe and cosmetically acceptable alternative technique.

Effect of ifosfamide on bone healing.

The effect of ifosfamide on bone healing was tested in a controlled experiment of fibular osteotomy in immature rabbits. Standardized shaft osteotomy was implemented in 10 experimental subjects (group 2) and 10 controls (group 1). Experimental animals received a 50 mg/kg ifosfamide dose by intraperitoneal injection on the fourth post-operative day, and for five days thereafter, while controls received injections of distilled water. After five weeks, all animals were submitted to pharmacological euthanasia and the resulting bone callus samples were studied with histomorphometry, using hematoxylin-eosin stain. Group 2 presented smaller bone volume (69.03% versus 84.98%), larger fibrosis volume (30.96% versus 15.02%), and larger resorption surface (22.02% versus 16.17%) than group 1 (all p< or = 0.05). We conclude that ifosfamide is able to alter the physiological bone healing process by producing a less mature callus (characterized by a smaller quantity of bone tissue), a larger quantity of fibrous tissue, and a smaller resorption surface.

Comparative study of the strength of the flexor and extensor muscles of the knee through isokinetic evaluation in normal subjects and patients subjected to trans-tibial amputation.

This study compares the strength of the flexor and extensor muscles of the knee in a group (A) of 25 patients with unilateral trans-tibial amputation, regardless of cause, and a group (B) of 27 normal volunteers. Measured parameters were peak bending moment, total work, maximum power and flexor/extensor relation. The dynamometer used was a Cybex model 6000, set at velocities of 60 degrees/s and 180 degrees/s (4 and 20 repetitions). Exercise type was concentric, both for flexion and extension of the knee joint. Patients were grouped according to stump size, age and time since amputation. These patients were tested with their prosthesis. Mean age in group A was 35.9 +/- 13 years (age range: 12-59 years). Mean age in group B was 34 +/- 8 years (age range: 19-56 years). Comparison according to subject sex was similar. Data analysis between the amputated and the sound limb reveals strength deficit (bigger deficit at 180 degrees/s), which relates to age but not to stump size. When compared to non-amputated subjects in the measured parameters, negative relations both in the amputated side and the non-amputated side were found. The authors' conclusion is that revision of the parameters used until then for rehabilitation of the patients subjected to trans-tibial amputation is needed.

The use of bone bridges in transtibial amputations.

UNLABELLED: We sought to describe the bone bridge technique in adults, and present a variation for use in children, as well as to present its applicability as an option in elective transtibial amputations. This paper presents a prospective study of 15 transtibial amputations performed between 1992 and 1995 in which the bone bridge technique was employed. The patients' ages ranged from 8 to 48 years, with an average of 22.5 years. This technique consisted of the preparation of a cylinder of periosteum extracted from the tibia and with cortical bone fragments attached to it to promote a tibiofibular synostosis on the distal extremity of the amputation stump. We noted that the cortical bone fragments were dispensable when the technique was employed in children, due to the increased osteogenic capacity of the periosteum. This led to a variation of the original technique, a bone bridge without the use of the cortical bone fragments. RESULTS: The average time spent with this procedure, without any significant variation between adults and children, was 171 minutes. The adaptation to the definitive prosthesis was accomplished between 20 and 576 days, with an average of 180 days. Revision of the procedure was necessary in 3 amputations. CONCLUSIONS: This technique may be employed in transtibial amputations in which the final length of the stump lies next to the musculotendinous transition of the gastrocnemius muscle, as well as in the revision of amputation stumps in children, where the procedure has been shown to be effective in the prevention of lesions due to excessive bone growth.

Three-dimensional (3D) contrast-enhanced power Doppler imaging in Legg-Calvé-Perthes disease.

BACKGROUND: The revascularization process of the femoral head in Legg-Calvé-Perthes disease has not been well studied on Doppler images. We incorporated two relatively new developments in ultrasound: 3D power Doppler imaging combined with the use of contrast agents. PATIENTS AND METHODS: We studied two children with unilateral Legg-Calvé-Perthes disease through anterior-sagittal approaches with pre- and post-contrast power Doppler images, acquired in 2D and 3D planes. RESULTS: In one patient, intraosseous vessels were detected only in the pathological femoral head both pre- and post-contrast administration. In the other, no flow was identifiable without the use of contrasts. CONCLUSION: The use of ultrasound contrast agents combined with 3D imaging modalities offers new alternative methods for visualization of intraosseous vascularity.

[Results of femoral varus osteotomy in the treatment of Legg-Calvé-Perthes disease]. / Resultados da osteotomia femoral varizante no tratamento da doença de Legg-Calvé-Perthes (DLCP).

The authors studied a group of 52 patients with Legg-Calvé-Perthes disease who had been treated by femoral varus osteotomy (54 osteotomies) aiming to show the end results and complications of the procedure based on Stulberg et al's evaluation. Regarding this classification of results were found 19 osteotomies (35.1%) with a good result (Stulberg's Groups 1 and 2), 35 (64.8%) with a fair end result (Stulberg's Groups 3 and 4) and none poor result. Few complications were observed in this series: pseudarthrosis occurred in three cases; Trendelemburg was observed in five patients postoperatively and overgrowth of the greater trochanter was observed in seven patients. In nine patients it was observed a significant leg length discrepancy with more than 2.1 cm of difference. However by the end results observed we may say that good results can be obtained with this technique in the treatment of patients with Legg-Calvé-Perthes disease. It is very important the indication criteria adopted based on the prognosis of the individual case studied.

[Treatment of pseudarthrosis of the long bones using the Ilizarov method in children]. / Avaliação do tratamento de pseudartroses dos ossos longos com o método de Ilizarov na criança.

In the period 1987-1993, 13 patients were treated for both infected and non-infected long bone pseudoarthrosis by Ilizarov method. The records and radiographs of nine boys and four girls, with the age ranging from 7 to 16 years, with an average of 12.3 years, were reviewed. All but one concerned the tibia. In one case the pseudoarthrosis was localized in the humerus. Ten were infected. Ten had bone loss, all in the tibia, 2.5 to 8.0 cm in the extension of. All the results were considered good and the complications observed were few and not related with the treatment.

[Vascular complications of the Ilizarov method]. / Complicações vasculares no método de Ilizarov.

Between 1987 and 1991, 209 patients were operated by the Ilizarov method in the Department of Orthopaedic and Traumatologic Surgery of the University of São Paulo Medical School. Five of them presented vascular complications during the treatment. All were adults treated for long bone pseudarthrosis. The vascular lesion occurred in the femoral superficial artery (one case), in the popliteal artery (one case), and in the posterior tibial artery (one case); in the remaining two patients it was not possible to determine the exact site of the lesion. The clinical manifestation of the vascular problem was bleeding at the cutaneous point of the Kirschner transfixation wires. Arteriography was done in all cases but its interpretation was difficult because of the presence of the external fixator. The treatment of the vascular complications was following: in the case of injury in the femoral artery, the external fixator was taken off and a by-pass with an inverted graft of the saphenous vein was made the same procedure was done in the popliteal artery but in this case it was not necessary to remove the external fixator; the remaining case with the lesion in the posterior tibial artery was treated by ligature. In two cases where the artery involved was not determined--one in the upper extremity with the external fixator applied to the femur--the bleeding stopped after the removal of wires.

[Pyogenic arthritis: case reports and a review of the literature]. / Artrite piogênica: relato de casos e revisão da literatura.

The authors studied septic arthritis in patients of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. The pathogeny, the etiology and the diagnosis with clinical and laboratory findings are discussed. Our data are in accordance with those found in the literature. The main site was the knee joint and the etiologic agent Staphylococcus aureus. The authors point to the necessity of an early diagnosis and to the fact that the treatment of septic arthritis must be started as soon as possible.

Study of fracture healing in protein malnutrition.

The present study was designed to assess the effects of nutrition on fracture healing in a controlled animal model. Tibial fractures were studied in 115 Wistar rats divided into four groups: group 1,50 control animals kept on a normal diet; groups 2 and 3, 45 protein-deprived animals, and group 4, 20 animals submitted to protein malnutrition before the fracture and then placed on a normal laboratory diet. The parameters evaluated during the study were: variation in animal weight during the experiment (confirmation of protein malnutrition), fracture healing as determined by bone callus radiology, macroscopic evaluation of bone callus mechanical resistance, and histological fracture examination by common light microscopy after staining with hematoxylin-eosin. The results showed the beneficial effects of protein nutrition support on the healing of lone bone fractures. Callus formation was significantly improved in groups 1 and 4 compared to groups 2 and 3. In groups 1 and 4, callus development was normal, with regular bone tissue formation, whereas in groups 2 and 3 there was a large amount of fibrous-connective tissue with scarce formation of osseous tissue.

[Evaluation of treatment of the hip in arthrogryposis multiplex congenita]. / Avaliação do tratamento do quadril na artrogripose múltipla congênita.

In a retrospective review of 77 patients with arthrogryposis multiplex congenita, 21 showed involvement of the hip (28%). The authors studied 18 cases with hip dislocation (11 bilateral and seven unilateral) and three with hip contracture. There were 12 female and nine male patients ranging their age from one month to 14 years. The follow-up in this series lasted from two to 23 years. The treatment was conservative or surgical. The contractures were treated by manipulation and abduction orthosis in one patient and surgically by multiple hip tenotomy in two. The dislocation was treated by abduction orthosis (two cases), closed reduction (two cases) and open reduction (one case) in the 11 cases with bilateral involvement; for the seven unilateral dislocations the treatment was: closed reduction and abduction orthosis (one case), closed reduction with abductor tenotomy and hip spica cast (four cases) and open reduction followed by hip spica and abduction orthosis (one case); one case remained without treatment of the hip involvement because of severity of deformities in knee and foot. Ten patients of this groups were not treated because they were confined to wheelchairs. The overall result was good in six patients, regular in four and poor in two in the dislocation group; for the three cases of hip contracture the result of treatment was good. In conclusion the authors recommend such treatment for the independent ambulatory patients and emphasize the necessity of treatment of patients with unilateral hip involvement.

Femoral lengthening by the Wagner method.

Lengthening procedures can yield excellent results, but are associated with potentially serious complications that require multiple operations and prolonged hospitalization. Femoral lengthening by the Wagner technique was performed from 1981 to 1987. The various complications and technical problems of 38 procedures in 37 patients were studied. Only 18 of the 38 procedures were uncomplicated. The main complication was related to the osteosynthesis with plates and screws in the second stage of the method, i.e., six broken plates, six minor pin-tract infections, two deep infections. The results were good in 28 procedures. To treat a leg length inequality, the physician must consider several treatment modalities, such as a lift for the short side. Each patient must be individually evaluated to select the adequate modality of surgical treatment including shortening or epiphysiodesis of the sound limb or lengthening of the shortened limb, procedures with relatively low morbidity.

Plasty of tendon with dura mater. Experimental study.

The authors present an experimental study of 30 rats, in which human dura mater preserved in glycerin was used to repair gaps in the Achilles tendon. The animals were killed 8 weeks after the surgery and evaluated by gross and microscopic examination. The results showed that the dura mater did not cause foreign-body reactions or adhesions and was surrounded by concentric layers of fibroblasts and collagen fibers, suggesting that it could be employed as a substitute for damaged tendons.

Intrauterine diagnosis of congenital dislocation of the knee.

The authors present a case of congenital dislocation of the knee diagnosed in utero, when an abdominal radiograph was performed on a woman in the eighth month of pregnancy.

Transferencia distal e lateral do grande trocanter em criancas. / Distal and lateral transfer of the greater trochanter in children

Quinze pacientes com hipercrescimento do grande trocanter tratados no Alfred I. Dupont Institute, pela transferencia distal e lateral do grande trocanter, estudados e acompanhados para investigar o resultado dessa tecnica cirurgica, segundo a avaliacao clinica dos parametros dor, claudicacao, sinal de Trendelemburg, forca de abducao e funcao articular, bem como a avaliacao radiografica, pre e pos-operatoriamente. A observacao desses pacientes mostrou que a tecnica cirurgica e de facil execucao e geralmente nao ocorreram complicacoes. A transferencia do grande trocanter esta indicada para a crianca mais velha (ao redor dos 10 anos de idade) e leva a bons resultados para os pacientes que necessitam de alongamento do braco de alavanca para a musculatura abdutora do quadril