The Prevalence of Scoliosis after Fontan Circulation Surgery Followed-Up to Adolescence.

Introduction: The advancement of surgical techniques and perioperative management for congenital heart disease (CHD) has increased life expectancy. The surgical creation of the Fontan circulation maintains pulmonary blood flow without relying on an effective pump from the abnormal heart, relying on peripheral vascular resistance to maintain effective flow through the lungs. Unfortunately, this delicate mechanism is compromised when scoliosis restricts ventilation, leading to Fontan failure and a poor prognosis for life. This report describes the prevalence of scoliosis with Fontan completion surgery and the role of screening and surgical correction. Methods: Ninety-six consecutive Japanese patients undergoing Fontan completion surgery for CHD between 2000 and 2017 were identified in our institutional records. The inclusion criterion was at least 7 years of follow-up after Fontan completion surgery, while the exclusion criteria were congenital, syndromic, and neuromuscular scoliosis. Radiographic and clinical parameters, including cardio-thoracic ratio (CTR) for cardiomegaly and cyanosis saturation, were compared between with and without scoliosis. Results: There were 23 and 40 patients in the scoliosis and no scoliosis groups, respectively. The mean age at the final follow-up was 18.5 and 16.7 years in the scoliosis and no scoliosis groups, respectively (p=0.02). Mean CTR was 43.7% and 39.4% in the scoliosis and no scoliosis groups (p=0.016), and the mean saturation in room air at the final follow-up was 88.8% and 93.2%, respectively (p=0.036). There were no significant differences to clarify the risk factors with multivariate logistic regression analysis. Conclusions: The prevalence of scoliosis with Fontan completion surgery was 36.5%. Screening for scoliosis is important for children with Fontan circulation surgery as part of their routine follow-up at least until they reach adolescence.Evidence Level: 4.

RASopathies and spinal deformities for screening of scoliosis.

BACKGROUND: The RASopathies (Noonan syndrome [NS] and Costello syndrome [CS]) are rare disorders. Although these have been characterized, precise delineation of the differences in the spinal deformities associated with RASopathy has not been described. This study characterized the spinal deformities found in NS and CS and describes a strategy for the screening of scoliosis. METHODS: The clinical records and spinal X-rays of 35 consecutive NS and CS patients were reviewed. Spinal X-rays were assessed to define the presence and progression of scoliosis. Clinical records were examined to identify the risk factors associated with scoliosis. In addition, we investigated the association between clinical records and scoliosis using logistic regression analysis. RESULTS: Twenty-four patients with NS and 11 with CS were included. Nine patients with NS and five with CS showed scoliosis. The mean ± SD age at diagnosis was 12.6 ± 2.4 years in NS and 11.4 ± 2.5 years in CS (p = 0.55), and mean follow-up period was 4.8 ± 2.6 years and 6.3 ± 2.4 years (p = 0.42), respectively. The coronal angular deformity at final follow-up was 27.3 ± 8.5° in NS and 19.4 ± 6.9° in CS (p = 0.030) with a mean annual progression of 2.8 ± 1.1° in NS 1.0 ± 1.0° in CS (p = 0.030). Cardiac disease was present in eight out of nine patients with NS with concomitant scoliosis in NS, and significantly more than in CS (p = 0.007). PTPN11 significantly correlated with scoliosis (odds ratio 12.4 0.035, 95% confidence interval: 1.20-128.00). CONCLUSIONS: Spinal deformity in NS is more severe than in CS. This study identified a relationship between PTPN11 and scoliosis. Therefore, PTPN11 can be used for the screening of scoliosis.

Costello syndrome-associated orthopaedic manifestations focussed on kyphoscoliosis: a case series describing the natural course.

Costello syndrome (CS) is a rare genetic condition caused by a heterozygous mutation in the HRAS gene, with an estimated prevalence of 1: 300 000. Individuals with CS present with characteristic features including scoliosis, kyphosis, Chiari 1 malformation, and syringomyelia. The natural history of the spinal deformity associated with CS has been incompletely described. This case series describes the spinal deformity associated with CS and sets out a strategy for screening and treatment. The clinical records and spinal radiographs of nine consecutive CS patients encountered at a single centre were reviewed. Radiological assessments for the presence and progression of scoliosis were studied. Nine patients with confirmed CS were followed for a mean of 6.6 years. Five patients showed mild scoliosis. Two patients had lumbar kyphosis in addition to their scoliosis, and one showed scoliosis with proximal thoracic kyphosis. Three patients underwent investigation with MRI, one of which showed Chiari I malformation and a syrinx. One showed no change in the severity of their deformity over time. The remaining four patients showed a rate of increasing coronal deformity of 2.1° per year. There were no cases of rapid progression. All cases showed delayed skeletal maturity. The spinal deformity in CS appears to be slowly progressive. To identify those at risk of more rapid progression, brain and spine MRI should be carried out to exclude structural neurological abnormalities. Long follow-up is required for patients with spinal deformity in CS due to the delay in reaching skeletal maturity. Evidence level: 4.

Peroneal Nerve Palsy Caused by Proximal Fibular Solitary Osteochondroma: Case Report and Literature Review.

Osteochondroma is a relatively common benign tumor of the bone, and compressive neuropathies due to osteochondroma are comparatively rare. Here, we present a rare case of osteochondroma of the fibular head that caused peroneal nerve palsy in an 8-year-old girl. Physical examination revealed 0/5 tibialis anterior, 1/5 extensor hallucis longus, and 1/5 peroneal brevis muscle power-according to the manual muscle testing grading system, as well as numbness on the lateral side of the right leg and the back of the foot. Radiological examination and ultrasound revealed a bone tumor in the head of the right fibula. Magnetic resonance imaging ruled out spinal nerve root compression. It was discovered that the bone tumor in the fibular head had compressed and displaced the common peroneal nerve. The patient underwent surgical decompression of the right peroneal nerve. A bone region measuring 22 × 14 × 8 mm was removed. Three months postoperatively, the preoperative neurological deficits were found to be nearly resolved. The patient presented with a foot drop for 1 year, but symptoms resolved 3 months after surgery. Conventional wisdom states that surgery should be performed within 3 months, but we recommend that surgery be performed as soon as diagnosis is made even in cases with a long history, as it may improve patient symptoms and outcomes.

The Association Between Radiographic and MRI Cervical Spine Parameters in Patients With Down Syndrome.

Introduction Many patients with Down syndrome (DS) develop upper cervical spine instability that may lead to spinal cord injury. The purpose of this study was to investigate the association between the spinal cord compression in MRI and the occipto-cervical instability evident on plain radiographs in a Japanese population. Methods A retrospective analysis of cervical spine radiographs and MRI acquired from patients with DS was performed. Radiographic evaluation included measuring the atlanto-dental interval (ADI) and space available for the cord. The basion axial interval (BAI) and Weisel-Rothman (WR) measurements were taken to quantify occipto-axial (OA) and atlanto-occipital (AO) instability. These parameters were collected in patients both with (positive) and without (negative) spinal cord compression evident on MR imaging in a neutral position and the values were compared. In addition, we investigated the association between spinal cord compression and previously defined abnormal values with logistic regression analysis (abnormal values: ADI>6mm, SAC<14mm, BAI<-12mm or >5mm in neutral position). Results There were 17 patients in the positive group and 52 patients in the negative group. WR was 7.4 mm±6.0 in positive group and 8.6 mm±4.8 in negative group (p=0.31) in neutral position, 3.9 mm±5.4 and 6.3±5.0 (p=0.06) in flexion, and 7.0 mm±6.8 and 7.2 mm±4.8 (p=0.75) in extension, respectively. The difference in WR between flexion and extension was 3.1 mm ± 4.6 and 0.9 mm ± 3.8, respectively (p=0.15). All other parameters showed significant differences between the two groups excluding BAI in extension (p<0.05). In addition, abnormal values that significantly correlated with cord compression were ADI (odds ratio 42.3 p<0.01 95% CI 4.16-430.0) and SAC (odds ratio 31.90 p=0.013 95% CI 2.06-494.0). Conclusions These data suggest that OA and AA instability measured with ADI, SAC, and BAI are significantly associated with spinal cord compression in MRI; whereas instability measured with WR and DWR is not. In addition, the previously defined abnormal thresholds for the ADI and SAC can be used for screening the Japanese population.

Endoscopic Surgery under Fluoroscopic Guidance Is Useful for Diagnosing and Treating Epiphyseal Osteomyelitis Caused by Mycobacterium Species.

Osteomyelitis caused by Mycobacterium species may be difficult to diagnose and treat. We report a case of treatment for osteomyelitis caused by Mycobacterium species in the epiphysis of the right proximal tibia. A 28-month-old boy presented to a hospital with symptoms of fever and right knee pain. He had been vaccinated with Mycobacterium bovis Bacille Calmette-Guérin (BCG) at five months of age. The epiphyseal radiolucent lesion had increased in size and extended to the metaphysis through the physis on a plain radiograph of the right proximal tibia. Surgical drainage and curettage of the lesion were performed with an endoscope under C-arm fluoroscopy. The intraoperative histopathological examination revealed granulation tissue composed of caseous necrosis and Langerhans giant cells, revealing Mycobacterium species to be the causative pathogen. Because of suspected osteomyelitis caused by BCG, the antituberculosis drugs were administered orally from an early postoperative stage. A plain radiograph taken eight months postoperatively showed bone regeneration in the area of curettage and a slight physeal bridge, in addition to normalization of the inflammatory response on blood sampling. It was possible to perform accurate diagnosis and rapid treatment for epiphyseal osteomyelitis caused by Mycobacterium species using endoscopic surgery under fluoroscopic guidance.

Supermicrosurgical free sensate superficial circumflex iliac artery perforator flap for reconstruction of a soft tissue defect of the ankle in a 1-year-old child.

Although a superficial circumflex iliac artery perforator (SCIP) flap has recently been widely used owing to its various advantages, reports on its use in the pediatric population are limited. A case of a supermicrosurgical reconstruction of a soft tissue defect of the ankle associated with the congenital deficiency of the tibia using a free sensate SCIP flap in a 1-year-old child has been presented. The correction of the valgus deformity of the ankle resulted in a soft tissue defect, which required flap coverage. The lateral cutaneous branch of the intercostal nerve of the flap was coapted with the deep peroneal nerve for sensory recovery. Postoperative course was uneventful and the flap completely survived. The patient was able to ambulate independently at 7 months after surgery. To the best of our knowledge, this is the youngest case of a SCIP flap transfer in literature. This case showed that young age is not a contraindication for SCIP flap transfer. It is believed that the SCIP flap procedure may be a useful option for free flap reconstruction in children.

Long-term results of bulk femoral head autograft in cementless THA for developmental hip dysplasia.

We evaluated the fate of bulk femoral head autograft in cementless total hip arthroplasty (THA) for developmental hip dysplasia. Of 87 hips (80 patients) studied, 37 hips (32 patients) were available for follow-up at a mean of 18.5 years (range, 15-24 years) postoperatively. The mean age of these 32 patients at the index procedure was 53.8 years (range, 40-65 years). The initial diagnosis was osteoarthritis in all 32 patients. The degree of acetabular dysplasia according to Crowe classification was type I in 18 hips (48.6%), type II in 14 (37.8%), type III in 5 (13.5%). The mean percentage of horizontal coverage of the acetabular components with graft bone was 34% (range, 25%-45%). Trabecular bridging across the graft-host interface was seen at a mean of 4 months (range, 2-6 months) postoperatively. Trabecular reorientation of the grafted bone was seen in all hips at a mean of 27 months (range, 12-36 months) postoperatively. There was no evidence of collapse and bony resorption of the grafted bone in the weight-bearing portion. Acetabular component fixation was stable in all hips at final follow-up. Of the 37 hips (32 patients), 2 acetabular components required revision: 1 for a late postoperative deep infection and 1 for dissociation of the polyethylene liner. The survival rate was 94.5% (95% confidence interval, 91.3-96.5) for the acetabular component at 18.5 years of follow-up. This study found that bulk femoral head autograft in cementless THA for developmental hip dysplasia produces excellent long-term results.