Comparison of three surgical treatment options for unicameral bone cysts in humerus.

Treatment of unicameral bone cysts (UBC) in the humerus with drainage screws is scarcely reported in the literature. The aim of this retrospective study was to compare drainage screws and alternative treatment methods with respect to the number of required surgical procedures to achieve sufficient UBC healing, postoperative fractures/recurrences/complications, and radiological outcome. Medical archives of two tertiary orthopedic referral centers were screened for all patients who were treated surgically for humeral UBC in the period 1991-2015 with a histologically/cytologically confirmed diagnosis. Sex, age, all surgical procedures, fractures, complications, recurrences, and the final radiological outcome were compared between patients treated with drainage screws, elastic intramedullary nails, or curettage with optional grafting. The study included 106 operated patients with a mean age of 10.3 years, with a mean follow-up of 5.7 years. The average number of UBC-related surgical procedures in sex-matched and age-matched treatment groups was 2.7 with drainage screws, 2.8 with intramedullary nails, and 3.5 with curettage/grafting (P=0.54). Intramedullary nails (odds ratio 0.20) and older age (odds ratio for each year 0.83) predicted a lower risk of postoperative UBC recurrence. Patients with drainage screws had the highest UBC recurrence rates and the lowest rates of changed initial treatment method. There was no difference between the treatment groups in the postoperative fracture rate, complications, or the final radiological outcome. UBC treatment in the humerus therefore requires approximately three surgical procedures, irrespective of the treatment modality chosen. Adding an elastic intramedullary nail to a humeral UBC cyst may reduce recurrence risk and prevent further fractures. Level of Evidence: Level III - therapeutic retrospective comparative study.

Observational retrospective study on socio-economic and quality of life outcomes in 41 patients with adolescent idiopathic scoliosis 5 years after bracing combined with physiotherapeutic scoliosis-specific exercises (PSSE).

PURPOSE: We analysed socio-economic- and health-related quality of life (primary outcome) and radiological outcome (secondary outcome) 5 years after full time rigid bracing (FTRB) plus physiotherapeutic scoliosis-specific exercises (PSSE) in adolescent idiopathic scoliosis. METHODS: We included 41 patients (38 female and 3 male) treated with FTRB (Chênau brace) and PSSE (Schroth) between 2001 and 2010. The study protocol included a clinical and radiological examination, the completion of the SRS-24 questionnaire and acquisition of data on socio-economic factors (educational and employment status) and physical activity. Descriptive statistics were used to analyse the data; differences between patients with mild (< 30°) and severe curves (30°-50°) regarding hrQoL outcomes were analysed using the Mann-Whitney U Test. RESULTS: Primary outcomes showed full employment (higher education, 39%, and full-time work, 61%) and the majority of the patients (79.9%) performing moderate sports two to four times per week. The SRS-24 questionnaire produced a total mean score (MS) of 4.0 (79.9%). Patients with mild curves had a significantly better total score (MS 4.1 vs. MS 3.8, p = 0.020) and were more satisfied with the treatment (MS 4.3 vs MS 3.9, p = 0.020). As to the secondary outcomes, from start of bracing to follow-up (a mean of 6.7 years after brace weaning), the average Cobb angle changed from 28.6° to 25.6° (range 4°-48°); in 51.2% the curve angles could be maintained after weaning. CONCLUSIONS: Compared with the literature, our results showed similar curve development and hrQoL (pain, self-image and function) and better results regarding satisfaction with treatment. In comparison with the average population, there were no disadvantages as to occupation, education and sports. These slides can be retrieved under Electronic Supplementary Material.

Video-game-assisted physiotherapeutic scoliosis-specific exercises for idiopathic scoliosis: case series and introduction of a new tool to increase motivation and precision of exercise performance.

BACKGROUND: It is important to monitor how patients with juvenile and adolescent idiopathic scoliosis comply with their physiotherapeutic scoliosis-specific exercises (PSSE). Physiogame, a newly developed video game using the Game-Trak 3D interactive game controller, combines correct PSSE performance with gaming. It tracks the position of the working limb in 3D space during the exercises as participants aim to hit certain targets and avoid others, and gives direct feedback by stopping the game if the working limb leaves the target 3D space, which is chosen to secure the corrective position according to the Schroth method. Physiogame records the quality and frequency of the exercises performed. We aimed to investigate the influence of this tool on motivation to perform regularly and, correctly, and with self-assessment of performance quality. METHODS: This case series included 8 consecutive patients with idiopathic scoliosis (thoracolumbar 7, lumbar 1), ages 7-13 years, all female and treated according to SOSORT guidelines; the COBB angle of primary curve at the start of brace therapy was 22-34°. In addition to Full Time Rigid Bracing (FTRB, Cheneau) and PSSE (Schroth), the participants were to perform two standardized Schroth exercises (muscle cylinder in standing position, mainly addressing the thoracic curve, and in side-lying position, mainly addressing the lumbar curve) with video game assistance every day for 6 months. The development (first to last month) of the following parameters was analyzed with descriptive methods: the actual training time to assess motivation, the ratio of the actual playing time versus total playing time to assess exercise improvement, and self-assessment of quality of performance. RESULTS: The average number of sessions with Physiogame was 217 per study participant (range 24 to 572, the study protocol targeted at least 180); actual training time decreased from 79 to 52 min (first to last month). Actual playing time increased from 73% of the total playing time to 83% (first to last month), and positive hits per second from 0.33 to 0.56. Self-assessment increased from "good" to "very good". The curve angles (°Cobb) were maintained over the study period (upper thoracic mean -1.3°, median -1°; lower thoracic mean 3°, median 2°; lumbar mean 0.5, median 0). CONCLUSIONS: The improvement we saw in exercise performance, is thought to result primarily from the direct given feedback during the game, as the exercises themselves were already familiar to the patients. The synchronous recording of actual training time allows evaluation of Schroth therapy for idiopathic scoliosis, since both prescribed training time and actual training time are captured. No comparable tool was found in literature.

The influence of age at single-event multilevel surgery on outcome in children with cerebral palsy who walk with flexed knee gait.

AIM: Information on the timing and long-term outcome of single-event multilevel surgery in children with bilateral spastic cerebral palsy (CP) walking with flexed knee gait is limited. Based on our clinical experience, we hypothesized that older children with bilateral spastic CP would benefit more from single-event multilevel surgery than younger children. Moreover, any improvement in older children could be maintained with fewer additional surgery events. METHOD: We performed a retrospective analysis of the long-term outcomes of single-event multilevel surgery. Thirty-two children (17 males, 15 females) who had received single-event multilevel surgery between 1995 and 2000 with a mean age at the time of surgery of 10 years 6 months (range 5y 8mo-15y 6mo; SD 3y 1mo) and in Gross Motor Function Classification System level II (n=12) or III (n=20) were included in the study. The inclusion criteria required that all children were ambulatory with spastic bilateral CP, had a flexed knee gait, had a full set of data for single-event multilevel surgery preoperatively and at 1 year and 10 years postoperatively, had not had previous surgery on their lower limbs, had not had any treatment with botulinum toxin A before gait assessment, and had not received intrathecal baclofen medication. The follow-up time lasted for over 10 years until the participants reached adulthood (mean age at the last follow-up 21 years 4 months, SD 3y 4mo). Data were collected on six separate occasions: preoperatively, at 1 year, at 2 to 3 years, at 5 years, at 7 to 8 years, and at 10 or more years postoperatively. The primary outcome was the Gait Deviation Index, and the secondary outcomes were the number and type of initial and additional surgeries. A linear mixed model and Spearman's rank correlation coefficient were used to prove the hypothesis. RESULTS: The older the child was at the time of the surgery, the better the long-term result ((Age,Time) =0.15; p=0.03). We did not find any correlation between age at the time of surgery and the number of bony or soft-tissue procedures performed initially as well as during the 10 years of follow-up. INTERPRETATION: Children with CP who require single-event multilevel surgery at an older age fare better in the long term than those who are younger at the time of surgery. The pubertal growth spurt is discussed as a contributing factor to gait deterioration.

Genu recurvatum in cerebral palsy--part A: influence of dynamic and fixed equinus deformity on the timing of knee recurvatum in children with cerebral palsy.

The aim of the study was to confirm the hypothesis of the influence of the dynamic and fixed equinus deformity on the timing of knee recurvation (hyperextension). According to our hypothesis, dynamic equinus is linked to early and fixed equinus and to late knee hyperextension. A group 35 children with cerebral palsy (47 lower limbs) was divided into two subgroups according to the timing of maximum knee hyperextension. Clinical examination confirmed our hypothesis. Gait analysis and musculoskeletal modelling results were compared with 12 normally developing children. Both recurvatum groups had forefoot landing and neither achieved normal ankle dorsiflexion. Electromyographic examination revealed an abnormally high soleus activity in a single stance. Muscle length changes of medial gastrocnemius and soleus were in agreement with our hypothesis. Such a finding might simplify the decision as to which treatment to select for equinus deformity, present in patients with genu recurvatum.

Genu recurvatum in cerebral palsy--part B: hamstrings are abnormally long in children with cerebral palsy showing knee recurvatum.

Hyperextension of the knee in stance (knee recurvatum) is a common disorder in patients with spastic cerebral palsy (CP). A group 35 children with CP (47 lower limbs) was divided into two subgroups according to the timing of maximum knee extension during the stance phase of gait. Gait analysis and musculoskeletal modelling data were compared with a control group of 12 normally developing children. We observed no difference in kinematics between the CP groups who showed an equinus position of the foot at initial contact. Both groups showed increased external extensor moments across the knee. The muscle-tendon lengths of the hamstrings were abnormally long at initial contact, and in both recurvatum groups, contracted faster compared with the control group. Surface electromyography revealed prolonged activity of the hamstrings in stance and early activation in swing. Abnormally long hamstrings at initial contact together with equinus position of the foot are the main causes of genu recurvatum in children with CP.

Preliminary report: resection and interposition of a deepithelialized skin flap graft in tarsal coalition in children.

Six tarsal coalitions in children were managed surgically using a deepithelialized skin flap for interposition after resection of the bony, fibrous or cartilaginous coalition. The advantage of this technique is that due to positioning the skin flap, joint motion can be preserved. The clinical results using the Ankle Hindfoot Scale of the American Orthopedic Foot and Ankle Society were excellent in two and good in four cases. The radiographs at follow-up showed no recurrences of the resected coalitions. This study shows that the use of deepithelialized skin flap interposition is effective in providing pain relief for the patients in symptomatic coalitions.

Leg lengthening as part of gait improvement surgery in cerebral palsy: an evaluation using gait analysis.

Eleven children with hemiplegic or an asymmetric diplegic cerebral palsy who had a preoperative leg length discrepancy of more than 2.5 cm underwent gait improvement surgery which included leg length equalisation. Sagittal plane kinematics and kinetics before and about 3 years after surgery for the lengthened limb and contralateral limb were evaluated. Preoperatively the unaffected limb had excessive stance phase flexion at the hip and knee, and dorsal flexion at the ankle joint. These changes could be partially reversed to produce a kinematic gait pattern comparable to age matched normal controls on the uninvolved side after equalisation of leg length.

Comparative evaluation of luque and isola instrumentation for treatment of neuromuscular scoliosis.

Surgical treatment of neuromuscular scoliosis is controversial. Owing to the presumed improvements of the newer instrumentation, we hypothesized that the Isola-Asher instrumentation would have better radiographic results that the Luque-Galveston instrumentation and that these differences would be reflected by the patients' subjective assessment of activities of daily living. We retrospectively reviewed patients with neuromuscular scoliosis who were treated using Luque-Galveston or Isola-Asher instrumentation to compare the outcomes. Preoperative, postoperative, and followup radiographs were evaluated for change in scoliosis angle, lordosis angle, and pelvic tilt. Subjective and functional results of surgery were evaluated with questionnaires. We found no difference in the degree of scoliosis correction, correction of lumbar hypolordosis or hyperlordosis, pelvic tilt, or complication rate between the two groups of patients with neuromuscular scoliosis treated with Luque-Galveston or Isola-Asher instrumentation. Patient satisfaction based on the response to the questionnaires was similar in both groups. Luque-Galveston and Isola-Asher instrumentation were comparable and equally reliable methods for surgical stabilization and correction of neuromuscular scoliosis.

Evaluation of spinal fusion using autologous anterior strut grafts and posterior instrumentation for thoracic/thoracolumbar kyphosis.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To evaluate anterior strut grafts in spinal fusion for thoracic/thoracolumbar kyphosis. SUMMARY AND BACKGROUND DATA: Autologous strut grafts harvested from the fibula, iliac crest, and rib are frequently used for treating severe kyphosis and kyphoscoliosis. However, a majority of the studies have presented mixed patient populations kyphosis and/or scoliosis, treated either with anterior or anteroposterior fusion. Very few reports have presented an evaluation of autologous strut grafts for anterior fusion with posterior instrumentation for the treatment of kyphotic deformities. METHODS: A total of 23 patients comprised the study. Diagnosis was granulomatous infection (9 patients), congenital (6), posttraumatic (4), neurofibromatosis (1), ankylosing spondylitis (1), Scheuermann disease (1), and plasmacytoma of the vertebral body with pathologic fracture (1). Average age at surgery was 41 years (range 6-77). Indication for surgery was pain with or without progression in 15 patients and additional progressive neurologic deficit in the other 8. Anterior strut grafts consisted of the autologous fibula (9 patients), iliac (10), fibula and ribs (2), fibula and iliac (1), and fibula, iliac, and ribs (1). The fusion areas were thoracic (11 patients), thoracolumbar (11), and cervicothoracic (1). Anterior decompression was performed in 8 patients because of the presence of neurologic symptoms caused by cord compression. Dorsal fusion was performed in all patients with third-generation systems. RESULTS: Average 4.2 vertebrae were fused anteriorly. Mean follow-up bracing time was 9.7 months. Average kyphosis measured 50.9 degrees before surgery and 32.5 at a mean follow-up of 4.5 years (P < 0.0001). No graft breakages were noted at final follow-up. Solid fusion was achieved in all patients. No donor site complications were observed. Of the 8 patients presenting with neurologic deficits, 4 had full recovery, 3 had partial recoveries, and 1 had no improvement. Loss of postoperative correction > 5 degrees was observed in 3 patients. At final follow-up, 3 patients complained of occasional pain, and 1 complained of pain when lying on the back, particularly on hard surfaces. CONCLUSION: Adequate correction was maintained throughout an average follow-up of 4.5 years, and solid fusion was obtained in all patients. Anterior strut grafts, supplemented with posterior fusion with instrumentation provide a good treatment alternative for the treatment of kyphosis deformity of the spine as a result of various etiologies.

Operative treatment of scoliosis with the Kaneda anterior spine system.

STUDY DESIGN: Prospective, single-cohort study. OBJECTIVE: To evaluate thoracic and thoracolumbar scoliosis using the Kaneda anterior spine dual-rod system (KASS). SUMMARY OF BACKGROUND DATA: In selected cases, anterior correction of scoliosis has several advantages over the traditional posterior instrumentation. Other than 2 primary reports by Kaneda, there are no clinical outcome reports with the KASS in the literature. METHODS: A total of 24 patients with thoracic (n = 10)/thoracolumbar (n = 14) scoliosis were corrected using the KASS. Sagittal and coronal plane radiologic parameters were evaluated before surgery, 1-year after surgery, and at final follow-up (approximately 40 months). RESULTS: Average coronal correction of the primary curve was from 61 degrees to 24 degrees (61%). Apical vertebral rotation decreased by 69%. Apical vertebral translation decreased 10-2 cm. The secondary thoracic and lumbar curves showed a spontaneous correction between 27% and 46%, respectively. Thoracic kyphosis increased 25 degrees -38 degrees (52%), lumbar lordosis showed a minimal decrease from 48 degrees to 43 degrees . Fusion was achieved in all cases. No neurovascular or implant-related problems were observed at final follow-up. CONCLUSIONS: Anterior instrumented fusion for thoracic/thoracolumbar scoliosis using the KASS is a good treatment option for idiopathic thoracic/thoracolumbar curves.

Gait improvement surgery in diplegic children: how long do the improvements last?

Gait improvement surgery in ambulatory children with cerebral palsy performed as single-event multilevel surgery is today a well-established modality of treatment, but follow-up studies are lacking. Preoperative and follow-up gait analysis data of 32 diplegic children who underwent single-event multilevel surgery for gait improvement between 1995 and 1998 were evaluated retrospectively. Relevant sagittal plane kinematic parameters of the hip, knee, and ankle joint and time-distance parameters were considered for outcome measures in this study. Postoperative gait analysis was performed three times in all the cases: after discontinuation of the dynamic AFOs (mean 1.0 +/- 0.3 years), after discontinuation of the night splints (mean 2.3 +/- 0.7 years), and at least 1.5 years after discontinuation of physiotherapy and splints (mean 4.4 +/- 1.1 years). The aim of the study was to ascertain whether the improvements in gait function were maintained over these examinations. The authors found that gait function continued to change over 1, 2, and 3 years of follow-up. A general decrease in gait function was measurable in this collective between the first postoperative and the second postoperative evaluations. The results indicate that evaluation of gait improvement surgery in cerebral palsy performed at a minimum of 3 years after surgery would give the most predictive outcome of treatment.

Modern treatment of pathological fractures in children.

Pathological fractures in children occur from a variety of causes. The clinician has to develop an individual strategy that weighs up the pros and cons of treatment, considering the bone biology and the biomechanics at the fracture site. Determining the lesional pathology is paramount, whether it is in the form of a neoplastic or non-neoplastic entity, so that bone healing can be maximized. Time-efficient protection and reconstruction of the child's musculoskeletal system is the aim of the surgeon's intervention. The whole strategy must be individualized to every situation. Combinations of diseases, fracture sites, and children are many, whereas treatment options are fewer. Options include non-operative management with observation, and intralesional resection with or without bone grafting, and with or without internal fixation. A thoughtful, disciplined, and systematic approach will be successful most often. The goals of treating a child's pathological fracture are all based on establishing a diagnosis. Only after establishing the diagnosis with certainty can a proper treatment strategy be formulated. Fracture management is then based on five points: (a) pain relief and comfort of the child; (b) achieve Local control or containment of the pathological lesion; (c) skeletal stabilization, preservation of growth, and maintain anatomical alignment; (d) fracture union; and (e) restoration of function. Maintaining perspective will facilitate optimal patient care and minimize the confounding variables that seem to plague the treatment of pathological fractures.

Tibial lengthening over nails in children using modified Ender nails: preliminary results of a new treatment.

Tibial lengthening over nails, using modified Ender nails, was performed in nine children whose mean age at surgery was 12.8 years. The prerequisite for using this technique was the absence of axial malalignment and an indication for tibial lengthening only. Lengthening was not performed in one case due to the development of a compartment syndrome after the tibial osteotomy. Breakage of one interlocking screw without loss of alignment or length was observed in one case. Superficial pin tract infections were observed in two cases. An average of 4.1 cm (range 3-4.5 cm) lengthening of the tibia was achieved in eight of the nine cases. The modified Ender nails used permitted locking at both ends after achieving the desired distraction and permitted early removal of the external fixator. The advantage of this technique is that it permits early removal of the fixator and thus decreases the incidence of fixator related problems and facilitates early rehabilitation.

Classification of equinus in ambulatory children with cerebral palsy-discrimination between dynamic tightness and fixed contracture.

In this study a generalised dynamic neural network (GDNN) was designed to process gait analysis parameters to evaluate equinus deformity in ambulatory children with cerebral palsy. The aim was to differentiate dynamic calf muscle tightness from fixed muscle contracture. Patients underwent clinical examination and had instrumented gait analysis before evaluating their equinus under anaesthesia and muscle relaxation at the time of surgery to improve gait. The performance of the clinical examination, the subjective interpretation of gait analysis results, and the application of the neural network to assess ankle function were compared to the examination under anaesthesia. Evaluation of equinus by a Neural Network showed high sensitivity and specificity values with a likelihood ratio of +14.63. The results indicate that dynamic calf muscle tightness can be differentiated from fixed calf muscle contracture with considerable precision that might facilitate clinical decision-making.

Treatment of unicameral calcaneal bone cysts in children: review of literature and results using a cannulated screw for continuous decompression of the cyst.

Nine unicameral bone cysts of the calcaneus in children were managed surgically using the technique of continuous decompression with titanium cannulated cancellous screws. The average age of the patients at surgery was 12.8 years. At follow-up a minimum of 2 years after surgery, eight cysts showed complete healing; one patient showed healing with residuals. Irritation at the screw insertion site necessitated early removal of the screw in one patient; implant-related problems were not observed in the other patients. Patients were allowed to bear weight after surgery. Implant extraction was performed after full consolidation of the cyst and was uneventful in all patients. A review of the literature and the different treatment modalities used for managing calcaneal cysts is also presented.

Treatment of femoral neck and trochanteric simple bone cysts.

INTRODUCTION: Problems associated with common treatment modalities of bone cysts located in the proximal femur include a high blood loss, infection, lack of stability, donor-site morbidity, restriction to normal activity, and high recurrence rate. MATERIALS AND METHODS: Twelve patients with a simple bone cyst of the proximal femur were treated with retrograde flexible nailing. Six showed a pathological fracture. Mean age at surgery was 10.4 years, mean follow-up was 57 months. Radiographs were classified as healed, healed with residuals, recurred, or no response. RESULTS: The mean healing period was 38.8 months. Two cysts healed completely, nine healed with residuals. There was no recurrence or non-responder. In a fractured cyst a perforation of a nail through the cyst occurred 4 months after nailing. CONCLUSION: The method is less invasive and offers early stability to the bone without the need for cast immobilization.

Medial hamstring lengthening in the presence of hip flexor tightness in spastic diplegia.

This study evaluated the effects of medial hamstring lengthening on gait in patients with diplegic cerebral palsy. A group of patients who underwent medial hamstring lengthening and distal rectus transfer was compared to a group of patients who underwent intramuscular psoas lengthening as well. Patients who underwent a psoas lengthening showed an increased anterior pelvic tilt and a tendency towards genu recurvatum, features that could indicate postoperative hamstring weakness. These results underline the importance of medial hamstrings for pelvis and knee motion in the sagittal plane during walking. In additional the limitations of the popliteal angle as a clinical measure to evaluate hamstring length in the presence of hip flexor tightness are discussed.

Effect of derotation osteotomy of the femur on hip and pelvis rotations in hemiplegic and diplegic children.

The purpose of this study was to evaluate hip and pelvis rotations in groups of hemiplegic and diplegic children before and after surgical correction of fixed internal rotation deformity of the hip. Twenty-two children with cerebral palsy (eight diplegia, 14 hemiplegia) having fixed internal rotation deformity at the hip were treated by multilevel surgery which included derotation osteotomy of the femur. Evaluation was done before and at a mean of 3.1 years after surgery using three-dimensional computerized gait analysis. Preoperatively, the patients in the hemiplegia group had a significantly greater compensatory external rotation of the pelvis than those in the diplegic group. Post-operatively there were no significant differences between the two groups. In the hemiplegia group the external rotation of the pelvis was corrected after correction of hip rotation by derotation osteotomy. Patients in the diplegia group showed significant improvements in the hip rotation with no significant change in the pelvis rotation after multilevel surgery.