Does Prolonged Weight Relief Increase the Chances of a Favourable Outcome After Containment for Perthes Disease?

We have been treating children with Legg-Calvé-Perthes disease (LCPD) with a femoral varus osteotomy (PFVO) and weight relief till the disease evolves to the latter part of the stage of reconstitution (Stage IIIb). This entails weight relief for 18 to 24 months. We undertook this case-control study to test if a shorter period of weight relief would compromise the chance of retaining the spherical shape of the femoral head when the disease healed. Forty-one children diagnosed in the early stages of LCPD (Stages Ia, Ib, and IIa), were treated by PFVO and non-weight-bearing for a period of 6 months following surgery (6m group). Eighty-two children with LCPD matched for age, sex, and stage at surgery, who resumed weight-bearing only once they reached Stage IIIb, served as the control group (3b group). Both groups were followed up till the disease healed. The sphericity deviation score was calculated, and the height and width of the epiphysis were measured on the first radiograph designated as Stage IV. The median sphericity deviation score value at healing was 3 in the 3b group and 11 in the 6m group (P<0.001). The frequency of spherical heads was 76% in the 3b group and 49% in the 6m group (P<0.003). The Odds Ratio of the disease healing with an aspherical head in 6-month group was 3.05 (CI: 1.28 to 7.22) compared with the 3b group. The percentage increase in width of the femoral epiphysis at healing was greater in the 6 group (111.5±8.5% vs. 106.5±7.2%; P<0.001). The study confirms that containment by PFVO performed early in the course of LCPD combined with weight relief till the disease has evolved to Stage IIIb is likely to result in spherical hips in 75% of children. Reducing the period of weight relief to 6 months may yield significantly poorer results with only 49% spherical femoral heads.

An unusual presentation, novel treatment with Meropenem PMMA beads and complications of Klebsiella osteomyelitis in a healthy adult- A case report.

Osteomyelitis caused by Klebsiella Pneumoniae in a healthy adult person is rare. We present an unusual case of Klebsiella Pneumoniae osteomyelitis of both femurs in an immunocompetent adult. The infection was resistant to local debridement and got complicated with pathological fracture, ultimately leading to infected non-union. The challenges faced in the management of sequential complications while treating this atypical osteomyelitis are discussed. Unusual presentation of femur osteomyelitis due to Klebsiella pneumonia can happen in a healthy adult. The Meropenem PMMA beads can be valuable for treating Klebsiella osteomyelitis. Staged procedures might be helpful to improve the condition.

Slipped capital femoral epiphysis in a healed Perthes hip.

Perthes disease and slipped capital femoral epiphysis (SCFE) in the same child is a rare occurrence. A 7-year-old boy with the left hip Perthes' disease was managed with femur osteotomy. The femur head healed with a spherical congruent hip. After 3 years, he developed right tibia vara which was treated with growth modulation. The deformity was corrected after one and a half years. At age of 15 years, he presented with left side painful limp and typical features of SCFE. The left hip was managed with modified Dunn's osteotomy. The hip range of movements was painless and near-normal range at final follow-up. Though this is the first case of ipsilateral SCFE following healed Perthes in a non-syndromic child, one must always consider SCFE in adolescents with hip or knee pain or altered gait, even if they have had other conditions like Perthes disease in the past.

Surgical management of the congenital dislocation of the knee and hip in children presented after six months of age.

PURPOSE: Congenital dislocation of the knee and hip is a rare congenital disorder. The specific aim of the study was to evaluate the clinical and radiological outcomes of the children with congenital dislocation of the knee and hip who presented after six months of age. METHODS: All the consecutive children with congenital dislocation of the knee and hip joints were retrospectively reviewed. We included cases that were treated after six months of age and followed up for a minimum of two years. Twenty-four children with congenital dislocation of the knee and hip (thirteen with ligamentous laxity, eleven children with stiff joints) were included. The knee was dislocated in 45 limbs; the hip was dislocated in 40 instances. The knee joint dislocation was treated with quadricepsplasty in all twenty-four children (45 knees). The hip dislocation (n = 32) was addressed with either closed reduction (n = 8) or open reduction of the hip (n = 24). Eight hip dislocations were not addressed. The outcome of the hip and knee was evaluated. RESULTS: The clinical and radiological outcomes were better in children with ligamentous laxity than without laxity. Twenty-two children were community walkers. An orthosis was needed in eight children. The frequency of spontaneous reduction of unreduced dislocation of the hip was noted in three children (5/8 hips). CONCLUSION: Outcome in combined dislocation of knee and hip is good in most cases with surgical interventions. The outcome is better in children with ligamentous laxity. Spontaneous reduction of the dislocated hips might be achieved after gaining knee flexion following knee surgery for congenital the knee in a few cases.

Orthopedic manifestation as the presenting symptom of acute lymphoblastic leukemia.

INTRODUCTION: The diagnosis of Acute lymphoblastic leukemia (ALL) is delayed due to vague presentation and normal hematological investigations. OBJECTIVE: The objectives were to identify the frequency of ALL cases presented to the orthopedic department and with normal hematological investigations. MATERIAL AND METHODS: 250 consecutive ALL cases were retrospectively evaluated to identify cases with musculoskeletal manifestations, and laboratory investigations. RESULTS: Twenty-two patients (4- vertebral compression fractures, 12- joint pain, 6- bone pain), presented primarily to the orthopedic department. Six patients had a normal peripheral smear. CONCLUSION: The primary physician should maintain a high index of suspicion despite a normal peripheral smear.

Does the timing of treatment affect complications of pediatric femoral neck fractures?

OBJECTIVES: Pediatric femoral neck fractures were reviewed to compare complications with the time of presentation. METHODS: 34 pediatric femoral neck fractures were studied to detect union time, avascular necrosis, premature physis fusion, and the neck-shaft angle. All complications were comparable between both groups. RESULTS: The mean union time was more in late presented group. Four children developed AVN. The neck shaft angle and pre mature fusion of growth plate were same in both groups. CONCLUSIONS: The frequency of the complications except union time in pediatric neck femur fracture is comparable in early and late presented groups.

Evolution of Legg-Calvé-Perthes disease following proximal femoral varus osteotomy performed in the avascular necrosis stage:a prospective study.

PURPOSE: This prospective study was undertaken to describe patterns of fragmentation of the femoral epiphysis following a proximal femoral varus osteotomy (PFVO) done during stage I of LCPD and to assess the disease duration and outcome in each pattern. METHODS: A total of 25 children treated by a PFVO in stage I of LCPD were followed until healing. The MRI Perfusion Index, radiographic changes in the femoral epiphysis, disease duration and the Sphericity Deviation Score (SDS) at healing were documented. The reproducibility of classification of the pattern of fragmentation, estimation of disease duration and SDS were assessed. The duration of the disease and SDS in the patterns of fragmentation were compared. RESULTS: Four patterns of fragmentation were noted, namely, typical fragmentation, bypassing fragmentation, abortive fragmentation and atypical fragmentation with horizontal fissuring. The reproducibility of classifying the pattern of fragmentation was moderate (Kappa: 0.48) while the reproducibility of other continuous variables was excellent. The Perfusion Index was less than 50% in every affected hip. The duration of the disease and SDS were lowest in children in whom the stage of fragmentation was bypassed but these differences were not statistically significant. CONCLUSION: Following a proximal femoral osteotomy during stage I of LCPD the fragmentation stage may be bypassed partially or completely and the chances of a good outcome appear to be very good if fragmentation is bypassed. LEVEL OF EVIDENCE: Level II Prognostic Study.

Unusual case of hereditary multiple exostoses presenting with compressive myelopathy.

A 15-year-old boy presented with progressive weakness of both lower limbs. He had classical clinical features suggestive of multiple hereditary exostoses (MHE). Imaging studies of the spine revealed osteochondromas at D7, D11 and L5 vertebrae. The tumour at D11 was encroaching into the spinal canal and causing cord compression. The patient underwent osteochondroma excision and posterior spinal stabilisation, following which there was complete neurological recovery by 3 months.

A Rare Presentation of Cervical Spine Osteochondroma.

INTRODUCTION: Cervical spine osteochondromas are rare tumors that usually involve the posterior spinal elements. Osteochondromas of the cervical spine presenting anteriorly as a mass over the supraclavicular region has not been reported in the literature. CASE REPORT: A 12-year-old boy presented with right sided supraclavicular swelling. Plain radiographs revealed a bony mass. Computerized tomography (CT) and magnetic resonance imaging scans of the cervical region showed a bony mass arising from pedicle and encroaching onto lamina of C6 vertebra. He underwent excision biopsy of the mass through an anterior approach. The histopathological diagnosis was osteochondroma. At 4-year follow-up, he was asymptomatic and CT scan revealed no recurrence. CONCLUSION: Tumors arising from the posterior elements are difficult to diagnose by plain radiographs alone and require special imaging modalities to show their exact location, nature, and extent.