The Vascularized Fibula as Salvage Procedure in Extremity Reconstruction: A Retrospective Analysis of Time to Heal and Possible Confounders.

The vascularized fibula transfer is a well-established technique for extremity reconstruction, but operative planning and patient selection remains crucial. Although recently developed techniques for bone reconstruction, such as bone segment transfer, are becoming increasingly popular, bone defects may still require vascularized bone grafts under certain circumstances. In this study, 41 cases, 28 (68%) men and 13 (32%) women (median age: 40 years), were retrospectively analyzed. Therapy-specific data (flap vascularity [free vs. pedicled] size in cm and configuration [single- vs. double-barrel], mode of fixation [internal/external]) and potential risk factors were ascertained. Indications for reconstruction were osteomyelitis at host site (n = 23, 55%), pseudarthrosis (n = 8, 20%), congenital deformity (n = 6, 15%), traumatic defect, and giant cell tumor of the bone (n = 2, 5% each). Complete healing occurred in 34 (83%) patients after a median time of 6 months. Confounders for prolonged healing were female gender (p = 0.002), reconstruction in the lower limb (p = 0.011), smoking (p = 0.049), and the use of an external fixator (p = 0.009). Six (15%) patients required secondary limb amputation due to reconstruction failure, and one patient had persistent pseudarthrosis at last follow-up. The only risk factor for amputation assessed via logistic regression analysis was preexisting PAOD (peripheral artery occlusive disease; p = 0.008) The free fibula is a reliable tool for extremity reconstruction in various cases, but time to full osseous integration may exceed six months. Patients should be encouraged to cease smoking as it is a modifiable risk factor.

Radiographic early to midterm results of distraction osteogenesis in radial longitudinal deficiency.

PURPOSE: To analyze early to midterm radiographic results after forearm lengthening in children with radial longitudinal deficiency. METHODS: We conducted a retrospective chart review of patients with radial longitudinal deficiency undergoing distraction osteogenesis with an Ilizarov device. We retrospectively reviewed 8 lengthening procedures in 6 children with respect to distraction details and assessed anteroposterior and lateral radiographs of the hand and forearm of the preoperative and postoperative follow-up investigations. RESULTS: The mean age at time of ulna lengthening was 9.9 years (range, 6.3-14.0 y). The mean follow-up period was 4.7 years (range, 1.0-8.5 y). Mean lengthening of the ulna was 7.0 cm (range, 3.5-8.7 cm), and the mean length gain of the ulna compared with its preoperative length was 75% (range, 42% to 103%). The mean ulna bowing was 25° preoperatively (range, 7° to 42°), 6° after forearm distraction (range, 0° to 14°), and 17° at latest follow-up (range, 0° to 45°). The mean hand-forearm angle was 25° of radial deviation preoperatively (range, 15° ulnar to 60° radial deviation), 11° of radial deviation after distraction (range, 0° to 41°), and 23° at latest follow-up (range, 0° to 45°). We encountered 2 major complications: 1 ulna fracture after removal of the Ilizarov device and 1 insufficient bone regenerate during lengthening. CONCLUSIONS: We achieved both deformity correction and improvement of limb length after distraction osteogenesis with an Ilizarov device. However, some of the deformity-in particular, ulnar bowing and radial deviation of the hand-recurred at midterm follow-up.

Extracorporeal shockwave therapy in calcifying tendinitis of the shoulder.

PURPOSE: Strategies for extracorporeal shockwave therapy in calcifying tendinitis of the rotator cuff vary concerning quantity of sessions and doses. The purpose of this prospective pilot study was to determine the difference between the outcome of a single high-dosage extracorporeal shockwave therapy and two sessions of low-dosage extracorporeal shockwave therapy. METHODS: This study compared a single high-level middle-energetic extracorporeal shockwave therapy (0.3 mJ/mm(2)) with a low-level middle-energetic extracorporeal shockwave therapy applied twice in a weekly interval (0.2 mJ/mm(2)). Thirty patients that suffered from calcifying tendinitis for at least 6 months received navigated, fluoroscopy-guided extracorporeal shockwave therapy. The gain of Constant Murley Score, Visual Analogue Scale during state of rest and weight-bearing situations ("stress") and radiographic progress was documented 6 and 12 weeks after therapy. RESULTS: In both groups, a significant reduction in pain during stress and improvement of function was observed. In contrast, no significant reduction in pain during rest was observed. No significant difference between both groups concerning reduction in the calcific deposit after 6 weeks was detected. Group B showed minor advantages in radiographical improvement after 12 weeks. In 36% of the patients, the calcific deposit completely dissoluted after 12 weeks. CONCLUSIONS: This pilot study indicates that a single high-level extracorporeal shockwave therapy may be as effective as two applications of a lower-dosed extracorporeal shockwave therapy for calcifying tendinitis. An effective single-session strategy could reduce treatment time, material costs and healthcare expenses and ionizing radiation in case of fluoroscopy guidance.

Professional awareness is needed to distinguish between child physical abuse from other disorders that can mimic signs of abuse (Skull base sclerosis in infant manifesting features of infantile cortical hyperostosis): a case report and review of the literature.

BACKGROUND: Infantile cortical hyperostosis is characterised by hyperirritability, acute inflammation of soft tissue, and profound alterations of the shape and structure of the underlying bones, particularly the long bones, mandible, clavicles, or ribs. CASE PRESENTATION: We report on a clinical case of a 3-months-old baby girl of non-consanguineous parents. Multiple long bone swellings were the motive of referral to our department for clinical evaluation. Radiographic documentation was consistent with infantile cortical hyperostosis (Caffey disease). Interestingly, skull base sclerosis associated with excessive thickening was the most unusual malformation. We report a baby with mixed endochondral and intramembraneous ossification defects. CONCLUSION: Bone dysplasias, mucopolysaccharidoses, and metabolic diseases are a group of disorders that cause abnormal growth, density, and skull base shape. Skull base sclerosis/thickening is a well-known malformation in connection with other forms of sclerosing bone disorders such as dysosteosclerosis, frontometaphyseal dysplasia, and progressive diaphyseal dysplasia with skull base involvement. It is noteworthy that our present patient had an unusually sclerosed/thickened skull base. Narrowing of skull foramina due to sclerosis of skull base is likely to result in cranial nerves deficits. In this baby, the pathology has been judged to be the result of child abuse and it is not, in this case considerable harm to his parents, and the doctor-parent relationship was the outcome.

Deformity correction in children with hereditary hypophosphatemic rickets.

UNLABELLED: X-linked hereditary hypophosphatemic rickets can induce various multiplanar deformities of the lower limb. We evaluated our ability to correct these deformities and assessed complications and recurrence rates in 10 children (eight girls and a pair of twin boys) followed from early childhood to skeletal maturity. We performed 37 corrective operations in 10 children. Depending on the patient's age, external fixation was used in 53 segments: Kirschner wires in 18, DynaFix in three, the Taylor Spatial Frame device in 13, and the Ilizarov device in 19. Internal fixation with intramedullary nailing was performed in 12. After bone consolidation, we radiographically determined the mechanical axis at an average distance of 0.5 cm medial to the center of the knee. The average mechanical lateral distal femoral angle was 85 degrees (range, 83 degrees-92 degrees) and the average mechanical medial proximal tibial angle was 91 degrees (range, 85 degrees-92 degrees). Deviation of the mechanical axis and knee orientation lines was increased at the followups conducted during a period of 5 to 12 months. Additional followups revealed a recurrence rate of 90% after the first corrective procedure and 60% after a second procedure. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Accuracy of complex lower-limb deformity correction with external fixation: a comparison of the Taylor Spatial Frame with the Ilizarov ring fixator.

PURPOSE: Circular external fixators have several advantages over other surgical options in the treatment of limb length discrepancy and axial deformity. The innovative Taylor Spatial Frame (TSF) combines a rigid hexapod fixation system with the support of a web-based software program, and thus offers the possibility of simultaneous corrections of multidirectional deformities. Whilst there is still some scepticism of many Ilizarov device users about the advantages of the TSF, the purpose of the study was to perform a comparison between the TSF and the Ilizarov ring fixator (IRF) with regard to the accuracy of deformity correction in the lower limb. METHODS: Two hundred and eight consecutive deformity corrections in 155 patients were retrospectively evaluated. There were 79 cases treated with the IRF and 129 cases treated with the TSF. The mean age of the patients at the time of surgery was 13.2 years (range; 2-49 years). Standing anteroposterior and lateral radiographs were evaluated preoperatively and immediately after removal of the frames. The final result was compared to the preoperatively defined aim of the deformity correction. According to the treated count of dimensions, we differentiated four types of deformity corrections. The results were graded into four groups based on the persisting axial deviation after removal of the frame. RESULTS: The aim of the deformity correction was achieved in a total of 90.7% in the TSF group, compared to 55.7% in the IRF group. On the basis of the count of dimensions, the TSF achieved obviously higher percentages of excellent results (one dimension: TSF 100%; IRF 79.3%; two dimensions: TSF 91.8%; IRF 48.6%; three dimensions: TSF 91.1%; IRF 28.6%; four dimensions: TSF 66.7%; IRF 0%). In addition, the degree of the persisting deformity increased with the number of planes of the deformity correction. CONCLUSIONS: The TSF allowed for much higher precision in deformity correction compared to the IRF. In two-, three- and four-dimensional deformity corrections in particular, the TSF showed clear advantages. This may derive from the TSF-specific combination of a hexapod fixator with the support of an Internet-based software program, enabling precise simultaneous multiplanar deformity corrections.

MRI-controlled analysis of 104 patients with painful bone marrow edema in different joint localizations treated with the prostacyclin analogue iloprost.

BACKGROUND: Bone marrow edema (BME) is a common cause of pain of the musculoskeletal system. The aim of the study was to assess the efficacy of iloprost in the treatment of BME of different localizations and etiologies. PATIENTS AND METHODS: We reviewed 104 patients (54 male, 50 female) with BME. Their mean age was 52.8 +/- 14.7 years. BME was located 50 times in the knee, 19 times in the talus, 18 times in the femoral head and 17 times in other bones. Patients were allocated to three distinct etiological groups: 27 cases were estimated to have idiopathic BME, 16 post-traumatic BME and the other 61 BME secondary to activated osteoarthritis or mechanical stress. Therapy consisted of a series of five iloprost infusions with either 20, 25 or 50 microg of iloprost given over 6 hours on 5 consecutive days each. RESULTS: At the clinical follow-up four months after therapy, the pain level of the 104 patients at rest had diminished by a mean of 73% (p<0.0001): 64% of patients reported a reduction, 34% no change and 2% an increase in pain at rest. Pain under stress decreased by a mean of 59%, (p<0.0001): 76% of patients had less pain during activity, 22% no change from baseline and 2% an increased pain level. On MRI, 65% had significant reduction of BME size or complete normalization and 20% showed no change. Worsening of the MRI pattern was found in 2%. 13% were lost to MRI follow-up. Side effects were significantly reduced by lowering the daily dose from 50 to 20 microg, without impairment of therapeutic effect. CONCLUSION: The authors conclude that the use of parenteral iloprost might be a viable method in the treatment of BME of different etiologies.

Bone marrow edema syndrome of the femoral head: treatment with the prostacyclin analogue iloprost vs. core decompression: an MRI-controlled study.

BACKGROUND: The purpose of this study was to assess the efficacy of the vasoactive drug iloprost in Bone Marrow Edema Syndrome (BMES) and to compare it to the results of a control group treated by core decompression. PATIENTS AND METHODS: 38 hips (36 patients) with BMES in the femoral head were investigated. In group A, 18 hips (17 patients; mean age 49 years) were treated with iloprost, a vasoactive drug that dilates arterioles and venules, reduces capillary permeability and suppresses platelet aggregation. The therapy comprised a series of five infusions with 20 microg iloprost over 6 hours on 5 consecutive days. Weight bearing was reduced for up to 3 weeks, depending on the severity of symptoms. In group B, 20 hips (19 patients; mean age 41 years) underwent surgical core decompression of the femoral head followed by 6 weeks of partial weight bearing. Both groups were evaluated clinically, radiographically and by MRI. RESULTS: In group A, one patient had to discontinue therapy on the first day because of severe headache. In the remaining patients the Harris Hip Score (HHS) improved from a mean of 64.7 points (range 44-89) before therapy to 97.0 points (83-100) after 3 months. MRI controls showed complete remission in all hips. In group B, the preoperative HHS improved from 53.7 points (31-82) to 95.1 points (39-100) after 3 months. MRI controls showed complete remission of BMES in 14 hips, residual focal bone marrow edema in four hips and a small osteonecrotic area in two hips. In both groups the high level of clinical recovery was maintained at the last examination after a mean follow up of 11 months in group A and 12 months in group B. CONCLUSION: The parenteral application of iloprost can achieve equal or better results in the treatment of bone marrow edema syndrome of the hip compared to core decompression.

Treatment options for developmental dislocation of the hip after walking age.

Cases of developmental dislocation of the hip occur after walking age because of late or missed diagnosis and failed conservative or operative treatment. Although a general consensus exists for the treatment in infants up to the age of 18 months, the recommendations for the treatment of developmental dislocation of the hip in older children range from conservative treatment up to 3 years of age to primary surgical procedures from the age of 18 months. A review of the pertinent literature and of the different treatment options was performed and the authors' preferred treatment regime and techniques for the operative treatment of developmental dislocation of the hip after walking age are reported.

Ligament reconstruction with or without tendon interposition to treat primary thumb carpometacarpal osteoarthritis. Surgical technique.

BACKGROUND: Trapezial excision with ligament reconstruction and trapezial excision with ligament reconstruction combined with tendon interposition have proven to be highly effective techniques for treating primary osteoarthritis of the thumb carpometacarpal joint. To determine whether tendon interposition and proximal migration of the thumb metacarpal affect the objective and subjective outcomes, we compared the long-term outcomes of these two procedures performed in similar patient groups. METHODS: Forty-three patients (fifty-two thumbs) were randomized to undergo either trapezial excision with ligament reconstruction or the same procedure combined with tendon interposition. Fifteen patients treated with ligament reconstruction (group I) and sixteen patients treated with the same procedure with concomitant tendon interposition (group II) were evaluated after a mean follow-up period of 48.2 months. The outcomes were assessed with the Buck-Gramcko score, with the total score calculated on the basis of the objective and subjective results. The ability to perform activities requiring use of the thumb and to return to work was analyzed as well. Radiographs were evaluated to determine the amount of proximal metacarpal migration at rest and under stress. RESULTS: Postoperatively, the mean total Buck-Gramcko score was rated as excellent in group I and as good in group II (p = 0.036). Group I had significantly better mean scores for palmar and radial abduction, cosmetic appearance, and willingness to undergo the surgery again under similar circumstances (p < 0.05). The mean scores for tip-pinch strength and the mean subjective scores for pain, strength, daily function, dexterity, and overall satisfaction did not differ significantly between the groups. Both groups had satisfactory results with regard to their performance of activities of daily living and their ability to return to work. With the numbers available, the amount of proximal metacarpal migration, at rest and under stress, did not differ significantly between the groups. CONCLUSIONS: Tendon interposition does not affect the outcome after the ligament reconstruction for the treatment of osteoarthritis of the thumb carpometacarpal joint. Furthermore, proximal migration of the thumb metacarpal does not appear to influence the functional outcome.

Pharmacological management of aseptic osteonecrosis in children.

Aseptic osteonecrosis (AON) in children can progress during ossification of cartilage in periods of increased growth or excessive physical stain and may occur in various locations in the skeleton. Disturbance of blood supply to the bone has been suggested as the main pathological mechanism involved in AON, which is characterised by the death of bone marrow and trabecular bone. The extent and development of osteonecrosis and the duration of disease until restorative healing, depend on the formation of new blood vessels, the spreading of vessels in the affected bony areas, the absorption of osteonecrotic tissue and the structure of new bone. Conservative and operative treatment options for AON vary according to the location and development of the disease and the age of the patient. The goal of all treatment options currently used today is to achieve relief of physical load in the affected bone and to promote and regulate blood supply. Treatment should be started early in order to minimise the extent of osteonecrosis and allow restorative healing. As the processes of myelopoiesis, myelophthisis and fracture healing become more clear, interest has focused on advances in the utilisation of bioactive factors to salvage bone in children affected by AON. Such methods include the use of osteoinductive agents, such as cytokines and bone morphogenetic proteins, as well as factors that stimulate angiogenesis and regulate blood supply. Currently, the prostacyclin analogue, iloprost (Ilomedin, Schering AG), has been successfully used in a pilot study in children suffering from early stages of AON.

Ligament reconstruction with or without tendon interposition to treat primary thumb carpometacarpal osteoarthritis. A prospective randomized study.

BACKGROUND: Trapezial excision with ligament reconstruction and trapezial excision with ligament reconstruction combined with tendon interposition have proven to be highly effective techniques for treating primary osteoarthritis of the thumb carpometacarpal joint. To determine whether tendon interposition and proximal migration of the thumb metacarpal affect the objective and subjective outcomes, we compared the long-term outcomes of these two procedures performed in similar patient groups. METHODS: Forty-three patients (fifty-two thumbs) were randomized to undergo either trapezial excision with ligament reconstruction or the same procedure combined with tendon interposition. Fifteen patients treated with ligament reconstruction (group I) and sixteen patients treated with the same procedure with concomitant tendon interposition (group II) were evaluated after a mean follow-up period of 48.2 months. The outcomes were assessed with the Buck-Gramcko score, with the total score calculated on the basis of the objective and subjective results. The ability to perform activities requiring use of the thumb and to return to work was analyzed as well. Radiographs were evaluated to determine the amount of proximal metacarpal migration at rest and under stress. RESULTS: Postoperatively, the mean total Buck-Gramcko score was rated as excellent in group I and as good in group II (p = 0.036). Group I had significantly better mean scores for palmar and radial abduction, cosmetic appearance, and willingness to undergo the surgery again under similar circumstances (p < 0.05). The mean scores for tip-pinch strength and the mean subjective scores for pain, strength, daily function, dexterity, and overall satisfaction did not differ significantly between the groups. Both groups had satisfactory results with regard to their performance of activities of daily living and their ability to return to work. With the numbers available, the amount of proximal metacarpal migration, at rest and under stress, did not differ significantly between the groups. CONCLUSIONS: Tendon interposition does not affect the outcome after the ligament reconstruction for the treatment of osteoarthritis of the thumb carpometacarpal joint. Furthermore, proximal migration of the thumb metacarpal does not appear to influence the functional outcome.