Use of the Pirani score in monitoring progression of correction and in guiding indications for tenotomy in the Ponseti method: Are we coming to the same decisions?

PURPOSE: The Pirani score is widely used in the treatment of idiopathic clubfoot. Some authors recommended to base decision for Achilles tenotomy in Ponseti method on this score (hindfoot score [HFS] > 1, once reducibility of lateral head of talus (LHT) is zero) instead of originally described indications (dorsiflexion < -10-15° once complete abduction is achieved). Yet correspondence of these indications has not been evaluated. Aim of this study was to verify whether in a cohort, where decision is based on dorsiflexion, the Pirani score corresponds to the limits suggested. Secondarily, to describe temporal variation in Pirani score along treatment, which has not been previously investigated. METHODS: In a prospective study, 79 idiopathic clubfeet in 47 cases consecutively treated with Ponseti method by a single orthopaedic surgeon were evaluated at each casting session with Pirani system; score progression and scores at time of decision to perform tenotomy were determined. RESULTS: HFS and its subcomponents showed minimal improvement during subsequent sessions of casting and then rapid correction with tenotomy. Medial crease resolved rapidly. Midfoot score and its remaining subcomponents corrected gradually. Total Pirani score showed initially a progressive correction and then a more abrupt improvement with tenotomy. At the time of decision to perform tenotomy, in 8 (10.1%) of 79 cases, the decision whether or not to perform tenotomy based on dorsiflexion would have been different based on the cut-offs for Pirani score suggested. CONCLUSION: Using Pirani score in guiding indication for tenotomy may imply different decisions in a portion of cases, which should be considered when comparing series.

Intra-articular deformities of the knee in congenital hypoplasias of the lower limb: an arthroscopic study.

A knowledge of the morphology of the cruciate ligaments in congenital hypoplasias of the lower limb, susceptible to treatment to even the length discrepancy, is of practical importance in the prevention of subdislocation and dislocation of the knee during the distraction phase of femoral and/or tibial lengthening. The authors report their experience with 20 arthroscopies diagnosed in 20 children affected with congenital hypoplasia of the lower limb (shoft congenital femur, longitudinal peroneal hemimelia) performed prior to assembling the Ilizarov external fixator for femoral and/or tibial lengthening. None of the patients had congenital dislocation of the knee or knee with recurvation. In the patients in our study, it is possible to demonstrate that the anatomical cause of instability of the knee in congenital hypoplasias of the lower limb may be constituted by aplasia of one or both cruciate ligaments.

The surgical treatment of inveterate hip dislocation in children affected with cerebral palsy: a preliminary report.

The incidence of hip dislocation in patients affected with cerebral palsy is directly correlated with the degree of neurologic deficit. Surgical treatment aimed at stabilization of the coxofemoral joint relieves pain and avoids the occurrence of changes in the static of the pelvis and vertebral column. The authors report their experience with procedures for the recovery of joint congruency (release of the adductors and psoas, surgical reduction of the dislocated epiphysis, femoral shortening associated with varus-derotation at the osteotomy level, acetabuloplasty) performed in one or more surgical stages, and operations with a purely anthalgic purpose (innominate osteotomy according to Chiari), specifying relative indications in relation to age.

Fracture of the patella in children and adolescents.

Fractures of the patella in childhood and adolescence are a rare occurrence, and they are differentiated from those occurring the adult. Between 1975 and 1995, 76 cases of fracture of the patella in patients aged under 15 years were treated at our institute. A mean clinical-radiographic follow-up of 2 years was available for all of the patients; 18 patients were followed-up after a considerable amount of time (mean 18 years). After analyzing the specific features that distinguish there fractures when they affect a subject who is still growing, the authors report the results obtained and the short and long-term complications observed.

Complications in acetabuloplasty in the treatment of CHD during the growth age.

The authors analyze the complications of acetabuloplasty in the treatment of CHD during the growth age, evaluating the incidence and the possible causes, that emerged from a review of cases at the Rizzoli Orthopaedic Institute including 238 patients treated from 1970 to 1986 using different methods. The techniques adopted were: acetabuloplasty for lowering in 100 cases, Salter osteotomy in 30 cases, triple pelvic osteotomy in 48 cases and acetabuloplasty according to the Chiari method in 50 cases. Complications of various types were observed in 9.6% of the cases after a mean follow-up of 5 years. It is the purpose of ths study to discuss the complications that are observed during each operation, and to compare them with those reported in the literature, as well as to present a pathogenetic interpretation. A study of complications influences indications and surgical technique.

Arthroscopic surgery of the discoid meniscus during childhood.

A total of 43 lateral discoid menisci in 38 patients submitted to arthroscopy between 1990 and 1995 is discussed. Age ranged from 2 to 14 years. Morphological changes of the lateral meniscus were classified according to Watanabe criteria. The features of preoperative symptoms were related to the type of meniscal lesion and to the age of the patient, and the results evaluated according to the Ikeuchi scale.

Retrograde intramedullary osteosynthesis in the surgical treatment of fractures of the radial capitellum during childhood.

The authors report 12 cases of fracture of the radial capitellum occurring during childhood, treated by retrograde intramedullary osteosynthesis. Preoperative assessment involved the four-stage "prognostic-therapeutic" radiographic method proposed by Métaizeau. The results were extremely encouraging, 92% excellent and good, particularly when there were no (except in one case) severe complications (necrosis of the head, pseudarthrosis, poor consolidation, synostosis) typical of these traumatic lesions. At the same time clinical data observed, in agreement with what is reported in the literature, confirmed that the principal prognostic factors are represented by the amount of traumatic lesion, and above all by epiphyseal dislocation, the quality of reduction obtained, and the age of the patient.

Complications of varus derotation osteotomy in the treatment of CHD during growth.

Complications of varus derotation osteotomies in the treatment of congenital hip displacement (CHD) are reported. Only "true" complications were considered, that is, those related to errors in technique, while those related to errors in indications were excluded. An analysis of 150 cases with a mean follow-up of 4.2 years revealed that "true" complications are a rare occurrence. Among these the most frequent are dysmetria (20%), and infection (2.6%). There was only one case of osteochondrosis (0.6%). The dysmetria (usually under 2 cm) rarely required further surgical treatment involving temporary epiphysiodesis of the homolateral knee, while the infection responded satisfactorily to combined conservative and surgical treatment.

Mucous cysts of the external popliteal sciatic nerve during childhood: presentation of two cases and a review of the literature.

Mucous cysts of the peroneal head constitute the most frequent cause of compression of the external popliteal sciatic nerve (EPS). Depending on the site in which it occurs, we distinguish between intranervous cysts, which are very rare, and extranervous ones, which are more frequent. The two varieties, which constitute anatomical variants of the same lesion and, probably, of a metaplasia of the connective tissue, are, from an anatomical point of view, true cysts, with their own connective walls, endothelial covering, and mucoid contents. Clinically, there is pain, paresthesia, a palpable mass, and motor deficit, all occurring at an early stage of the disease, depending on its site and size. At times, when there is no palpable mass, there may be problems with differential diagnosis with regard to disc compression. Ultrasound examination, electromyography, and, above all, MRI, have all proven to be useful in the study of the features of the neoformation; nonetheless, in our experience, they were not able to reveal either intra- or extranervous localization.

The external fixator in the treatment of closed diaphyseal fractures of the lower limb during childhood. Indications and limits.

The authors successfully used an external fixator in 10 children affected by one of the following pathologies: fracture of the femur with poor consolidation and marked shortening of the limb; fracture in a hypoplastic segment; severe multiple trauma; delay in consolidation of pathologic bone; fracture in bone regeneration. On the basis of the results obtained, it is affirmed that the external fixator is the ideal means of osteosynthesis for use in any of the above-described situations.

Critical review of infantile fibrous dysplasia: surgical treatment.

A critical review of the surgical treatment of 65 patients with infantile fibrous dysplasia demonstrated that "circumscribed" types of the disease generally do not require surgical treatment, while "extended" types, as well as Albright's syndrome, require early surgical treatment aimed at preventing development of skeletal deformities which are difficult to correct later. Prophylactic intramedullary nailing with nails of suitable caliber is most effective.

The correction of valgus knee by temporary epiphyseal stapling.

Unilateral temporary epiphysiodesis with Blount staples is a surgical method used to gradually correct axial deviations of the knee, slowing down the growth of one side of the conjugate cartilage. The authors analyse the results obtained with this method in the treatment of infantile valgus knee, in an attempt to determine an average monthly value of angular correction, based on which it is possible to plan the best time to perform this type of surgery. They affirm the effectiveness of the procedure, the success of which nonetheless appears to be related to the correct choice of the site of application and the number of staples used.

The Steindler method in the treatment of paralytic elbow flexion.

Based on an average follow-up of 8.6 years, the authors analyse the functional results obtained in 16 patients submitted to Steindler flexoroplasty of the elbow between 1975 and 1986. The absence of active flexion of the elbow produces a severe deficit in the upper limb even when there is good function of the shoulder and hand. Since 1921, the year in which Steindler published a report on his surgical method, numerous surgical methods have been described for the treatment of paralytic elbow. Clark (1946), Merle d'Aubigné et al. (1956), Brook and Sendon (1959) propose transposing pectoralis major by suturing it to the tendon of the biceps muscle. Le Coeur (1953) instead isolates pectoralis minor and then transposes it on the biceps tendon. Bunnel (1951) describes two methods: the first consists in isolating the sternocleidomastoid by lengthening it with the fascia lata and inserting it into the tendon of the biceps, the second proposes anteriorly transposing the distal triceps tendon. Hovnanian (1956) and Zancolli and Mitré (1973) transpose the latissimus dorsi by inserting it distally on the distal biceps tendon, while Axer et al. (1973) transpose part of the same muscle. It is the purpose of this study to report the experience obtained using the Steindler method in 22 patients affected with paralysis of the flexor muscles of the elbow.

Arthroscopic surgical technique in the treatment of lesions of the discoid meniscus.

The authors analyse the results which emerged from a long-term follow-up of 15 patients affected with lesions of the discoid meniscus treated arthroscopically, by expressing both a subjective and an objective evaluation and emphasizing several details concerning the surgical method used.