Treatment of chronic osteomyelitis with antibiotic-impregnated polymethyl methacrylate (PMMA) - the Cierny approach: is the second stage necessary?

BACKGROUND: Chronic osteomyelitis is a challenge for orthopedic surgeons. Most patients with osteomyelitis receive two-stage management according to Cierny-Mader. The first stage includes radical debridement and insertion of an antibiotic-impregnated cement spacer (ACS) (beads, rods, nails, or blocks) into the bone defect. The second stage is performed 6-8 weeks later, when the spacer is removed and a cancellous autograft is placed within the bone defect. The possibility of ACS as definitive management for osteomyelitis, avoiding the second stage, is presented. METHODS: Sixteen patients with osteomyelitis received radical debridement and insertion of an ACS in all forms into the bone defect as a definitive management. In 8 patients, the tibia was infected, 4 had femur infection, 2 humerus, 1 fibula, and 1 ankle. The mean age at the time of the first stage of reconstruction was 49 years (range, 13-71 years). According to the Cierny-Mader classification, 1 patient was C-M IA, another was IB, 7 IIIA, 6 IIIB, and 1 was 4A. All B hosts had systemic illnesses. The mean follow-up period was 6 years (1.5-16 years). RESULTS: No patient exhibited radiographic evidence of excessive bone loss. Signs of recurrence of osteomyelitis were not noted in any of the patients, and no fractures had occurred by the last follow-up. CONCLUSION: Our study suggests that a proportion of patients with planned retention of ACS appear to function well without requiring further surgical intervention, especially in elderly or vulnerable patients.

Pediatric Femoral Neck Fractures after Sliding in a Water Slide: A Case Report of Two Patients.

INTRODUCTION: In contrast to adults, fractures of the neck of femur in children are relatively rare. The commonly described mechanism of injury is high energy trauma. Treatment options are almost always surgical. Prognosis, which entails relatively high rates of complications, varies with specific anatomic location, time to surgery, and reduction quality. CASE REPORT: We describe two cases of 10- and 12-year-old girls who suffered a fracture of the neck of the femur, Delbet Type II and Type III, respectively, due to a suspected hyper-abduction injury while sliding on a water slide. Both patients were treated surgically, with the younger one developing signs of femoral head avascular necrosis a year postoperatively. CONCLUSION: Children with pain and an inability to bear weight after water sliding together with an adult companion at their backs should raise suspicion among medical staff of a femoral neck fracture. Prompt pediatric orthopedic consultation and treatment are needed in case of fracture diagnosis to reduce the risk of complications.

The Paley ilioischial limb modification of the Dega osteotomy.

Background: We aim to describe a modified Dega osteotomy technique in detail, emphasizing its eventual advantages in comparison to the original Dega osteotomy and 'San Diego' modification. We also present our related literature review on various osteotomy techniques. Methods: We reviewed the radiological indices of 27 dysplastic hips in 25 children with cerebral palsy and developmental dislocation of the hips (9 boys, 16 girls; mean age, 5 years) who underwent a modified Dega osteotomy according to Paley. Results: Comparing the radiological indices results between our patients and those reported by the various authors in the literature, the data are almost identical. Conclusions: The modified Dega osteotomy is the only technique wherein all two limbs of the triradiate cartilage are true, which becomes a single hinge where the osteotomy turns. Despite the similar results in the radiological indices between our patients and those in the literature, we still consider that the entire triradiate cartilage is a better hinge point for the iliac osteotomy. The difference between the osteotomy adopted in our institution and the modality described by most authors in the literature is that the latter mostly ignore or miss the ischial limb of the triradiate cartilage.

Autologous cell-coated particles for the treatment of segmental bone defects-a new cell therapy approach.

BACKGROUND: Adipose tissue-derived mesenchymal stem cells (AT-MSCs) are one of the most potent adult stem cells, capable of differentiating into bone, cartilage, adipose, muscle, and others. An innovative autologous AT-MSC-derived cell-based product (BonoFill-II) for bone tissue regeneration was developed to be suited as a bone graft for segmental bone defects. METHODS: BonoFill-II was transplanted into 8 sheep with 3.2-cm full cortex segmental defect formed in the tibia. Bone regeneration was followed by X-ray radiographs for 12 weeks. At experiment termination, the healed tibia bones were analyzed by computed tomography, histology, and mechanical tests. RESULTS: Our results indicate that one dose of BonoFill-II injectable formula led to an extensive bone growth within the transplantation site and to a complete closure of the critical gap in the sheep's tibia in a relatively short time (8-12 weeks), with no inflammation and no other signs of graft rejection. This new and innovative product opens new prospects for the treatment of long bone defects. CONCLUSIONS: Injection of BonoFill-II (an innovative autologous cell therapy product for bone tissue regeneration) into a critical size segmental defect model (3.2 cm), generated in the sheep tibia, achieved full bridging of the gap in an extremely short period (8-12 weeks).

Fixator-Assisted Plating in Pediatric Supracondylar Femur Fractures.

Purpose. Pediatric femoral supracondylar fractures are difficult to reduce by either closed or open reduction. The abnormal muscle forces around the knee tend to significantly displace the distal short metaphyseal fragment. We describe a novel technique utilizing the combination of a temporarily intraoperative external fixation in order to achieve and maintain the reduction followed by internal fixation. Method. Three male patients younger than 16 years of age were operated in our department. The fractures were defined as pathological in 2 patients. In order to facilitate and maintain fracture reduction, an external fixator was temporarily used intraoperatively; once the fractures were internally fixed, the fixator was removed. Results. Anatomical reduction was achieved in all patients. In an average follow-up of 2 years, all the fractures are solidly healed and the various bone lesions are healing. All patients have returned to regular physical activity. Conclusion. Difficult supracondylar femur fractures in children are easier to manipulate and reduce with the assistance of an intraoperative external fixator. Once the fracture is internally fixed and stable, the external fixator is removed.

Tardy Ulnar Nerve Palsy.

Tardy ulnar nerve palsy is a chronic clinical condition characterized by a delayed onset ulnar neuropathy after an injury to the elbow. Typically, tardy ulnar nerve palsy occurs as a consequence of nonunion of pediatric lateral condyle fractures at the elbow, which eventually lead to a cubitus valgus deformity. While the child grows, the deformity worsens and the ulnar nerve is gradually stretched until classic symptoms of ulnar nerve neuropathy appear. Other childhood elbow trauma has also been associated with tardy ulnar nerve palsy, including supracondylar fractures resulting in cubitus varus, fractures of the medial condyle and of the olecranon, as well as radial head or Monteggia fractures/dislocation, with or without deformity. The clinical assessment includes obtaining a complete history, physical examination, nerve conduction tests, and elbow imaging studies. Treatment consists of ulnar nerve decompression, with or without corrective osteotomy, with overall successful results usually achieved.

Intermediate to Long-term Results of Femoral Neck Lengthening (Morscher Osteotomy).

BACKGROUND: Femoral neck lengthening and transfer of the greater trochanter were introduced by Morscher as treatment for patients with coxa breva and overgrowth of the greater trochanter. In this study we evaluated intermediate and long-term results of this operation. METHODS: We reviewed clinical and radiographic results of 18 patients (20 hips) who were treated by Morscher osteotomy. Ten patients had Perthes disease, 4 had developmental dysplasia of the hip, and 4 had avascular necrosis of the hip. The median age at surgery was 16 years [interquartile range (IQR): 14 to 17.5]. The median follow-up period was 7 years (IQR: 4.5 to 10). All patients were evaluated clinically by means of Harris Hip Score (HHS) before and after surgery. RESULTS: Preoperative clinical examination revealed that all patients had a limp and a positive Trendelenburg test. Median HHS was 72.5 (IQR: 69 to 83). Postoperatively, the Trendelenburg test was negative in 14 hips and positive in 6 hips. Postoperative median HHS was 94.5 (IQR: 89 to 96). Radiographic examination showed progression of osteoarthritis in 3 patients. One operation failed and was converted to total arthroplasty (total hip replacement) after 4 years. Two hips required total hip replacement 10 years after the operation. Leg length discrepancy was reduced in 17/20 hips. Overall patient satisfaction level was good-excellent in 12 patients, fair in 4, and bad in 2 patients. Postoperative complications included blade migration (1 patient (and wire breakage (2 patients). CONCLUSIONS: Morscher osteotomy can be effective for the treatment of patients with short femoral neck and overgrowth of the greater trochanter with a positive Trendelenburg test and mild leg length discrepancy. A congruent nonarthritic hip joint is a prerequisite for the success of the operation. LEVEL OF EVIDENCE: Level IV.

Can a linear external fixator stand as a surgical alternative to open reduction in treating a high-grade supracondylar humerus fracture?

OBJECTIVE: High-grade pediatric supracondylar humerus fractures are commonly treated with closed reduction and internal fixation with percutaneous pinning. When this fails, open reduction followed by internal fixation is the widely accepted procedure of choice. Use of a lateral external fixator was recently described as an optional procedure, but evidence is scarce. METHODS: We investigated the outcomes of upper limbs treated by either open reduction with internal fixation or closed reduction and external fixation. RESULTS: Twenty-one patients completed the long-term follow-up; 11 underwent open reduction, and 10 underwent external fixation. Most patients in both groups reported excellent satisfaction. In both groups, the modified Disabilities of the Arm, Shoulder, and Hand score was extremely low and the average elbow range of motion was almost identical. Radiographic analysis consisting of Baumann's angle and the carrying angle revealed no statistical difference between the two groups. DISCUSSION: Optional treatment using a linear external fixator for complex nonreducible supracondylar humerus fractures yielded acceptable clinical and radiographic results, as with open reduction. Our sample size was small, but the promising results may assist in the implementation of an alternative surgical procedure, especially in more complicated cases involving flexion-type fractures or severe soft tissue damage and swelling.

Congenital pseudoarthrosis of the clavicle: Should we reconsider timing and fixation method?

BACKGROUND: Congenital pseudoarthrosis of the clavicle (CPC) is rare and may require treatment, usually because of an unacceptable appearance or occasionally because of pain in an adolescent patient. Spontaneous union is unknown, and consequently any desired union requires open reduction and bone grafting. Many authors recommend performing the operation at the age of 3-5 years and using different fixation methods. We present our experience with three cases and literature review in an attempt to further elucidate the appropriate timing of the procedure and the fixation method. METHODS: This was a retrospective review of three cases presenting with pseudoarthrosis of the clavicle. All cases were treated by curettage of the pseudoarthrosis, with the void filled using full-thickness ileac crest autologous bone graft and bridging plate-one compression and two anatomical, at different ages. We performed a literature review with emphasis on timing of the procedure, fixation method and complications. RESULTS: All patients healed with good callus formation. One patient (5-year-old female treated using a compression plate) experienced overlying skin irritation and underwent removal of the plate. There were no restriction of movement, pain or any other complaint on the final follow-up. We did not find any difference in the operating complexity at different ages, but when a compression plate was used, it had to be removed later due to bulging of the plate. DISCUSSION: No clinical difference was observed between earlier and late operation. Therefore, we suggest performing a curettage of the pseudoarthrosis, gapping the void using autologous bone graft, and using an anatomical bridging plate.

Outcomes of French's Corrective Osteotomy of the Humerus for Cubitus Varus Deformity in Children.

BACKGROUND: Supracondylar humerus fractures are the most common elbow fractures in the pediatric population. OBJECTIVES: To evaluate the outcomes of French's corrective osteotomy for correction of post-traumatic cubitus varus deformity in children. METHODS: We conducted a retrospective review of medical charts of all patients who had undergone French's corrective osteotomy in our institution from 1998 to 2012. We recorded range of motion, cosmetic deformity, carrying angle, lateral cortex prominence index, hyperextension, and lateral cortex step before and after the surgery. RESULTS: Seven patients were enrolled the study. Average follow-up time was 4.6 years (range 2-9 years). An average of 18.3º of limited flexion (range 5º-35º) compared to the healthy elbow was recorded in three patients. Lateral condylar prominence was recorded in one patient. The average preoperative carrying angle was -20.5º (range -15º-30º) and postoperative angle was 9.6º (range 7º-13º). In comparison, the average carrying angle in the healthy elbow was 8.5º (range 4º-13º). No lateral cortex prominence was recorded. An average of 27.5º (range 15º-35º) of hyperextension of the distal fragment was recorded immediately postoperatively in four patients; however, during postoperative follow-up, the hyperextension was corrected spontaneously in all patients. CONCLUSIONS: As described by French, osteotomy has the ability to correct the varus deformity only in the coronal plane. However, our research supports the assumption that hyperextension in the sagittal plane might be corrected spontaneously.

Circular hexapod external fixation for periprosthetic tibial fracture.

A poor soft tissue envelope often accompanies periprosthetic tibia fracture around a well-fixed total knee arthroplasty and the tibial stem leaves little room for screw fixation. This article describes the practicability and effectiveness of a novel surgical technique using circular hexapod external fixation, in patients with this clinical scenario. It was applied for fixation of periprosthetic tibia fracture in 2 patients. Contact between the external fixation pins and the prosthesis was avoided. Using a web-based software program, a gradual reduction in all planes was achieved. Adequate fixation, stability, reduction, and quick healing were obtained in the 2 cases, with minimal complications. The patients returned to their activity level a few months after external fixation removal.

Correction of Cubitus Varus After Pediatric Supracondylar Elbow Fracture: Alternative Method Using the Taylor Spatial Frame.

BACKGROUND: Cubitus varus is a well-reported complication of supracondylar fracture of the humerus potentially resulting in cosmetic problems, impaired function, and malpractice claims. Traditional methods of correcting malunited distal humeral fractures involve complex osteotomies that have a high complication rate, require a large exposure, and challenging fixation. We present a technique of gradual correction using a percutaneous transverse osteotomy and 3 dimensional correction with a Taylor Spatial Frame. METHODS: This was a retrospective, IRB-approved study of 12 patients between 2006 and 2010, with cubitus varus after a malunited pediatric supracondylar fracture. The average age at initial injury was 5+8 years. The average age of the patients at surgery was 8+8 years. We measured technical (radiographic parameters and complications), functional (clinical carrying angle, range of motion, QuickDash), and satisfaction domain (questionnaire) outcomes at a minimum follow-up of 6 months. RESULTS: The osteotomy healed in all patients by 10 weeks after the index surgery. The mean external fixator time was 10 weeks. The average preoperative and postoperative humeroulnar angles for the affected elbow were 23 degrees varus and 5.8 degrees valgus, respectively. This was statistically significant (P<0.001). The mean preoperative and postoperative carrying angles were 22 degrees of varus and 5.8 degrees of valgus. This was statistically significant (P<0.001). The results of the QuickDash assessment showed that patients were doing very well with regard to the use of their upper extremity. The mean symptom/disability score was 0.80. No major complications or neurovascular complications were encountered. Overall satisfaction with the procedure was high. CONCLUSIONS: The Taylor Spatial Frame as used in this case series provides the experienced surgeon another safe, accurate, and reliable method to correct cubitus varus after pediatric supracondylar fracture. We used in 7 of our 12 cases, a previously unreported pattern of distal humeral pin fixation that allows for a very distal metaphyseal osteotomy, close to the deformity apex. This is a biplanar delta configuration that straddles the olecranon fossa and is appropriate for both children and adults. LEVEL OF EVIDENCE: Level IV.

Treatment of Longitudinal Epiphyseal Bracket by Excision and Polymethylmethacrylate Insertion at the Preossified Disease Stage.

Longitudinal epiphyseal bracket is a rare ossification anomaly involving the tubular bones of the hand or foot that have a proximal epiphysis, which becomes deformed as a result of the bracket. Untreated, the deformity becomes worse with age, because longitudinal growth cannot occur. The present report discusses the use of polymethylmethacrylate at the preossified disease stage in 2 patients with first metatarsal involvement. A medical record and radiographic review was performed for 2 children (3 feet), aged 1 year and 2 years and 5 months, who were treated with insertion of polymethylmethacrylate after excision of the aberrant epiphyseal bracket. Two different radiographic parameters (i.e., the intraosseous angulation and the metadiaphyseal length index) were used to measure the effect of treatment on the subsequent longitudinal growth of the metatarsals. An excellent clinical result after a long follow-up period was observed in 2 feet, and a good result was documented in 1 foot, which developed hallux valgus angulation. The use of polymethylmethacrylate as an interposition material after excision of the aberrant metatarsal epiphyseal bracket appeared to be an effective method of treatment during the preossified first stage of the disease, despite the general recommendation to use a cement spacer during the third ossified stage. Normal longitudinal growth of the metatarsals was noted without complications or risk of deformity recurrence.

Chronic anterior monteggia lesions in children: report of 4 cases treated with closed reduction by ulnar osteotomy and external fixation.

BACKGROUND: Chronic, subacute, and chronic Monteggia fracture dislocations of the elbow are challenging problems. The literature generally recommends complex open reconstructive procedures. We present an alternative, minimally invasive, percutaneous method with external fixation. METHODS: This was a retrospective review of 4 cases presenting with chronic Monteggia lesions with anterior dislocation of the radial head. RESULTS: Reduction of the radiocapitellar joint was successfully achieved in all patients after ulnar osteotomy and gradual correction using the Ilizarov external fixation. Open reduction or reconstruction of the radio-ulnar-capitellar joint and/or ligament was not undertaken. The patients were between 9 and 11 years of age at the time of injury. The time from injury to treatment was between 3 and 56 months. At follow-up of an average of 3.5 years (range, 2 to 6 y), all patients had full movement of the elbow and normal function of the forearm. Radiographically, all radial heads were well reduced and the ulnar osteotomy showed remodeling. CONCLUSIONS: The technique is relatively simple and avoids the risks and technical challenges of open osteotomies, open reduction, and ligament reconstruction. Gradual reduction of the radial head with the aid of an external fixation is a safe and effective method of treatment for chronic Monteggia lesions.

Treatment of intra-articular distal radius fractures by the volar intrafocal Kapandji method: a case series.

At present, the most common treatment for intra-articular fractures with a volar fragment is open reduction and internal fixation with a volar locking plate. This manuscript describes and evaluates the safety and efficacy of a modified Kapandji technique with insertion of a volar Kirschner wire for osteosynthesis of intra-articular distal radius fractures with a volar fragment. Four patients treated with the "volar Kapandji technique" completed follow-up of at least 12 (12 to 54) months. The mean age was 43 (23 to 53) years. The mean Disability of the Arm, Shoulder, and Hand score was 21.7 (0 to 41) and the mean Patient-Rated Wrist Evaluation score was 12.9 (0 to 25.8). The mean loss of flexion was 13.7 (0 to 30) degrees, the mean loss of extension was 10 (0 to 30) degrees, the mean loss of supination was 0 degrees, and the mean loss of pronation was 10 (0 to 20) degrees. There was no loss in dorsal angulation, radial inclination, or radial length compared with the other hand. No early or late complications were recorded.

Gradual correction of congenital radioulnar synostosis by an osteotomy and Ilizarov external fixation.

PURPOSE: To report the method, outcome, and complications with Ilizarov external fixation for correction of congenital radioulnar synostosis with fixed forearm pronation greater than 60°. METHODS: We treated 4 patients with an average age of 11 years (range, 9-13 y). Three patients had bilateral deformity and 1 had deformity of the right forearm only. All forearms were classified as type 3 according to Cleary and Omer. Indications were severe (> 90°) bilateral pronation deformity in 3 patients, with a mean preoperative pronation deformity of 100° (range, 90° to 110°), whereas 1 patient had unilateral right forearm deformity treated for cultural reasons. All patients underwent osteotomy at the level of the synostosis and gradual correction of the deformity using an Ilizarov external fixation device. RESULTS: Mean supination position of the forearms after the correction was 15° (range, 0° to 30°). Two patients experienced neurapraxia of the radial nerve attributed to acute initial partial correction of the deformity in the operating room; the correction was returned to its original position, resulting in complete neurological recovery. One patient experienced a pin track infection, which we treated successfully with oral antibiotics. CONCLUSIONS: Our small series demonstrated the ability to gradually correct forearm rotation deformities greater than 90° using Ilizarov external fixation devices.

Fracture management in pycnodysostosis: 27 years of follow-up.

Pycnodysostosis is a rare hereditary disease, characterized by systemic bone sclerosis, which is often brought to the orthopedic surgeon's attention because of repeated fractures. The operative treatment of the patient with a fracture is a real challenge for the orthopedic surgeon because of the unusual problems imposed by the hard but-brittle bone characteristics of the disease. We report a 27-year follow-up of a patient treated for fractures of both femurs and tibia with intramedullary nailing. According to our experience and literature review, we recommend the use of an internal fixation, preferably intramedullary nailing as the treatment of choice for these rare cases. Once the fractures are healed, the removal of the hardware is not recommended, as these keep the bones from further fractures.

Subacute osteomyelitis of the talus mimicking arthritis of the ankle joint: a case report with 16 years follow-up.

A 7-year-old girl suffering from subacute osteomyelitis of the talus is presented. The main presenting symptoms were mild pain and limping. Owing to the relatively benign course and the rarity of the disease, there was a delay in the diagnosis of about 7 weeks. Laboratory investigation indicated inflammation rather than infection. Roentgenological signs of osteomyelitis appeared at a later stage. Treatment included surgical exploration, curettage, and antibiotics. The patient was seen 16 years later, at the age of 23 years, and there were no sequelae of the infection clinically or radiographically. This study presents the existence of this rare disease, so that it can be promptly diagnosed, possibly avoiding surgical intervention.

Chronic osteomyelitis in children: treatment by intramedullary reaming and antibiotic-impregnated cement rods.

BACKGROUND: Chronic osteomyelitis (CO) is rarely encountered in developed countries and is especially rare in children and adolescents. However, on occurrence, it can pose a difficult therapeutic challenge necessitating a combination of aggressive surgical treatment and prolonged antibiotic administration. METHODS: Four patients were treated for CO in the Pediatric Orthopaedic Unit at Schneider Children's Medical Center between June 2005 and December 2006 and were reviewed retrospectively. Surgical treatment consisted of debridement and lavage, reaming of the intramedullary canal and insertion of gentamycin-impregnated polymetamethacrylate rods into the canal and beads around the infection site. At rod removal reaming and lavage were repeated. Antibiotic treatment was initiated with intravenous cephalothin, followed by prolonged oral treatment according to bacterial sensitivity. RESULTS: Cement rods and beads were removed 16 to 62 days after insertion. Intravenous antibiotics were continued for 6 weeks (3-13) and total antibiotic treatment length was 16 weeks (10-37). Total treatment time from presentation to full resolution averaged 8 months (2-18). One patient sustained a fracture requiring osteotomy and correction. At mean follow-up of 41 months from rod removal (36-46), all patients are asymptomatic and fully functional with no clinical signs of infection. C-reactive protein is within normal limits in all 4 patients. CONCLUSIONS: The method presented combining reaming, lavage and local and systemic antibiotic treatment was found to be safe and effective in the treatment of CO, eradicating the infection and preventing further tissue loss. LEVEL OF EVIDENCE: Therapeutic study, clinical case series: level IV.

Ponseti treatment for idiopathic clubfoot: minimum 5-year followup.

UNLABELLED: Ponseti clubfoot treatment has become more popular during the last decade. We reviewed the medical records of 74 consecutive infants (117 club feet) who underwent Ponseti treatment. Minimum followup was 5 years (mean, 6.3 years; range, 5-9 years). We studied age at presentation, previous treatment, the initial severity score of the Pirani scoring system, number of casts, need for Achilles tenotomy or other surgical procedures, and brace use. We measured final ankle motion and parents' perception of outcome. Late presentation and previous non-Ponseti treatment were associated with lower initial severity score, fewer casts, and less need for tenotomy. Forty-four percent of patients had poor brace use. We observed better brace use (75%) in babies who presented late for treatment. Good brace use predicted less need for extensive surgical procedures. Twenty-four (32%) babies underwent additional surgical procedures other than tenotomy, including 21% who underwent tibialis anterior tendon transfer. At followup, 89% of feet had adequate dorsiflexion (5 degrees or greater). Parents indicated high satisfaction with the treatment results. Ankle motion was not associated with parents' satisfaction. The Ponseti method is effective, even if treatment starts late or begins after failure at other centers. Brace use influenced the success of treatment. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.