Review of Current Concepts in Metatarsus Adductus.

Metatarsus adductus (MA), the most common congenital foot deformity, involves adduction of the forefoot at the tarsometatarsal joint, with normal hindfoot alignment. Early diagnosis is important because treatment is more successful if initiated before age 9 months. Treatment of MA depends on deformity severity, in which mild to moderate deformity can be treated conservatively. Current standard of care for severe or rigid deformity involves referral by primary care physicians to specialists for management by casting and splinting. Recently, several orthoses have demonstrated equal effectiveness to casting and may allow for primary care physicians to treat MA without the need for referral. In this review article, we provide an overview of MA and discuss diagnosis and treatment. We also discuss novel devices and suggest how they may affect the future management of severe and rigid MA. [Pediatr Ann. 2024;53(4):e152-e156.].

[METATARSUS ADDUCTUS - A COMMON DEFORMITY - WHAT TO DO AND WHEN?]

INTRODUCTION: The most common foot deformity in newborns is the forefoot adduction deformity (FAD), where the hindfoot foot is in a normal position. The diagnosis for this problem is mainly based on a physical examination. The use of imaging methods has been described, but no advantage was shown with their utilization in determining the diagnosis and guiding treatment. Several classification systems have been proposed to characterize the degree of severity. The classifications are based on the degree of deviation and the flexibility of the foot. Early diagnosis and early treatment, if necessary, are extremely important to improve the chances of treatment success. Treatment depends on the severity of the deformity. For mild deformities the treatment is conservative - follow-up or stretching of the foot. The usual treatment for severe deformities is serial casting. Several orthoses have recently been proposed to address the problem and these demonstrated similar results, higher comfort and satisfaction, lower cost and a similar side effect profile. Surgical treatments to correct the deformity are reserved for cases where conservative treatment failed and for older children. This review aims to summarize the current knowledge on the subject, describe the ways to diagnose and classify the deformity, and present the variety of ways to treat the problem including the use of innovative braces. In addition, we will offer a protocol for the treatment of the deformity that is accepted in our institution. The protocol will assist primary care physicians to both diagnose and treat appropriate deformities, and know when a specialist referral is necessary.

Simultaneous tibio-talar fusion and tibial lengthening for end-stage ankle arthritis.

PURPOSE: Arthrodesis of the ankle joint is an accepted treatment option in patients with end-stage ankle arthritis. The goal is to achieve fusion between the tibia and the talus, thereby stabilizing the joint and alleviating pain. There might be associated limb length discrepancy, especially in post-traumatic and post-infectious cases. These patients require limb lengthening and arthrodesis. The purpose of this study is to report our experience with simultaneous ankle arthrodesis and lengthening using external fixation in adolescent and young adult patients. METHODS: This retrospective case series included all patients treated in our hospital by concomitant ankle arthrodesis and tibial lengthening procedures on the same limb, using ring external fixation system. All surgeries included distal tibial joint surface resection and the talar dome, thereby correcting any associated deformity at the ankle. The arthrodesis was fixed and compressed using ring external fixator. A concurrent proximal tibial osteotomy was done, and limb lengthening, or bone transport was performed. RESULTS: Eight patients operated between the years 2012-2020 were included in this study. Median patient age was 20.4 years (range 4-62 years), 50% women. Median limb lengthening was 20 mm (range 10-55 mm), and median final leg length discrepancy (LLD) was 7.5 mm (range 1-72 mm). The most common complication recorded was pin tract infection, which resolved with empiric antibiotics in all cases. CONCLUSION: Based on our experience, combined arthrodesis and proximal tibial lengthening is efficient solution that provides stable ankle and restores length of the tibia even in complex and challenging situations.

Rebound predictors of varus-valgus deformities around the knee corrected by guided growth.

PURPOSE: Coronal plane deformities around the knee are rather common condition in children. Guided growth by temporary hemiepiphysiodesis is considered to be the preferred primary treatment in many cases. Despite the popularity of hemiepiphysiodesis, the incidence of recurrence of deformity and predictors for rebound are not well defined. The objectives of this study were to determine the incidence of the recurrence of varus-valgus deformities around the knee treated by temporary hemiepiphysiodesis and possible predictors for the rebound. METHODS: We retrospectively reviewed medical records and x-ray images of 130 patients with varus-valgus deformities around the knee treated by tension-band (eight-plate) hemiepiphysiodesis, between the years 2006 and 2016 in our institution. The incidence of rebound of varus-valgus deformities around the knee and possible predictors were analyzed. RESULTS: Rebound of the deformity was observed in 10% of patients. Risk factors found to be in correlation with recurrence include young age, deformity of proximal tibia, proximal tibial medial growth plate beaking, and comorbidities (like metabolic disorders, multiple hereditary exostoses and genetic syndromes). CONCLUSION: The results of this study show that there is a noteworthy incidence of rebound in patients treated by temporary hemiepiphysiodesis for coronal deformities around the knee. The risk factors are also outlined. These patients, especially the ones with risk factors, require close surveillance until maturity. LEVEL OF EVIDENCE: Level III-Case control study.

Novel device for nonsurgical correction of rigid forefoot adduction in children.

Forefoot adduction deformity (FAD) (commonly called metatarsus adductus) is reported as the most common congenital foot deformity in newborns. Early diagnosis and treatment are important in rigid cases, as better outcomes have been reported if treatment was initiated before 9 months of age. While casting and splinting is the current standard of care for nonsurgical management of rigid FAD (RFAD), several orthoses have demonstrated equal benefit. The Universal Neonatal Foot Orthotic (UNFO) brace is below ankle orthosis that provides continuous pressure, thereby correcting the deformity without casting. To the best of our knowledge, UNFO is the first brace that operates below the ankle. The aim of this study was to compare the effectiveness of UNFO shoe to standard serial casting in the treatment of RFAD in infants. Between the years 2012 and 2019 we treated 147 feet (94 patients): 52 using the UNFO shoes and 95 by standard casting and splinting protocol. The treatment groups were compared based on treatment duration, complications, and recurrence of deformity. Mean full-time treatment duration was significantly shorter in the UNFO group, while no significant difference in the total duration of treatment was observed. Similar complication and recurrence rates were demonstrated. In conclusion, treatment with UNFO is equally effective to serial casting. The use of UNFO increases convenience and diminishes social burden, thus providing a distinct advantage over other treatment modalities.

The use of real-time sonography-assisted fracture reduction in children with displaced forearm fractures.

Pediatric forearm and wrist fractures are common; furthermore, some are displaced and require manipulation and reduction. The procedure is commonly performed without real-time image guidance and evaluated radiographically after reduction and casting, leading to multiple reduction attempts and malalignment. Although fluoroscopy can provide real-time assessment of fracture alignment during the procedure, it is not readily available in many emergency departments (EDs) and involves radiation exposure. Ultrasonography is an alternative real-time imaging modality that is inexpensive and readily available. The purpose of this study was to determine whether the use of real-time bedside sonography during closed reduction of distal and middle third forearm fractures can decrease the number of reduction attempts and reduce the number of patients requiring surgery. We compared the results of a conventional blind manipulation, fracture reduction, and casting to fracture reduction under real-time ultrasonographic guidance, in patients treated in our ED between 2014 and 2016. Overall, 458 patients with distal or middle third fractures were included. Of these reductions, 289 were performed without real-time imaging (group 1) and 169 under real-time ultrasound guidance (group 2). In group 1, 10% of patients required re-reduction, and 5% of patients needed surgery. In group 2, only one patient (0.6%) required re-reduction and 1% of patients required surgery due to fracture instability. In conclusion, the current study shows that real-time ultrasound-guided forearm fracture reduction is an effective and inexpensive method for correction of displaced forearm and wrist fractures in children, which does not involve any radiation exposure.

Correction of Posttraumatic Medial Growth Arrest of the Distal Tibia in Adolescents.

BACKGROUND: Partial growth arrest of the medial part of the distal tibial physis following fractures that penetrated the epiphysis is relatively common. We present the results of treatment, based on a protocol of supramalleolar tibial and fibular osteotomy for ankle alignment correction, and contralateral epiphysiodesis of distal tibia and fibula to balance leg length discrepancy (LLD). METHODS: This case series study describes the results of 7 patients with a median age of 14 years (range = 10-15 years) who were operated in our institution. All were treated by closed or open reduction and internal fixation after Salter-Harris (SH) types 3 and 4 fractures of the distal tibia. All patients had a partial medial growth arrest, distal tibial varus, relative overlengthening of the distal fibula, and slight leg shortening. TREATMENT PROTOCOL: Contralateral distal tibial and fibular epiphysiodesis to prevent significant LLD, completion of closure of the ipsilateral epiphysis, supramalleolar osteotomy of the distal tibia and fibula, and insertion of a triangular wedge cortical allograft into the tibial osteotomy creating a normal ankle joint orientation. The osteotomy was supported by a medial anatomically contoured locking plate. The fibula was fixed with an intramedullary wire. RESULTS: All patients had uneventful healing of the osteotomy after 6 weeks. At the latest follow-up (mean 3 years, range 1.5-5 years), 6 out of 7 patients reached maturity, and the lateral distal tibial angle was within normal limits. The LLD in all patients was less than 8 mm. CONCLUSIONS: Our protocol provides anatomic correction with the restoration of the ankle joint and prevents the progression of LLD. LEVELS OF EVIDENCE: Level IV.

Treatment of Adolescent Hallux Valgus With Percutaneous Distal Metatarsal Osteotomy.

Background. Hallux valgus is a complex deformity of the first ray of the foot, and a significant number of adolescents develop this deformity. More than 130 surgical procedures have been described to treat hallux valgus, but there is no compelling evidence to prefer one method over another. Minimal invasive techniques have been proposed and reported to be successful and cost-effective. The objective of this study was to describe the clinical course of adolescent patients treated with percutaneous distal metatarsal osteotomy. Methods. A retrospective study included patients who had a percutaneous hallux valgus correction during the years 2008 to 2015. The following measurements were compared before surgery up to last follow-up: AOFAS Hallux-Metatarsophalangeal-Interphalangeal questionnaire and radiological measurements (HVA, IMA, DMAA). Any postoperative complications were extracted from the medical records. Results. The procedure was performed on 32 feet (27 patients). All patients were <18 years of age. There were 10 male patients (12 feet) and 17 female patients (20 feet). Average age at surgery was 15.8 years (range = 13-18 years). Average follow-up time was 43 months (range= 24-94 months). The average AOFAS score before surgery was 66, and after surgery, at last follow-up was 96. This difference was significant (P value <.0001). Most patients were pain free after the procedure and returned to appropriate age functioning. Significant improvement was noted in all radiological criteria. Conclusions. Percutaneous distal metatarsal osteotomy is safe, reliable, and effective for the correction of mild to moderate symptomatic hallux valgus in adolescents.Levels of Evidence: Level IV.

Q Fever Osteoarticular Infection in Children.

Q fever osteoarticular infection in children is an underestimated disease. We report 3 cases of Q fever osteomyelitis in children and review all cases reported in the literature through March 2018. A high index of suspicion is encouraged in cases of an unusual manifestation, prolonged course, relapsing symptoms, nonresolving or slowly resolving osteomyelitis, culture-negative osteomyelitis, or bone histopathology demonstrating granulomatous changes. Urban residence or lack of direct exposure to animals does not rule out infection. Diagnosis usually requires use of newer diagnostic modalities. Optimal antimicrobial therapy has not been well established; some case-patients may improve spontaneously or during treatment with a ß-lactam. The etiology of treatment failure and relapse is not well understood, and tools for follow-up are lacking. Clinicians should be aware of these infections in children to guide optimal treatment, including choice of antimicrobial drugs, duration of therapy, and methods of monitoring response to treatment..

Direct Lateral Approach for Triple Pelvic Osteotomy.

INTRODUCTION: Triple pelvic osteotomy (TPO) involves periacetabular osteotomies of the ilium, ischium, and pubis to reorient the acetabulum. This operation is indicated in certain situations for the treatment of developmental dysplasia of the hip, dysplastic neuromuscular hips, and for containment of the femoral head in cases of Legg-Calvé-Perthes disease. METHODS: This retrospective cohort study compares radiographic outcomes of patients who underwent TPO using two different techniques and describes a novel single-incision direct lateral approach. TPO was performed on 22 patients by the senior author. The first 10 patients underwent TPO through a single-incision anterolateral approach. The last 12 patients underwent TPO using the direct lateral approach. Preoperative and postoperative pelvic radiographs were reviewed for each patient, and the migration index and center-edge angle were recorded. RESULTS: The migration index and center-edge angle were evaluated and were not found to be significantly different between the anterolateral and direct lateral groups. The direct lateral approach is described. CONCLUSION: The direct lateral approach for TPO is equivalent to the anterolateral approach on radiographic evaluation. Advantages of the direct lateral approach include direct visualization of the ischial osteotomy, effective mobilization of the acetabulum, and safety of the sciatic nerve.

Treatment and outcomes of arthrogryposis in the lower extremity.

In this multiauthored article, the management of lower limb deformities in children with arthrogryposis (specifically Amyoplasia) is discussed. Separate sections address various hip, knee, foot, and ankle issues as well as orthotic treatment and functional outcomes. The importance of very early and aggressive management of these deformities in the form of intensive physiotherapy (with its various modalities) and bracing is emphasized. Surgical techniques commonly used in the management of these conditions are outlined. The central role of a multidisciplinary approach involving all stakeholders, especially the families, is also discussed. Furthermore, the key role of functional outcome tools, specifically patient reported outcomes, in the continuous monitoring and evaluation of these deformities is addressed. Children with arthrogryposis present multiple problems that necessitate a multidisciplinary approach. Specific guidelines are necessary in order to inform patients, families, and health care givers on the best approach to address these complex conditions.

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.

Removal of Metaphyseal Screw Only After Hemiepiphysiodesis Correction of Coronal Plane Deformities Around the Knee Joint: Is This a Safe and Advisable Strategy?

PURPOSE: Correcting lower limb angular deformities in the skeletally immature patient with guided growth is a very common procedure. Using an 8-plate construct to produce reversible hemiepiphysiodesis allows correction of the mechanical axis of the limb. It has become routine strategy to remove only the metaphyseal screw from the 8-plate construct after desired correction is achieved, in order to ease its reinsertion in case of deformity recurrence. In this study, we evaluated the efficacy and safety of this technique. METHODS: We reviewed the results of 80 patients (133 limbs) who were treated by guided growth using 8-plate hemiephisiodesis around the knee. After achievement of the correction goal, both screws and plate were removed in 78 limbs while only the metaphyseal screw was removed in 55 limbs. RESULTS: The mean age of patient was 8.9 years at the time of surgery. Within the group whose metaphyseal screw was removed, 12 limbs showed radiographic signs of deformity recurrence and underwent reinsertion of the metaphyseal screw. In 9 of the cases of metaphyseal screw reinsertion, the plate or its location had to be changed (mean follow-up after screw removal was 14 mo). There were 2 cases where leaving the plate with an epiphyseal screw caused a radiographic bone bar and undesired clinical growth arrest. CONCLUSIONS: On the basis of our experience, leaving the 8-plate construct with an epiphyseal screw in place exposes the patient to risks of bony bar, growth arrest, and an additional surgery for hardware removal. The majority of 8-plate constructs are not suitable for reinsertion of the metaphyseal screw.

Reliability of Smartphone-Based Instant Messaging Application for Diagnosis, Classification, and Decision-making in Pediatric Orthopedic Trauma.

OBJECTIVE: Smartphones have the ability to capture and send images, and their use has become common in the emergency setting for transmitting radiographic images with the intent to consult an off-site specialist. Our objective was to evaluate the reliability of smartphone-based instant messaging applications for the evaluation of various pediatric limb traumas, as compared with the standard method of viewing images of a workstation-based picture archiving and communication system (PACS). METHODS: X-ray images of 73 representative cases of pediatric limb trauma were captured and transmitted to 5 pediatric orthopedic surgeons by the Whatsapp instant messaging application on an iPhone 6 smartphone. Evaluators were asked to diagnose, classify, and determine the course of treatment for each case over their personal smartphones. Following a 4-week interval, revaluation was conducted using the PACS. Intraobserver agreement was calculated for overall agreement and per fracture site. RESULTS: The overall results indicate "near perfect agreement" between interpretations of the radiographs on smartphones compared with computer-based PACS, with κ of 0.84, 0.82, and 0.89 for diagnosis, classification, and treatment planning, respectively. Looking at the results per fracture site, we also found substantial to near perfect agreement. CONCLUSIONS: Smartphone-based instant messaging applications are reliable for evaluation of a wide range of pediatric limb fractures. This method of obtaining an expert opinion from the off-site specialist is immediately accessible and inexpensive, making smartphones a powerful tool for doctors in the emergency department, primary care clinics, or remote medical centers, enabling timely and appropriate treatment for the injured child. This method is not a substitution for evaluation of the images in the standard method over computer-based PACS, which should be performed before final decision-making.

Three point fixation of pediatric proximal humerus fractures by prebent wave-shaped wires: technical notes.

Pediatric proximal humerus fractures are uncommon and mostly treated conservatively. However, surgical treatment should be considered in displaced fractures classified as Neer-Horowitz grade III-IV in children older than 11 years. We describe a three-point fixation method of applying two Kirschner wires, prebent into a wave shape, and inserted into the proximal humerus through a single cortical hole. In this minimally invasive approach, we treated four boys, obtaining accurate reduction and stable fixation, with all patients starting pendulous exercises the day after surgery. At follow-up, all patients had regained full shoulder range of motion, with no residual pain and no complications recorded.

Clinical utility of the Taylor spatial frame for limb deformities.

The Taylor spatial frame (TSF) is a hexapod external fixator that can correct six-axis deformities. The mathematical base of all hexapod systems is projective geometry, which describes complex repositioning of an object in space. The Taylor brothers developed one of the first six-axis correction systems, which is known today as TSF. Over the years, this system has become the most used six-axis deformity correction device. In this review, we describe the history behind TSF development, and describe the principles and clinical utility for application of the TSF in different settings, such as acute trauma, malunions, and various deformities of the lower and upper limb.

Femur shaft fracture following osteoid osteoma radiofrequency ablation.

INTRODUCTION: Radiofrequency ablation is an effective modality in treating osteoid osteoma while avoiding the complications of an open procedure. Its complications are usually self-limited consisting mostly of local skin burns. This report presents a major complication, a femur shaft fracture following an osteoid osteoma radiofrequency ablation. The fracture occurred approximately one year after the ablation at the site of the osteoid osteoma. DISCUSSION: Few case reports have been published regarding subtrochanteric femur fracture after ablation of an osteoid osteoma. To our knowledge this is the first report of a femoral shaft fracture following an ablation. Another unique characteristic of the presented case is the late presentation, approximately one year following ablation. Factors which may have contributed to the fracture include lateral entry point of the drill which may have weakened the femur when taking its biological and mechanical properties into account, and the fact that the patient was a soldier who was allowed to continue his military training only six weeks after the ablation. CONCLUSION: Radiofrequency ablation is an effective and relatively safe technique in treating osteoid osteomas, however the physician should be aware of the fracture risk involved, consider mechanical and biologic factors of the bone prior to drilling, and be very conservative when recommending return to high level activity. In addition, a close follow-up should be carried on after the procedure in order to supervise bone remodeling.

Hip stability during lengthening in children with congenital femoral deficiency.

BACKGROUND: Congenital femoral deficiency (CFD) is one of the most challenging and complex conditions for limb lengthening. We focused on the problem of hip instability during femoral lengthening because subluxation and dislocation are potentially catastrophic for hip function. METHODS: We assessed for hip stability in 69 children (91 femoral lengthenings) who had CFD Paley type 1a (43 children) and 1b (26 children). The mean age at first lengthening was 6.4 years. RESULTS: Hip subluxation/dislocation occurred during 14 (15 %) of 91 lengthenings. Thirty-three pelvic osteotomies were performed before lengthening in an attempt to stabilize hips. Thirteen patients (type 1a, eight; type 1b, five) had acetabular dysplasia at initiation of lengthening. One of the eight with type 1a experienced mild femoral head subluxation; four of the five with type 1b experienced three dislocations and one subluxation. Eight patients (type 1b) experienced hip instability although they had pelvic osteotomies. Proximal femoral lengthening was a significant factor for hip subluxation. Patients with hip subluxation more likely underwent monolateral fixation and the original superhip procedure. Age ±six years was not a contributing factor for hip instability. CONCLUSIONS: Important risk factors for hip instability during femoral lengthening are severity of CFD, residual acetabular dysplasia, and proximal femoral lengthening. We recommend routine performance of pelvic osteotomy for patients with Paley type 1b CFD and distal lengthening. LEVEL OF EVIDENCE: Therapeutic Level IV.

Multiplanar Deformities Correction Using Taylor Spatial Frame in Skeletally Immature Patients.

BACKGROUND: Taylor Spatial Frame (TSF) is a modern circular external fixator that, using a virtual hinge, is able to correct six axis deformities simultaneously. Despite the growing popularity of this method, few reports exist about its use in children and adolescents. To evaluate the effectiveness of TSF in correcting multiplanar deformities in patients with open physis, we reviewed the results of treatment in children who had at least two planes deformities of lower limbs. METHODS: Over a period of 8 years, we treated 51 patients, 40 boys, 11 girls, with a mean age of 12.4 years (range, 2-16 years). All patients had open physis at the time of the TSF application. All patients had at least two deformities (angular and/or rotational). Fifty-five osteotomies (11 femoral, 44 tibial) were performed. Patients were divided into four groups: 13 with post-traumatic malunions, 18 with tibia vara, six with rickets, and 14 with miscellaneous deformities. Correction goal was determined as correction of deformities to population-average parameters of the lower limbs in frontal and sagittal views and normal mechanical axis deviation. RESULTS: Correction goal was achieved in all except one patient; four patients had recurrence of deformities post-operatively and were re-operated. Most common complications were pin tract infection (20 patients), delayed union (2), regenerate translation (1), post-removal femoral fractures (2), knee subluxation (1), nonunion (1), and one patient developed chronic osteomyelitis secondary to deep pin tract infection. CONCLUSION: TSF allowed accurate correction of complex limb deformities in children and adolescents with relatively few serious complications. LEVEL OF EVIDENCE: Level IV. Case series.