Osteonecrosis of the Femoral Head: A Proposed New Treatment in Homozygous Sickle Cell Disease.

UNLABELLED: Possibilities for bone reconstruction in osteonecrosis of the femoral head in sickle cell hemoglobinopathies before the end of growth have not been assessed. The aim of our study was to evaluate the morphological and functional results in 11 osteonecrosis of the femoral head because of homozygous sickle cell disease. Surgical treatment consisted of a triple acetabular osteotomy in seven cases, femoral varus osteotomy in two cases and a combination of both in two cases. The severity of the osteonecrosis was evaluated on radiographs and magnetic resonance imaging (MRI), pre- and postoperative, and function of the hip joint was assessed by Harris and Postel Merle d'Aubigné scores. The anesthetic part (pre- and postoperative) and eventual complications were collected and analyzed. The maximum follow-up was between 1 to 9.6 years. All patients were considered to be satisfactory at maximum follow-up. The severity of the initial damage was not associated with any morphological or functional outcome at maximum follow-up. All patients had an objective functional gain. We found no general complications. We proposed a decision tree for the patient's management of avascular necrosis of the femoral head in sickle cell hemoglobinopathies before bone maturity, and with an Arlet and Ficat's stage of 3 or 4. The results of this study confirmed the interest of conservative surgical treatment in children with homozygous sickle cell anemia in case of osteonecrosis of the femoral head. LEVEL OF EVIDENCE: IV (cases series of our department).

Case reports: Treatment of traumatic triradiate cartilage epiphysiodesis: what is the role of bridge resection?

BACKGROUND: Acetabular fractures are rare in children and can be complicated by premature fusion of the triradiate cartilage resulting in secondary acetabular dysplasia. Early recognition and treatment of a physeal bar in this location can be difficult. The purpose of this case report was to investigate whether early intervention could restore acetabular growth and prevent secondary acetabular dysplasia as measured on plain radiographs. CASE DESCRIPTION: We report a series of three patients (3, 4, and 5 years old) who underwent physeal bridge resection and methylmethacrylate or fat interposition through an extended Pfannenstiel approach. The mean followup was 6 years. After resection of the osseous bridge the physis initially remained open with evident acetabular growth in all three patients. In one patient, the bridge reformed 6 years after the procedure. All patients had a slight increase in the thickness of the acetabular wall relative to the contralateral side but no radiographic evidence of acetabular dysplasia. LITERATURE REVIEW: To our knowledge, there are only two reports of physeal arrest resection of triradiate cartilage with one successful result. CLINICAL RELEVANCE: Posttraumatic, partial physeal arrest of the triradiate cartilage may be treated with resection of the bone bridge resection through an extended Pfannenstiel approach. The potential benefits of this treatment must be weighed against the risks.

Spinopelvic fixation with iliosacral screws in neuromuscular spinal deformities: results in a prospective cohort of 62 patients.

PURPOSE: The results of a prospective series of 62 patients treated for neuromuscular spinal deformities with spinopelvic fixation using iliosacral screws are presented and discussed. METHODS: Sixty-two consecutive patients diagnosed with neuromuscular disorders were prospectively included. Pelvic obliquity and other angular parameters were measured. RESULTS: Mean age was 15.2 years (11.9 to 19.2 years). Spinal deformity was a thoracolumbar curve in 36 cases, a lumbosacral curve in 14 cases, a lumbar curve in four cases, and a combined thoracic and lumbar curve in eight cases. Lumbo-pelvic correction was done using two different strategies. In 15 patients with a normal frontal spinopelvic balance, the two rods were extended directly down to the iliosacral screws. In 47 patients with pelvic obliquity, iliosacral screws were linked to two short rods. The correction was then corrected by distraction and contraction maneuvers applied between the long and short rods. Postoperative angular parameters showed a good correction of spinal deformity in both groups. Patients with preoperative pelvic obliquity had a satisfactory and stable correction at final follow-up. CONCLUSIONS: The technique of pelvic fixation using iliosacral screws and connectors reduce difficulties and operative time due to the complicated three-dimensional bending of the rods for proper placement within the ilium. In patients with preoperative pelvic imbalance, a powerful pelvic anchorage as the iliosacral fixation allowed to use intraoperative reduction maneuvers. Despite the high rate of infectious complications in our patients, we think that our technique provided effective and improved spinal correction for patients with neuromuscular scoliosis.

Proximal femoral osteotomy in neurologic pediatric hips using the locking compression plate.

BACKGROUND: Proximal femoral osteotomy (PFO) is a widely performed reconstructive surgery in pediatric patients with diagnosis of neurologic abnormalities. Many implants have been used for the fixation of these osteotomies. These devices have been evolved to provide stable fixation. A novel fixation system, the proximal femoral locking compression plate (LCP), which has a low lateral profile system, has been developed to address the problem of loosening in the osteoporotic bone, and to reach a more precise angular reduction and fixation stability through the use of locking screws. In this study, we report the surgical technique and results of PFO in children with a neurologic diagnosis. METHODS: Fifty-two children with a primary neurologic diagnosis had a femoral osteotomy with the LCP device. Clinical records and radiographs, neck-shaft angle (NSA), acetabular slope, the Reimer migration percentage, and healing of the osteotomy site were studied. Among the 70 operated hips, 59 operated hips had a follow-up superior to 1 year and were included in this study. RESULTS: Among the 59 operated hips, 25 operated hips presented with subluxations. NSA improved from 145 degrees (130 degrees to 165 degrees) to 120 degrees (110 degrees to 125 degrees) and to 125 degrees (115 degrees to 130 degrees) on last follow-up. The Reimer migration percentage improved from 60% (35% to 90%) to 25% (15% to 35%). Ten operated hips presented with dislocations. Their NSA improved from 150 degrees (145 degrees to 170 degrees) to 122 degrees (115 degrees to 125 degrees) and to 125 degrees (118 degrees to 130 degrees) at last follow-up. The stability of the operative reduction was maintained and full range of motion was preserved. Five operated hips presented with dysplastic hips with NSA>130 degrees without associated subluxation, 6 operated hips presented with windswept deformities, 10 operated hips presented with excessive femoral anteversion, and 3 operated hips presented with pseudarthrosis after earlier PFO were also treated and neither presented angular loosening at last follow-up. No major complications were observed. CONCLUSIONS: The LCP system may be used for a wide range of indications if precise preoperative planning was achieved. Rigid primary fixation allows early mobilization and weight bearing in ambulant patient. LEVEL OF EVIDENCE LEVEL IV: Therapeutic study investigating the results of a treatment studying a case series.

Traumatic transepiphyseal separation of the upper femoral epiphysis following seizures in a 5-month-old child: a case report.

INTRODUCTION: Traumatic transepiphyseal separation of the upper femoral epiphysis is a rare lesion of the hip in children. CASE REPORT: We report a case of conservative treatment of transepiphyseal separation of the upper femoral epiphysis following tonic/clonic seizures in a 5-month-old child. Magnetic resonance imaging confirmed the diagnosis The fracture was maintained with hip spica cast for 6 weeks. At the age of 2, complete healing of the lesion including femoral neck remodeling was noted on frontal and lateral radiographs. There was no radiological evidence of AVN or premature closure of the physis. He continues to be followed up. DISCUSSION: Because of the remodeling potential in young children, we assume not to perform additional reduction procedures in such traumatic lesions.

Case reports: lengthening of a vascularized free fibular graft.

Wide bone resection is sometimes necessary for bone tumors, and reconstruction is a major challenge. Vascularized fibular graft is one alternative but may result in progressive limb-length discrepancy (LLD) in children with substantial growth left. Progressive distraction lengthening with an external fixator is now a standard procedure to generally correct LLD. However, lengthening of free vascularized fibular grafts for lower limb reconstruction has not been reported frequently and then only in small series or case reports. We report our experience with three patients with lengthening after tibial reconstruction with a free vascularized fibular graft and review the literature.

The sagittal balance of the spine in children and adolescents with osteogenesis imperfecta.

In severe forms of osteogenesis imperfecta, multiple compression fractures of the spine, as well as vertebral height shortening could be responsible for an increased thoracic kyphosis or a diminished lumbar lordosis. Theses progressive changes in sagittal shapes of the trunk could be responsible for a global sagittal trunk imbalance. We compare the parameters of sagittal spinopelvic balance in young patients with OI to those parameters in a control group of healthy volunteers. Eighteen patients with osteogenesis imperfecta were compared to a cohort of 300 healthy volunteers. A standing lateral radiograph of the spine was obtained in a standardized fashion. The sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, thoracic kyphosis, T1 and T9 sagittal offset were measured using a computer-assisted method. The variations and reciprocal correlations of all parameters in both groups according to each other were studied. Comparison of angular parameters between OI patients and control group showed an increased T1T12 kyphosis in OI patients. T1 and T9 sagittal offset was positive in OI patients and negative in control group. This statistically significant difference among sagittal offsets in both groups indicated that OI patients had a global sagittal balance of the trunk displaced anteriorly when compared to the normal population. Reciprocal correlations between angular parameters in OI patients showed a strong correlation between lumbar lordosis (L1L5 and L1S1) and sacral slope. The T9 sagittal offset was also strongly correlated with pelvic tilt. Pelvic incidence was correlated with L1S1 lordosis, T1 sagittal offset and pelvic tilt. In OI patients, the T1T12 thoracic kyphosis was statistically higher than in control group and was not correlated with other shape (LL) or pelvic (SS, PT or PI) parameters. Because isolated T1T12 kyphosis increase without T4T12 significant modification, we suggest that vertebral deformations worsen in OI patients at the upper part of thoracic spine. Further studies are needed to precise the exact location of most frequent vertebral deformities.

Proximal tibial epiphyseal intraosseous schwannoma: a rare entity.

Schwannoma is a benign nerve sheath tumor most commonly located in the soft tissue. Occasionally, schwannomas involve osseous structures. The rarity of osseous involvement leads to omission of schwannoma from the initial differential diagnosis in the majority of cases. Intraosseous schwannomas arising in children have not been reported. We present the case of a schwannoma affecting the proximal tibial epiphysis in a growing child. Intraosseous schwannomas should be included in the differential diagnosis of lytic epiphyseal benign-appearing bone lesions in children. Its radiographic characteristics mimic those of benign chondroblastoma.

Acute L5 pedicle fracture and contralateral spondylolysis in a 12-year-old boy: a case report.

Acute unilateral L5 pedicle fracture associated with a pre-existing contralateral spondylolysis is a rare lesion. We report a case in a non-competitive 12-year-old boy. We present the clinical, radiological and specific management of this rare condition. The clinical and radiological draft of this patient was reviewed. The follow-up was 30 months after fracture healing. Some cases reported in the literature were analyzed and our clinical findings and therapeutic strategy was compared and discussed. Non-operative treatment was done including full-time bracing in a modified Boston brace incorporating one thigh for 3 months. Plain radiographs and computed tomographic (CT)-scan performed at 3 and 6 months showed progressive healing of the pedicle fracture and no modification of the contralateral isthmic spondylolytic lesion. At final follow-up, the patient was asymptomatic and resumed all his activities. In skeletally immature patients, we think that conservative treatment should be considered as a treatment option for this unusual injury.

Is the Caton-Deschamps index a valuable ratio to investigate patellar height in children?

BACKGROUND: Patellar height variations can be responsible for many functional disorders in children. The Caton-Deschamps index to measure patellar height has been described for adults. Our goal was to determine Caton-Deschamps index values in a pediatric population. METHODS: Lateral radiographs of the knee were analyzed in a cohort of 300 healthy patients. All radiographs were done to evaluate the patients after minor trauma and all were reported to be normal by a senior radiologist. The cohort was divided into ten groups on the basis of the age of the child. Radiographic measurements were done by a computer-assisted technique. Intraobserver and interobserver reliability studies were performed prior to the descriptive analysis of the data. RESULTS: Mean patellar length (and standard deviation) was 33.39 ± 7.4 mm. Mean patellar tendon length was 34.57 ± 6.7 mm. The mean Caton-Deschamps index was 1.06 ± 0.21. Patellar and patellar tendon length significantly increased with age, whereas the Caton-Deschamps index significantly decreased. Intraobserver and interobserver reliability studies showed excellent reliabilities with an intraclass correlation coefficient that was between 0.930 and 0.944 (95% confidence interval). CONCLUSIONS: The Caton-Deschamps index is a simple and reliable index for evaluating patellar height in children as well as adults. It is an alternative to the Insall-Salvati index measurement, in which reproducibility is poor due to difficulties in determining the distal point of the patellar tendon, and to the Koshino index, which is complex to use. In our study, there was a correlation between the Caton-Deschamps index and age, due to the progressive patellar ossification that begins at the proximal part of the patella. The Caton-Deschamps index is a pertinent and reliable ratio to evaluate patellar height in children and adolescents. To make an accurate diagnosis of patellar disorders in children, the normal, age-based Caton-Deschamps values need to be considered.

The posterior talofibular ligament: an anatomical study with clinical implication in clubfoot surgery.

BACKGROUND: The role of the posterior talofibular ligament (PTFL) in the clubfoot deformity remains unclear. We conducted an anatomical study to precise its topography and role in maintaining tibiotalar equinus in patients with clubfoot deformity. METHODS: Ten ankles were dissected using a wide posterior exposure. The PTFL was identified at the posterior aspect of the ankle and its relations with other anatomical structures were noted. RESULTS: After opening of the tibiotalar and subtalar joints, the superior aspect of the PTFL was clearly seen, running horizontally from the fibula to a prominent tubercle on the posterior surface of the talus. The tibiotalar and subatalar joint capsules joined together laterally on the posterior edge of the PTFL and medially on the posterior part of the talus. A fibrous structure identified as being the "tibial slip" was noted in four cases between the posterior medial aspect of the lateral malleolus and the tibiotalar posterior capsule. Two different groups of fibers were identified inside the PTFL. CONCLUSIONS: Correcting the equinus and inversion of the talus needed an extensive release of soft tissues of the posterior part of the ankle. Our description of both short anterior and long posterior fibers of the PTFL improved our comprehension of functional anatomy of this ligament. We have found that PTFL is part of a posterior joint complex between the tibiotalar and subtalar joint. The posterior joint complex is a heritage of ankle evolution from a prehensile to a weight-bearing joint pattern. The inferior tibiofibular transverse ligament, the tibial slip and the calcaneofibular ligament are interpreted as derivatives of this ancestral meniscus and stabilize the weight-bearing ankle. Because the posterior fibers of the PTFL and the tibial slip are part of the complex, they should be excised like the posterior capsules during clubfoot surgery.

Association of Ilizarov's technique and intramedullary rodding in the treatment of congenital pseudarthrosis of the tibia.

PURPOSE: Many surgical techniques have been published on how to treat congenital pseudoarthrosis of the tibia (CPT). We combined Ilizarov's fixator with intramedullary nailing of the tibia and developed a procedure which combines the advantages of both methods: Ilizarov's high fusion rate with alignment control and the protection against refracture provided by the intramedullary nail. The results of this approach are presented and discussed. MATERIAL AND METHODS: Seven boys and three girls aged 3-14 years (mean age 8 years 2 months) were treated using our combined technique. In six cases, the CPT was associated with neurofibromatosis. Two strategies were adopted: in six cases, a compression was applied on the bone defect, and in four cases, segmental bone transportation was performed before the compression procedure. The final follow-up (1.2-6.6 years) included a clinical and radiological examination. RESULTS: Tibial union was achieved in nine cases without bone grafting. In one case, tibial union still remains uncertain, despite intertibiofibular bone grafting and additional compression procedures. Thirteen overall complications were noted, including three valgus deformity of the ankle. Bone transportation failed to achieve complete limb lengthening in three cases. One deep infection occurred 4 years after removal of the external fixator. The treatment for this included nail removal and antibiotic therapy for 3 months. Despite a permanent protection of orthosis, a refracture occurred 2 years after nail removal, reverting to the initial level of pseudarthrosis. Another surgical attempt using the same method was then performed with a satisfactory result. CONCLUSIONS: The association of Ilizarov's technique and intramedullary nailing achieved and maintained tibial union in nine of ten patients at final follow-up. It also allowed correction of axial deformities and prevented refracture. Despite the short duration of the follow-up and a high rate of complications in our series, this method can be useful in many cases of CPT in which healing has failed to occur despite many previous surgeries.

The progressive longitudinal traction reduction of unstable slipped capital femoral epiphysis: preliminary results in 11 patients.

PURPOSE: Unstable slipped capital femoral epiphysis is rare, but is frequently associated with avascular necrosis. The rapid and complete reduction of the epiphysis displacement was shown to be responsible for this complication. We present the preliminary results of a progressive reduction technique of epiphysis displacement. METHODS: A total of 11 patients treated using progressive traction and internal fixation were reviewed retrospectively. Only children who underwent clinical and radiological follow-up for at least 18 months were included in this study to detect avascular necrosis. RESULTS: The mean posterior displacement of the femoral head was 67 degrees and mean traction duration was 13 days. Of the patients, 2 had cutaneous problems requiring traction interruption, one on day 5 and the other on day 9. The mean residual slip was 16 degrees and 3 patients had complete or partial avascular necrosis well tolerated at the final follow-up. CONCLUSION: Our experience showed that if traction is supported for more than 2 weeks, a good correction of the epiphysis displacement can be obtained. Our short series does not allow affirmation of the superiority of our therapeutic strategy, especially with regards to avascular necrosis of the femoral head.

Spinal fracture through the neurocentral synchondrosis in battered children: a report of three cases.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To report 3 cases of unusual spinal fracture through the neurocentral synchondrosis. SUMMARY OF BACKGROUND DATA: Traumatic lesions of the spine or spinal cord due to physical abuse are rare. We report 3 cases of vertebral fractures involving the neurocentral synchondrosis in battered children. METHODS: The medical data of the 3 cases were retrospectively reviewed. We discuss the pathomechanism and treatment strategies. RESULTS: In 2 cases, the vertebral body was displaced anteriorly and, in 1 case, posteriorly, all without neurologic compromise. The lateral radiographs showed vertebral displacement, but the diagnosis could be suspected on frontal views because of interpedicular distance widening. Treatment was nonoperative with bracing in 2 cases. In the third case, a posterior epiphysiodesis was done to avoid development of progressive kyphosis of the injured spine. One child treated nonoperatively died from other traumatic lesions associated with the physical abuse. In the 2 other cases, outcome was good with a well-balanced spine in 1 case and a moderate, well-tolerated kyphosis in the other case. CONCLUSIONS: Such spinal lesions are rare but could be conservatively treated in case of anterior vertebral displacement without vertebral endplate impairment. A posterior displacement of vertebral body could be responsible for a neurologic compromise.

Osteochondritis dissecans of the subtalar articular facet: an unusual diagnosis.

Osteochondritis dissecans of the talus is classically characterized by an abnormality of the articular cartilage of the talar dome. We report a rare case of a lesion of the subtalar facet in a 10-year-old boy. The lesion was responsible for a painful ankle with secondary instability. The diagnosis was made using plain radiographs and CT, which showed a well-circumscribed osteochondral fragment demarcated from the adjacent bone by a radiolucent line. The clinical outcome was favourable after a 6-week period with a non-weight-bearing short-leg cast.

Correction of equinus in clubfoot: the contribution of arthrography.

The equinus deformity in clubfoot is twofold: talocrural and talocalcaneal. No study has been carried out on the link between these two elements and whether they are mutually dependent or independent. This has led to an unvarying operative strategy confined to opening the talocrural capsule and section of the talofibular ligament. To assess the extent to which these procedures are warranted, the authors performed perioperative talocrural arthrography, taking radiographs before and after each stage of operative treatment. In all cases, talocrural equinus seemed to disappear without the need for opening the talocrural capsule or sectioning the posterior talofibular ligament. Capsulotomy produced only an artificial, temporary increase in dorsiflexion due to posterior gaping between the talus and the tibia. The anatomy of the posterior talofibular ligament, moreover, makes it improbable that there is anything to be gained by sectioning it when congenital equinovarus clubfoot is being operatively reduced.