The Role of Taylor Spatial Frame in the Treatment of Blount Disease.

BACKGROUND: Alteration of the posteromedial part of the proximal tibia is the main characteristic of Blount's disease and if left untreated, leg alignment and normal development of the lower limbs may be compromised. AIM: To report treatment outcomes in children with Blount's disease using the Taylor Spatial Frame (TSF). MATERIALS AND METHODS: From January 2007 to December 2014, 16 young children (24 tibia) with a mean age of 7.5 years (range of 3-14 yrs) and severe Blount's disease were treated using TSF. Preoperative long standing radiographs were performed and anatomic medial proximal tibial angle (MPTA), diaphyseal-metaphyseal tibial angle (Drennan), femoro-tibial angle and leg length discrepancy (LLD) were measured. RESULTS: Post-operative improvement of all measurements was observed. MPTA increased from a mean of 71.8° (58° - 79°) to 92.5° (90° - 95°), the Drennan decreased from 16.6° (14° - 18°) to 3.6° (0° - 6°), the F-T angle changed from 15.4° (10° - 25°) of varus to 5.9° (2° - 10°) of valgus and the LLD decreased from 208 mm (150-320) to 69 mm (0- +120). Mean follow-up was 45.6 months. According to Paley's criteria pin track infection was present in 6 tibiae, while in 5 patients software changes were necessary. Recurrence was observed in 3 patients (triplets). Complete restoration of the mechanical axis was obtained at the end of the treatment. CONCLUSIONS: In the last decades, different surgical treatments have been proposed for Blount's disease (tension band plate, staples, osteotomies using external or internal fixation). External fixation using the TSF allows gradual safe correction of multiplanar deformities and is a well-tolerated technique by patients with Blount's disease.

An Epidemiological Study of Non-specific Low Back Pain in Non-professional Female Greek Classic Ballet Dancers.

AIM: Epidemiological study of the incidence of mechanical low back pain (LBP) in non-professional female Greek classic ballet dancers over a year and therapeutic interventions required to address symptoms. MATERIALS AND METHODS: Forty-six female classic ballet dancers members of preprofessional schools, aged 16-37 years (mean 28.8 ±5.44 yrs) practicing and training in classic dance for 6-40 hours/week (mean 10.8±6.68) and 2-27 years experience (mean 11.9±4.20 yrs) participated in an epidemiological study concerning the incidence of LBP episodes within the last year, the treatment they received, as well as the period of absence of training and performance due to LBP. A selfadministered questionnaire was employed. Information regarding incidence, duration, and intensity of mechanical low back pain was gathered as well as length of time away from practice or performance. A secondary aim was to investigate the type of conservative treatment that participants in this study received. RESULTS: Thirty-one (67.4%) participants in the study experienced 1-10 (mean 3.26±1.7) episodes of mechanical LBP in the previous 12 months. They had to refrain from dancing activities from 2 to 90 days (mean 16.9±16.22). Twenty one of the participants received some kind of conservative treatment. CONCLUSION: The incidence of LBP was found to be high among Greek amateur classic ballet dancers resulting in absence from dancing activities for a considerable length of time and raising the need for therapeutic intervention for a considerable percentage of the studied population. Effective prevention strategies of LBP are of vital importance, particularly in younger dancers.

Evidence-based evaluation and current practice of non-operative treatment strategies for lumbar stenosis.

OBJECTIVE: A number of non-operative treatment protocols have been proposed in the literature for lumbar stenosis. However, the available primary research describes inadequately the employed protocol. This causes difficulties in distinguishing which interventions are more effective in reducing symptoms. METHODS: We reviewed existing studies in order to promote the construction of an evidence-based strategy for non-operative treatment rehabilitation of lumbar stenosis patients. Randomized controlled trials describing insufficiently the non-operative treatment rehabilitation protocols were excluded since the results may not direct this review towards a favorable treatment plan. RESULTS: A protocol has been outlined to inform the clinician and to elucidate the effectiveness of non-operative treatment through randomized controlled trials. The results of this study indicate that a comprehensive exercise and manual therapy protocol is more effective in reducing symptoms than a less intensive exercise program. CONCLUSIONS: A comprehensive non-operative treatment comprising of flexion exercises, manual therapy and treadmill exercises appears to be more beneficial in reducing symptoms than a less vigorous program comprising of flexion exercises, treadmill training and home exercise.

Treatment and outcomes of pelvic malunions and nonunions: a systematic review.

UNLABELLED: Although acute management of pelvic fractures and their long-term functional outcome have been widely documented, important information regarding malunion and nonunion of these fractures is sparse. Despite their relative rarity, malunions and nonunions cause disabling symptoms and have major socioeconomic implications. We analyzed the factors predisposing a pelvic injury to develop malunion/nonunion, the clinical presentation of these complications, and the efficacy of the reported operative protocols in 437 malunions/nonunions of 25 clinical studies. Treatment of these demanding complications appeared effective in the majority of the cases: overall union rates averaged 86.1%, pain relief as much as 93%, patient satisfaction 79%, and return to a preinjury level of activities 50%. Nevertheless, the patient should be informed about the incidence of perioperative complications, including neurologic injury (5.3%), symptomatic vein thrombosis (5.0%), pulmonary embolism (1.9%), and deep wound infection (1.6%). For a successful outcome, a thorough preoperative plan and methodical operative intervention are essential. In establishing effective evidence-based future clinical practice, the introduction of multicenter networks of pelvic trauma management appears a necessity. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Treatment of proximal humerus fractures with locking plates: a systematic review.

HYPOTHESIS: Locking plates with special configuration for the anatomic region of the proximal humerus have been introduced recently to address the difficulties of stabilizing proximal humeral fractures. The purpose of this study was to carry out a systematic review of the literature on the efficacy and early to medium term functional results of locking plates for stabilization of proximal humeral fractures. METHODS: Using the PubMed database, a systematic review of the English and German literature was carried out in order to assess the efficacy and complications related to the use of these plates and the patients' functional outcome, using the key words "locking plates proximal humeral fractures," "angular stability plates proximal humeral fractures," "PHILOS plate," and "LPHP plate." Our criteria for eligibility were clinical studies with more than ten cases followed-up, adult patients, and adequate data provided at least in terms of implant related complications. Articles written in English and German language were included. Exclusion criteria were: studies dealing exclusively with 2-part fractures (since this category has a more favorable outcome); experimental studies; case reports; and, literature other than English or German. Each one of the articles was evaluated for quality of the study using the Structured Effectiveness Quality Evaluation Scale (SEQES). RESULTS: Twelve studies including 791 patients met the inclusion criteria. Patients in these studies continued to improve up to one year, achieving a mean Constant score of 74.3. The incidence of the reported complications was: avascular necrosis 7.9%, screw cut-out 11.6% and re-operation rate 13.7%. DISCUSSION: The high incidence of cut-out may be secondary to the rigidity of the implant in combination with medial inadequate support, in cases compromised by severe underlying osteoporotic bone. Definition of indications for the use of locking plates and attention on technical aspects of applying them would help optimization of the results. LEVEL OF EVIDENCE: Systematic Review.

Update on diagnosis and management of cuboid fractures.

Cuboid fractures due to the particular bone anatomy and its protected location in the midfoot are rare, and they are usually associated with complex injuries of the foot. Clinical examination to diagnose these fractures should be detailed and the differential diagnosis, especially in the case of vague symptoms, should include the exclusion of all lateral foot pain causes. Conventional radiographs do not always reveal occult fractures, which can be under diagnosed especially in children. In this case, further investigation including magnetic resonance imaging or scintigraphy may be required. The treatment of these injuries depends on the particular fracture characteristics. Non-displaced isolated fractures of the cuboid bone can be effectively treated conservatively by immobilization and by avoiding weight bearing on the injured leg. In the case of shortening of the lateral column > 3 mm or articular displacement > 1 mm, surgical management of the fracture is mandatory in order to avoid negative biomechanical and functional consequences for the foot and adverse effects such as arthritis and stiffness as well as painful gait. In this review, an update on diagnosis and management of cuboid fractures is presented.

Evaluation of physical performance in musculoskeletal and rheumatic diseases with jumping mechanography.

OBJECTIVE: Low muscle function is a component of sarcopenia. Rheumatic and musculoskeletal diseases are related to increased muscle loss and decreased muscle performance. Our purpose was to study muscle function among pre and postmenopausal women and women with rheumatic diseases. METHODS: Two hundred fifty seven women were included in the study: Group POST OST included 61 osteoporotic postmenopausal women under treatment with osteoporotic drugs and calcium/vitamin D supplements (mean age 65±9.6 years), group POST HEALTH consisted of 117 healthy postmenopausal women (mean age 62.9±9.8 yrs), Group RHEUM included 20 women with rheumatic diseases (mean age 58.85±13yrs), and group PRE included 59 healthy premenopausal women (mean age 35±7.6 yrs). For the measurement of objective parameters of movement (Force, velocity, Power), we used the mechanography system in Leonardo platform (Novotec, Germany). Personal Power (Power/Weight) was also calculated. RESULTS: Height was decreased with age, while body mass index (BMI) and weight were significantly increased. In groups POST OST, POST HEALTH, RHEUM, all measured parameters were statistically decreased in comparison with group PRE. No statistical significance was found among POST HEALTH and POST OST women. CONCLUSIONS: Jumping mechanography can be proposed as a novel tool to assess physical performance in musculoskeletal and rheumatic diseases. It offers to the clinician additional information, while quantitatively assesses muscle function, for assessing sarcopenia.

Transforaminal Percutaneous Endoscopic Discectomy using Transforaminal Endoscopic Spine System technique: Pitfalls that a beginner should avoid.

Transforaminal Percutaneous Endoscopic Discectomy (TPED) is a minimally invasive technique mainly used for the treatment of lumbar disc herniation from a lateral approach. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss, trauma, and scar tissue compared to conventional procedures. However, the procedure should be performed by a spine surgeon experienced in the specific technique and capable of recognizing or avoiding various challenging conditions. In this review, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Synthesis of evidence for the treatment of intersection syndrome.

Intersection syndrome is a rare sports overuse injury occurring through friction at the intersection of the first and second compartment of the forearm. Differential diagnosis must be carefully made, especially from De Quervain tendonsynovitis. Clinical examination provides with the necessary information for diagnosis, still magnetic resonance imaging scans and ultrasonography may assist in diagnosis. Treatment consists mainly of rest, use of a thumb spica splint, analgetic and oral nonsteroidal anti-inflammatory drugs and after 2-3 wk progressive stretching and muscle strengthening. Should symptoms persist beyond this time, corticosteroid injections adjacent to the site of injury may be useful. In refractory cases, surgical intervention is warranted.

Osteitis pubis in elite athletes: Diagnostic and therapeutic approach.

Osteitis pubis (OP) is a debilitating overuse syndrome characterizing by pelvic pain and local tenderness over the pubic symphysis commonly encountered in athletes often involved in kicking, twisting and cutting activities in sports such as soccer and rugby and to a lesser degree distance running. It is a common source of groin pain in elite athletes attributable to pubis sympysis instability as the result of microtrauma caused by repetitive muscle strains on pubic bones. Diagnosis is based mainly on detailed sports history and a meticulous clinical examination, although occasionally is difficult to distinguish this nosological entity from other pathologies affecting the involved area which may occur concomitantly in the same patient. Radiologic examinations such as plain radiographs, magnetic resonance imaging and 3 phase bone isotope scanning may be helpful to differentiate from other clinical entities with similar clinical presentation. Most cases respond well to conservative treatment which includes several physical modalities and especially a progressive rehabilitation programmed individualized to each one of patients diagnosed with OP. Local injection therapies have been also been proposed as a non-operative therapeutic option for the efficient management of these patients. In refractory cases, surgical therapeutic strategies are warranted. These include several open or minimally invasive surgical interventions such as arthroscopic or open symphysis curettage, wedge or total resection of pubic sympysis, polypropylene mesh placement and pubic fusion. In this review a critical analysis of OP in elite athletes is performed with special focus on current concepts of diagnosis and management of this source of athletic groin pain.

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review.

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.

Low-intensity electrical stimulation in wound healing: review of the efficacy of externally applied currents resembling the current of injury.

OBJECTIVE: Low-intensity currents (LIC) have gained popularity during the last years, and nowadays the majority of electrotherapy units may produce LIC. On wounding, the body produces a current, the current of injury, which promotes healing. Still, this current may gradually decrease resulting occasionally to delayed or limited wound healing. Thus, by applying the same LIC externally, healing may be accelerated by sustaining the LIC throughout the healing phases. The first review of research studies on the effect of LIC on wound healing is attempted, which can be considered useful for the practicing clinician, to provide an overview of current evidence on the effectiveness of LIC and provide protocols of treatment. METHODS: Comprehensive review of randomized-controlled trials investigating the effect of LIC on wound healing. RESULTS: The review revealed that LIC promote wound healing and appear to be effective in the range of 200-800 muA. The direct current may be continuous or pulsed and polarity may or may not be reversed. CONCLUSION: Research available indicates that LIC accelerate wound healing. Further research is required to clarify the healing effects of LIC on wounds.

Effectiveness of electromyographic biofeedback in the treatment of musculoskeletal pain.

Electromyographic biofeedback is a therapeutic modality used along with other interventions in the treatment of pain. This article presents a brief review of the effectiveness of electromyographic biofeedback in treating musculoskeletal pain. Electromyographic biofeedback may provide pain relief for chronic musculoskeletal pain due to cumulative trauma, and may be proposed as an additional intervention to exercise in patellofemoral pain syndrome and acute sciatic pain. Electromyographic biofeedback is comparable to cognitive behavioral treatment and relaxation techniques. When added to an exercise program in patients with patellofemoral pain or acute sciatic pain, no further pain reduction is achieved. Electromyographic biofeedback promotes active participation and thus may motivate patients to adopt an active role in establishing and reaching goals in rehabilitation. Further research is required to investigate its effect on musculoskeletal pain.

Cowden syndrome. Managing multiple skeletal metastases of different origin: a case report.

BACKGROUND: Cowden Syndrome is a rare autosomal dominant multiple hamartomatous condition, characterised by both benign and malignant tumours affecting multiple systems. CASE PRESENTATION: We present a 47-year-old female patient with thigh pain that was diagnosed with Cowden syndrome 20 years ago and developed multiple and different skeletal metastases which became resistant to radio-chemotherapy. A percutaneous plate fixation of the distal femur with an intralesional excision and cementoplasty of the metastasis was performed initially. This was combined with a cemented total hip arthroplasty using an Exeter long revision stem and a cementoplasty of the femoral canal for the proximal lesions. CONCLUSION: A meticulous approach to her complex metastatic disease resulted in successful palliative prophylactic reconstructive surgery that improved her quality of life, allowing her independent pain free walking for 12 months.