A systematic review and meta-analysis of long-term outcomes of femoral derotation surgery for intoeing gait in cerebral palsy.

BACKGROUND: Femoral derotation osteotomy is treatment of choice in intoeing gait secondary to cerebral palsy (CP). RESEARCH QUESTION: The aim of this study was to critically appraise the literature regarding the long-term outcomes of femoral derotation surgery in CP. METHODS: Electronic databases of PubMed and Scopus was used for the literature review by two researchers independently (SB, SC). The study population included patients of cerebral palsy undergoing femoral derotation surgery. The keywords used were "cerebral palsy", "intoeing gait", "femur anteversion", "hip anteversion", "femur derotation" and "femur osteotomy". RESULTS: Nine studies which included 657 limbs in 407 patients were selected for this study of which eight were retrospective in nature. The improvement in hip rotation at stance at last follow up (more than five years) maintained a statistical significance (SMD 1.67 95 %CI 1.12-2.22). Similar statistically significant outcomes were noted for foot progression angle (SMD 1.19 95 %CI 0.92-1.47), anteversion (SMD 2.75 95 %CI 1.49-4.01) and total passive internal rotation (SMD 1.71 95 %CI 1.19-2.22). SIGNIFICANCE: Femoral derotation surgery is the procedure of choice for correction of intoeing gait in CP. Even though, there is deterioration of results on long-term as compared to short term, majority of the patients shall maintain overall correction without recurrence of an intoeing gait. Future studies with uniform criteria for defining recurrence on the basis of functional limitations shall provide better idea about the natural course of this procedure.

Use of Growth Rod Systems for Management of Early Onset Scoliosis in Cerebral Palsy: A Systematic Review.

AIM: To review the literature for the role and outcome of growing rod surgeries in patients with cerebral palsy associated neuromuscular scoliosis. MATERIAL AND METHODS: A systematic search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic literature search was conducted of PubMed and Embase databases. Patient demographics, type of growing rod used, lengthening and complications were analyzed from the included studies. RESULTS: A total of 11 studies with poor overall study quality (Level of evidence IV, V) were included in the study. A total of 181 patients with mean age 6.8 ± 1.3 (5-13 range) years at index surgery and mean follow-up of 3.02 ± 1.3 (2-5.8 range) years were included in the study, with a female preponderance. The most common curve and instrumentation was thoraco-lumbar and conventional dual growing rods respectively. All studies showed improvement in Cobb?s angle and pelvic obliquity. There was better improvement in pelvic obliquity if pelvis was included in instrumentation. Wound related complications (34.6%) were most commonly noted. CONCLUSION: Overall growing rod construct has shown questionable outcomes in cerebral palsy patients with scoliosis in terms of the complication rate observed although allowing growth of the spinal column with regular lengthenings. Magnetic controlled growth rods hold a bright promise for the future considering its ability to maintain correction as well as the lower rate of complications The benefits and risk of immediate fusion with respect to growth sparing surgeries should be considered before the decision.

Imaging Parameters of Hip Dysplasia in Cerebral Palsy: A Systematic Review.

Background: Cerebral Palsy is the leading cause of childhood physical disability globally. The motor disorders of CP are often associated with musculoskeletal anomalies, of which hip displacement is the second most common abnormality after abnormalities of foot and ankle. Various radiological parameters have been described in the literature which detects and quantifies hip dysplasia, with MP being the current gold standard. This study aims to review these radiological indicators of hip dysplasia in children with cerebral palsy from the published literature. Methods: A literature search using PubMed, Embase, and Google Scholar was done on 15th June 2021 focusing on surveillance of hip dysplasia in cerebral palsy. The studies to be included were to have used anyone or more radiological parameter for detection of hip dysplasia with the use of any of the radiological methods. Results: The initial search yielded 1184 results. After the screening of the abstracts and full texts, a final of 30 studies was included for this systematic review. The majority of the studies were graded as Level 3 evidence (16/30), followed by Level 2 studies (14/30). X-ray was the most common modality of detection of dysplasia followed by CT scan, ultrasonography, and arthrogram. The reproducibility of the various parameters shows good to excellent intraclass coefficients. Conclusions: Parameters other than MP can be used to screen hips in CP. This would be useful in patients in whom either the lateral acetabular edge is not discernible on a plain anteroposterior radiograph or there are issues in the positioning of the patient. Additional views and structures can be visualized which can lead to improved screening and planning. Further investigations are required to appreciate the full potential of these parameters and how they can be better utilized.

Quantification of Volume Mismatch of Acetabulum and Femoral Head in Developmental Dysplasia of Hip.

Objectives: The sustained subluxation or dislocation of the femoral head over time does not permit normal development of acetabulum and results in predictable pattern of acetabular growth disturbance that is termed hip dysplasia. The primary aim of this study is to analyze and quantify the volume mismatch between acetabulum and femoral head of affected side as compared to normal hip. Methods: A prospective observational study was conducted by including isolated untreated unilateral idiopathic developmental dysplasia of hip (DDH). After routine clinical and radiographic examination, computed tomography (CT) of both hips was done with pre-determined radiation dosage within safe limits for the pediatric age group in 18 patients of median age 2 years (range 1-5 years). Results: A significant difference was noted between acetabular index (p<0.001), acetabular volume (p<0.001), femoral head volume (p<0.001), and acetabular anterior sectoral angle (p=0.002) of the affected and the normal hips. As compared to the normal side, the acetabulum is 2.6 times smaller than the normal side and femoral epiphysis volume by 3.8 times. A significant negative correlation (r=-0.66, p=0.04) was noted between posterior acetabular sectoral angle and acetabular volume of affected hip. Conclusion: CT is an important investigation in evaluation of late-presenting DDH. The absence of femoral head in its orthotopic location affects the volume of acetabulum as well as that of femoral head. The abnormality of the volume of acetabulum which is seen as related to the dysplasia should be studied and assessed in detail in a child of late-presenting DDH. This would guide us toward the coverage defect and type of osteotomy to be performed.

Swashbuckler approach for distal femur fractures: A systematic review.

PURPOSE: The review aims to reach a common consensus regarding the swashbuckler approach for distal femur fractures by a systematic review of the available literature and to evaluate the complications, union, and outcomes. METHODS: Electronic database search engines like Cochrane Library, PubMed, Google Scholar, and Scopus were searched until May 2021. Studies comparing the clinical complications, and functional outcome scores of Swashbuckler approach for distal femur were considered. The quality of the articles were evaluated using Methodological Index for Non-Randomized Studies score. RESULTS: Eleven studies were included for the final analysis. An anterior midline incision was used in the majority of studies. Superficial infection was the most common complication seen followed by knee stiffness and deep infections. 66.45% of the patients had excellent/good outcomes. 1.08% had a painful implant and 1.89% had deep infection. CONCLUSION: Swashbuckler approach offers itself as a viable option in cases of distal femur fractures, especially in AO type C. The quadriceps sparing approach provides excellent/good outcomes in approximately 66.45% of the patients.

Isolated multidrug-resistant tubercular tenosynovitis of the flexor tendon of the little finger.

Isolated multidrug-resistant (MDR) tubercular tenosynovitis of the flexor tendons of finger without involvement of wrist is a rare presentation. Tenosynovitis of hand is an uncommon manifestation of extrapulmonary tuberculosis. Pyogenic flexor tenosynovitis of hand is frequently seen and is the closest differential. Non-specific clinical signs may lead to delay in diagnosis, which is often made after biopsy. Management includes surgical excision of necrotic tissue and infected synovium along with antitubercular therapy after histopathological diagnosis. MDR tuberculosis of hand is extremely rare and, to the best of our knowledge, has not been reported in the literature so far. We report an interesting case of MDR tubercular flexor tendon tenosynovitis of the little finger without any pulmonary involvement in an immunocompetent patient. The case was managed by complete synovectomy and second-line antitubercular therapy with complete resolution of disease and had no functional limitation.

Risk Factors for Avascular Necrosis of the Femoral Head in Pediatric Femoral Neck Fractures.

Introduction A neck of femur fracture is a rare injury in the pediatric population and is of foremost importance, as it is associated with a high rate of complications. It usually occurs due to high-velocity trauma or a fall from a height. There is a scarcity of data on risk factors and their role in the prognostication of avascular necrosis. The purpose of the study was to retrospectively analyze the association of various risk factors with avascular necrosis (AVN) of the femoral head in patients with a neck of femur fracture in the pediatric age group. Material and methods The study included 21 (13 males and 8 females) pediatric patients with a neck of femur fracture treated at a university-level hospital. The patients were followed for a minimum of one year and the clinico-radiological outcome was analyzed using Ratliff criteria. The association of AVN with age, gender, side, fracture type, and injury with treatment delay, type of reduction, and type of internal fixation used was studied. Results The mean age of the treated patients was 11 (±3.178) years (range=5-16 years). Avascular necrosis was seen in four patients and coxa vara occurred in two of them. A statistically significant association was seen between the Delbet fracture type and avascular necrosis, and three out of four cases of AVN were a Type I fracture (p-value=0.006). Three out of six patients having concomitant skeletal or other organ injuries developed AVN (p-value=0.022). The rate of AVN was higher in patients who were managed after 48 hours of initial injury but no statistically significant correlation was found (p-value=0.314). No statistically significant association with AVN was found between gender, age, type of reduction (closed/open), or the implant used (cannulated screws/k-wires). Conclusions Multiple independent factors may have a role in the development of AVN of the femoral head in children. Prognostication should not be based on a single factor. Statistically significant results in this study have shown that the type of fracture and concomitant skeletal or other organ injuries are important risk factors and should be kept in mind. All independent risk factors must be noted and should be considered while prognosticating the outcome of a child with a neck of femur fracture.

Non-Vascularized Tri-Cortical Iliac Crest Graft-A Reliable Option in the Management of Scaphoid Waist Non-Unions.

Background: Scaphoid non-union often leads to a change in biomechanics of the wrist joint. Various types of bone grafts and different sites of harvest have been described in the literature for scaphoid reconstruction. This study was conducted to assess the clinical and radiological outcome after non-vascularised tri-cortical iliac crest bone graft for non-union of scaphoid waist fractures. Methods: 12 adult patients who underwent reconstruction of scaphoid waist non-union with tricortical iliac crest grafting and internal fixation with headless compression screws (11 cases) and k-wires (1 case) were prospectively analysed. There were 11 males and 1 female (mean age 23.9 years). The mean duration of presentation was 5.7 months following injury. Outcome following surgery were analyzed clinically by range of movements (ROM) and functional scores like DASH and modified Mayo wrist score and radiologically by X-rays and Non contrast CT of the wrist. Radiological assessment included scaphoid length, radio-lunate (RL) angle and scapho-lunate (SL) angle at latest 6 months follow up. Results: Bony union was achieved in 10 cases (union rate 83%). All the cases which achieved union had a significant improvement in radiological and clinical outcome criterias at 6-month follow-up interval. 1 patient had persistent non-union and 1 had k-wire back out with fixation failure. Conclusions: It is important to restore scaphoid length and to correct flexion deformity for a successful outcome. This can reliably be acheived by a carefully planned wedge-shaped iliac crest graft along with secure fixation with a headless compression screw.

Pig Bite Injury Mimicking as Battered Baby Syndrome Leading to Bilateral Foot Amputation in a Toddler: A Diagnostic Dilemma and a Rare Case Report.

INTRODUCTION: Animal bites are a less common cause of pediatric injury. They are rarely associated with fractures in toddlers. Child abuse is the most closely related differential diagnosis in a child presenting with animal bite and it is a serious threat to both mental health and physical well-being of pediatric population. In all such cases with diagnostic dilemma, battered child syndrome (BCS) needs to be ruled out and reported. To the best of our knowledge, there has been no case report of bilateral femur fracture after a pig bite injury in a toddler with gangrene of bilateral foot. Hence, we report this case to highlight the importance of differentiating animal bite injuries to BCS. CASE REPORT: We report a rare case of pig bite injury with bilateral femur fracture and bilateral foot gangrene in a case of an 11-month-old female child suffering from BCS. CONCLUSION: Apart from the medical and surgical management of pediatric injuries, it is essential to determine the cause of pediatric fractures and differentiate between abuse and accidental trauma. Identification of the etiology is significant to make sure that proper multidisciplinary intervention is initiated for the safety of the child.