Sprengel deformity: morphometric assessment and surgical treatment by the modified green procedure.

BACKGROUND: We evaluated the pathologic anatomy of the Sprengel deformity using radiographs, 3-dimensional computed tomography (3D-CT), and magnetic resonance imaging (MRI), and reviewed our results of the modified Green procedure. METHODS: Between 2002 and 2009, 23 scapulae in 22 patients were treated. The average age at the time of surgery was 3.4 years (range, 1.9 to 7.1 y). The outcome of surgery was assessed on the basis of changes in shoulder abduction and the radiographic findings using Cavendish classification, Rigault classification, scapular elevation, and medialization. Preoperative appearance was classified as grade III in 13 cases and grade IV in 10 cases according to the Cavendish classification, and as grade II in 4 cases and grade III in 19 cases according to the Rigault classification. Using 3D-CT, we assessed the height to width ratio on the scapular posterior view, the superior displacement ratio and rotational difference on the trunk posterior view, and the anterior curvature of the supraspinous portion on the scapular medial view. RESULTS: The average follow-up postoperative period was 4.4 years (range, 2.2 to 8.7 y). Postoperatively, the shoulder abduction improved well, with a mean improvement of 63 degrees. Improvement of at least 1 Cavendish grade and 1 Rigault grade was attained in all cases. On preoperative 3D-CT, the mean height to width ratio of the affected scapula was significantly smaller than that of the contralateral scapula. There was an inverse relationship between the superior displacement ratio and the rotational difference. Anterior curvature of the supraspinous portion was seen in all cases. Omovertebral bone was found in 20 cases. MRI identified unossified omovertebral cartilage that was not evident by radiographs or CT. Transient brachial plexus palsy occurred in 2 patients, both of whom recovered within 4 months. Postoperative scapula winging and unsightly scarring were seen in 3 and 8 cases, respectively. CONCLUSIONS: 3D-CT and MRI were helpful in evaluating the pathologic anatomy of the deformity and in planning the surgery. The modified Green procedure provided successful functional and cosmetic results. LEVEL OF EVIDENCE: Level IV.

Angulated Salter osteotomy in the treatment of developmental dysplasia of the hip.

Salter osteotomy is widely used to improve acetabular coverage in the treatment of developmental dysplasia of the hip. Herein we describe angulated Salter osteotomy (ASO) as the modified Salter osteotomy, which creates a two-point contact between the proximal and distal fragments and better stabilizes the fixation of the fragments. We reported our results of ASO and compared it with that of Salter osteotomy performed previously by us. We retrospectively reviewed 41 unilateral hips that underwent ASO, with no other accompanying procedures, between 2012 and 2018. We investigated the radiographic measurements included the preoperative values of the acetabular index and center-edge angle (CEA), immediate postoperative values of distance d (lateral displacement of the distal fragment), lateral rotation angle (LRA), the ratio of the obturator height (ROH), pelvic height increase percentage (PHIP) and the values of acetabular index and CEA during the last follow-up. Measurements were compared with 20 unilateral hips that underwent Salter osteotomy. The mean age at the time of surgery was 5.4 years, and the mean follow-up duration was 3.3 years. Immediately after surgery, the mean distance d, LRA, ROH and PHIP were 8 mm, 19°, 70 and 1%, respectively. The last follow-up values of acetabular index and CEA significantly improved from the preoperative values by 18° and 21°, respectively. Patients treated with ASO showed significantly larger distance d, more improvement in CEA, and lesser PHIP than those treated with Salter osteotomy. The short-term outcomes of ASO are favorable. ASO was as effective as or better than Salter osteotomy in pulling out and stabilizing the distal fragment anterolaterally. ASO prevents elongation of the ilium, which causes pelvic obliquity.

Transtrochanteric rotational osteotomy for late-onset Legg-Calve-Perthes disease.

BACKGROUND: The pathology of late-onset Legg-Calve-Perthes disease (LCPD) is similar to that of avascular necrosis of the femoral head in adult and is associated with poorer prognosis of the hip. The optimal treatment for this condition is still controversial. The purpose of this study was to evaluate the long-term clinical results of the transtrochanteric rotational osteotomy for the patients with LCPD onset at more than 9 years of age. METHODS: Individuals included 14 hips in 13 cases with the mean age at onset of the disease and operation of 10 years 9 months and 12 years. Average follow-up periods were 12 years. All cases were resistant to the conservative treatments and did not have our indications for varus osteotomy. Clinical results were evaluated using Merle d'Aubigne Postel score and the modified Stulberg criteria. RESULTS: Average Merle d'Aubigne Postel score at the final follow-up was 16.2 points ranging from 12 to 18 points. All patients did not have additional treatment except nail removal. Stulberg class II, III, and IV were obtained in 5, 2, and 7 hips, respectively. More spherical femoral head was obtained in patients with less head involvement and more bone preservation or new bone formation at posterior pillar. Three hips showed slight narrowing of joint space without severe osteoarthritic changes. CONCLUSIONS: Transtrochanteric rotational osteotomy is an effective procedure to salvage the hips of the late-onset LCPD. Amount of head involvement, posterior and lateral pillar had influences on the surgical outcomes.

Multi-body dynamic coupling mechanism for generating throwing arm velocity during baseball pitching.

The purpose of this study was to identify the detailed mechanism how the maximum throwing arm endpoint velocity is determined by the muscular torques and non-muscular interactive torques from the perspective of the dynamic coupling among the trunk, thorax and throwing and non-throwing arm segments. The pitching movements of ten male collegiate baseball pitchers were measured by a three-dimensional motion capture system. Using the induced-segmental velocity analysis (IVA) developed in this study, the maximum fingertip velocity of the throwing arm (MFV) was decomposed into each contribution of the muscular torques, passive motion-dependent torques due to gyroscopic moment, Coriolis force and centrifugal force, and other interactive torque components. The results showed that MFV (31.6±1.7m/s) was mainly attributed to two different mechanisms. The first is the passive motion-dependent effect on increasing the angular velocities of three joints (thorax rotation, elbow extension and wrist flexion). The second is the muscular torque effect of the shoulder internal rotation (IR) torque on generating IR angular velocity. In particular, the centrifugal force-induced elbow extension motion, which was the greatest contributor among individual joint contributions, was caused primarily by the angular velocity-dependent forces associated with the humerus, thorax, and trunk rotations. Our study also found that a compensatory mechanism was achieved by the negative and positive contributions of the muscular torque components. The current IVA is helpful to understand how the rapid throwing arm movement is determined by the dynamic coupling mechanism.

Foot centralization for tibial hemimelia.

Nineteen foot centralizations were performed in 14 patients with Jones type I and II tibial hemimelia. All feet showed equinovarus deformity and were treated by foot centralization by means of calcaneofibular arthrodesis. The average age of patients at the time of surgery was 1.3 years (range 0.4-3.8 years). The average follow-up postoperative period was 10.2 years (range 2.2-22.9). At the time of the final follow-up, four of the operated feet were plantigrade without secondary surgery. The remaining 15 limbs, however, required secondary surgery to treat postoperative early loss of correction and/or recurrent foot deformities such as equinus, varus and adduction, in addition to talipes calcaneal deformities, and fibular angular deformity at the fibular shortening osteotomy site. The deformities were treated either by repeat foot centralization, or fibular or calcaneal osteotomy. Careful observation for recurrence of the deformity is necessary until the distal fibular epiphysis closes, and the cartilagenous distal fibular end and calcaneus finally achieve ankyloses.

Correlation between center-edge angle and acetabulum-head index in developmental dysplasia of the hip with avascular necrosis of the femoral head.

In order to clarify the relationship between the center-edge angle and the acetabulum-head index, we reviewed 97 hips in 86 patients suffering from developmental dysplasia of the hip. We measured the center edge angle and the acetabulum-head index, and evaluated avascular necrosis of the femoral head according to Kalamchi classification. The center-edge angle correlated highly with the acetabulum-head index in non-avascular necrosis, and in Kalamchi groups I and II, but not in Kalamchi groups III and IV. Because of difficulties in measurement, it is possible that the center-edge angle does not precisely indicate acetabular coverage of developmental dysplasia of the hip with avascular necrosis.

Primary lymphocutaneous nocardiosis caused by Nocardia otitidiscaviarum.

A case of primary lymphocutaneous nocardiosis caused by Nocardia otitidiscaviarum in a 69-year-old previously healthy woman is described. The organism was identified in cultures of pus specimens. The patient was treated with a six-month course of oral trimethoprim-sulfamethoxazole chemotherapy following incision and drainage, and the infection completely resolved.

Limb salvage treatment for Gollop-Wolfgang complex (femoral bifurcation, complete tibial hemimelia, and hand ectrodactyly).

We reported the findings from three patients with Gollop-Wolfgang complex and demonstrated the results of five limb salvage treatments for this condition. All three femoral bifurcations were accompanied by ipsilateral complete tibial hemimelia. Two patients showed contralateral complete or partial tibial hemimelia, and one patient had hand ectrodactyly. The five limb salvage treatments included resection of the anteromedial bifurcated femur in three limbs, foot centralization in five limbs, tibiofibular fusion in one limb with partial tibial hemimelia, fibular transfer (Brown's procedure) in three limbs with complete tibial hemimelia, and callus distraction lengthening in one limb. The duration from the first operation to the final follow-up ranged from 3.5 to 5.4 years. None of the three knees treated by fibular transfer achieved a successful functional result, but all of the knees were ultimately able to withstand weight bearing. Early knee disarticulation and resection of the protruded bifurcated femur, followed by fitting of a modern prosthesis is likely to be the best treatment for patients with Gollop-Wolfgang syndrome. We note that limb salvage treatment is an alternative in patients who opt to retain their feet and refuse amputation.

Surgical treatment of hip dislocation in amyoplasia-type arthrogryposis.

We reviewed our clinical and radiographic results in the operative treatment of five unilateral and six bilateral hip dislocations in 11 patients with amyoplasia-type arthrogryposis. The mean age at surgery was 1.8 (range, 1.1-3.2) years. Femoral and/or pelvic osteotomies were combined with an open reduction. The mean follow-up period was 12.7 (range, 5.2-23.2) years. Nine patients were community walkers and two were household walkers. The range of motion and the St Clair hip score of the bilateral hips were not significantly different from those of the unilateral hips. Successful reduction increases the ambulation potential in both unilateral and bilateral hip dislocations.

Surgical treatment of hip dislocation in Kabuki syndrome: use of incomplete periacetabular osteotomy for posterior acetabular wall deficiency.

PURPOSE: Kabuki syndrome is characterized by distinctive facial features, skeletal anomalies, persisting fingertip pads with dermatoglyphic abnormalities, postnatal growth deficiency and mental retardation. This report reviews our results in the operative treatment of hip dislocations in patients with Kabuki syndrome. METHODS: Between 2001 and 2009, seven dislocated hips (three unilateral and two bilateral hips) in five patients (all girls) were operatively treated at our institution. The operative treatment consists of open reduction, femoral derotation varus osteotomy, pelvic osteotomy (Salter in one and incomplete periacetabular osteotomy in six hips) and capsular plication. The age of the patients at the time of surgery ranged from 2.4 to 5.7 years, with an average of 3.6 years. RESULTS: The follow-up postoperative period ranged from 3.2 to 6.3 years, with an average of 5.0 years. At the final follow-up, all patients reported no click and no pain, and showed well-contained hips by radiographs. All seven hips were graded as Severin class I-II. One patient presented as having habitual dislocation of the hip 4.4 years after surgery. Computed tomographic (CT) scans revealed posterior acetabular wall deficiency, which was not corrected by the anterolaterally directed Salter osteotomy. The incomplete periacetabular osteotomy provided sufficient posterolateral coverage of the acetabulum. CONCLUSION: Operative treatment combining open reduction, femoral derotation varus and incomplete periacetabular osteotomies, and capsular plication provided successful results in patients with Kabuki syndrome who had the characteristics of hip instability such as ligamentous laxity, muscular hypotonia and posterior acetabular wall deficiency.

Long-term follow-up on the use of vascularized fibular graft for the treatment of congenital pseudarthrosis of the tibia.

BACKGROUND: Congenital pseudoarthrosis of the tibia (CPT) is one of the most difficult conditions to treat. METHODS: Five girls and 3 boys with CPT were treated by vascularized fibular grafting (VFG). The average age at VFG was 7.0 years (range: 1.9-11.5 years) with an average follow-up term of 11.7 years (range: 4.9-19.6 years). Five of the children had undergone multiple operations before VFG, while the other 3 had no such history. RESULTS: Bone consolidation was obtained in all cases after an average term of 6.6 months (range: 4-10 months); this was with the first VFG in 7 cases but with the second VFG in 1 case. Complication of stress fracture and ankle pain occurred in 1 and 3 cases, respectively, only in cases undergoing multiple operations. Leg-length discrepancy was more prominent in the patients with multiple previous operations (mean: 7.5 cm), than in the cases with no prior surgery (mean: 0.7 cm). CONCLUSION: The long-term results of VFG for CPT were excellent, especially in the cases, with no prior surgery. VFG should be considered as a primary treatment option for CPT.