[Retrosternal luxation of the clavicle. Apropos of 4 cases surgically treated using a temporary screwed anterior plate and review of the literature]

The authors report 4 new cases of retrosternal dislocation of the clavicle operated by capsular and ligament restoration, and temporary stabilization by anterior plating. The 4 patients were men with a mean age of 17.5 years. The lesion was caused by a sports injury (football, rugby) in 3 out of 4 cases and was related to an indirect mechanism. Clinical examination allowed the diagnosis, was related to based on painful palpation of a dip over the joint, supported by radiology and computed tomography. CT did not reveal the epiphyseal separation present in two cases. Complications were frequent: 1 case of tracheal compression, 2 cases of temporary paresthesia of the upper limb, 2 cases of venous compression with one case of subclavian and medial jugularis venous thrombosis, 1 hemopneumothorax. Surgical reduction was performed in all 4 cases after 2 failures of attempted orthopedic treatment under general anesthesia. All patients recovered a full range of movement, a painless shoulder and no recurrence has been observed. All complications resolved after reduction. Venous thrombosis responded favourably after 6 months of anticoagulant therapy. One plate breakage was observed with no clinical implications. On the basis of an extensive review of the literature, the authors discuss the epidemiology, pathology and the importance of associated injuries, which are frequent and sometimes serious, justifying urgent reduction. Computed tomography is the most useful radiologic modality, both for diagnosis and for investigation of complications. Orthopedic treatment must be attempted first (especially in children) according to a well systematized technique. One third of attempts fail, and cases of delayed diagnosis and serious vascular complications, then require surgical treatment. The costoclavicular ligament is repaired either by Burrows's ligamentoplasty or by bone suture; the clavicle is stabilized by bone suture or by anterior plating. The authors do not advocate either joint fixation by Kirschner wire, or resection of the medial end of the clavicle.

[Greater trochanter epiphyseodesis in treatment of hip deformity]

A series of 29 patients (33 hips) after greater trochanter epiphyseodesis in treatment for hip deformity has been reviewed. An indication for this surgery was increasing proximal femur deformity due to the damage of subcapital growth plate (avascular necrosis) during the treatment for congenital dysplasia of the hip. The age of patients at surgery was mean 8.1 years, mean follow-up was 10.1 year. Clinical and radiological assessment revealed ineffectiveness of greater trochanter epiphyseodesis in treatment for increasing hip deformity due to avascular necrosis in the age group in question.

Improving the distal fixation of intramedullary nails in osteoporotic bone

Twenty-four mildly osteoporotic human femurs were used to examine the fixation stability of several types of distal locking screws in osteoporotic femoral condylar segments. The fixated femurs were axially loaded to 1000 N at a rate of 100 N/sec to assess the locking screws' resistance to motion and then sinusoidally cycled to 10,000 cycles with a 500 N load to assess axial stability. Of the four screw configurations tested, the standard screws and the standard screws placed at a 30 degree crossing angle were significantly more stable (p < 0.05) than the step screw and osteoporotic bolt.

Totally absorbable fixation in the treatment of fractures of the distal femoral epiphyses. A prospective clinical study

Nine adolescent patients with a femoral fracture involving the physeal plate were treated by using self-reinforced absorbable polyglycolide (SR-PGA) and poly-L-lactide (SR-PLLA) screws with a follow-up for an average of 2 years and 2 months. During the follow-up all but one of the femurs became skeletally mature. In two of nine patients a clinically significant growth disturbance occurred. The average length difference of the femurs was -5 mm (ranging from +8 mm(-)-41 mm). One valgus deformity was noted. In four patients a lengthening and in four patients a shortening of the operated femur were registered at the end of follow-up. Open reduction and fixation with absorbable screws seem to be suitable for the fixation of distal femoral fractures in adolescents.

Screw epiphysiodesis for ankle valgus

Progressive ankle valgus is an insidious deformity that may develop during childhood due to a variety of etiologies including neuromuscular disease, skeletal dysplasia, chromosomal anomalies, and clubfoot. This may be concomitant with, or mistaken for, hindfoot valgus. The surgical options for treatment include supramalleolar osteotomy or hemiepiphysiodesis of the medial distal tibial physis. We report the rationale and technique of retarding medial malleolar growth by means of inserting a single 4.5-mm vertical screw. In a population of 31 children (50 feet), we have observed satisfactory improvement of ankle valgus with low morbidity and without permanent physeal closure. This represents a safe, predictable, and effective solution for children who present with progressive and symptomatic ankle valgus.

Accuracy of MR imaging for estimating intraosseous extent of osteosarcoma

OBJECTIVE

We compared how well T1-weighted and short inversion time inversion recovery (STIR) MR images obtained before and after preoperative chemotherapy reveal the extent of longitudinal intraosseous tumor involvement in osteosarcoma of children.

MATERIALS AND METHODS

MR images were obtained at diagnosis and after preoperative multiagent chemotherapy in 20 children with osteosarcoma arising in the long bones. Images were reviewed to determine the length of the abnormal intraosseous signal intensity on paired longitudinal T1-weighted and STIR images taken at diagnosis and after chemotherapy. These measurements were compared with those made during a review of similarly oriented pathologic sections of the resected bone. Median differences were calculated and analyzed using Wilcoxon's signed-rank test.

RESULTS

Abnormalities detected on T1-weighted images corresponded more closely to pathologic findings than did abnormalities detected on STIR images. On STIR images, readers overestimated tumor extent in 73% of both pre- and postchemotherapy studies. Readers overestimated tumor length on 29 of the 40 STIR images and on 13 of the 40 T1-weighted images. Readers underestimated tumor length on five STIR images and 11 T1-weighted images. Median differences between measurements made at the pathologic examination and on STIR images were statistically significant, both for imaging at diagnosis (p = .001) and for imaging after chemotherapy (p = .005); however, no significant differences were found between measurements made at the pathologic examination and measurements made on T1-weighted images. Measurements of tumor length on either type of imaging did not change significantly after chemotherapy. MR imaging showed 100% sensitivity for epiphyseal tumor spread but poor specificity. False-positive readings occurred in seven of 13 patients with abnormal signal intensity that extended into the adjacent epiphyses.

CONCLUSION

Readers estimated intraosseous tumor extent more accurately on T1-weighted images than on STIR images. Readers overestimated tumor length on STIR images. T1-weighted longitudinal images taken before chemotherapy can be used for early planning of surgical approaches to osteosarcoma in children.

Percutaneous vs modified phemister epiphysiodesis of the lower extremity

Epiphysiodesis of the lower extremity for limb-length discrepancy has been performed on 24 patients by both the modified Phemister and a percutaneous method. The primary complication of epiphysiodesis by both methods was continued growth of the physeal plate (12% and 15%, respectively). Failure of epiphysiodesis was attributed to young skeletal age at surgery in three of five cases. Closer attention to physeal ablation and close follow up should prevent this complication. No angular deformities resulted in any patient. During 16 proximal fibular procedures, there were no neurologic complications. The percutaneous method is preferred due to ease of surgical procedure, minimal incisions, limited disability to the normal extremity, and equal results.

Hemiepiphyseal stapling for knee deformities in children younger than 10 years: a preliminary report

Epiphyseal stapling, which is the only reversible method of growth alteration, has traditionally been reserved for teenagers. We are reporting the application of hemiepiphyseal stapling in a series of 25 children younger than 10 years. With a variety of underlying diagnoses, three children had genu varum and 22 had genu valgum. The technique involved fluoroscopic localization of all growth plates and careful preservation of the periosteum while inserting (and subsequently removing) one or two staples per physis. The mean age at stapling was 6 years + 4 months. Follow-up averaged 3 years + 3 months. The anatomic (tibiofemoral) angle and mechanical axis improved in all patients. One staple broke on removal; there were no other hardware failures. We conclude that hemiepiphyseal stapling is a safe and effective treatment for children younger than 10 years who have angular deformities of the knee. No growth-plate arrests have occurred. In the event of recurrent deformity, stapling may be repeated.

Avulsion of the patellar ligament with combined fracture luxation of the proximal tibial epiphysis: case report and review of the literature

Disruption of the extensor mechanism of the knee joint at the insertion site of the patellar tendon into bone is a somewhat common injury. Avulsion of the patellar ligament associated with fractures of the proximal tibial epiphysis is an extremely rare injury. Only three cases have been published in association with avulsion fracture of the tibial tubercle. We are reporting a case that has previously not been reported to our knowledge: an avulsion of the ligament in a closed fracture of the proximal tibial epiphysis with integrity of the tibial tubercle. We propose a three-type classification of an avulsion patellar ligament injury.

Deficiencies of current methods for the timing of epiphysiodesis

A review of 71 epiphysiodeses with adequate orthoroentgenographic and skeletal-age data was carried out to compare the accuracy of predicting outcome among the methods of Anderson and Green, Menelaus, and Moseley. Differing the methodology did not have a meaningful effect on their similar but limited accuracy. We advocate the use of the Menelaus method, which is simple and based on chronologic age, as it proved as accurate as any other method. The routine use of serial Gruelich and Pyle skeletal-age data could not be shown to increase the accuracy in predicting outcome over serial chronologic-age data, and thus its value in limb-length inequality is limited. Regardless of the method used, unpredictable results occur in a proportion of patients. The patient and parents should be advised of this when planning strategies for limb-length discrepancy.

Epiphyseal lengthening operation--an improved technique

An improved method of epiphyseal lengthening operation and subsequent outer fixation are presented on the basis of experience in 30 cases. The operative technique is described in detail, including the different options of separative traction and osteotomy at subtrochanteric, distal part of the upper femur and lower tibial levels. The physiological and histological research concerning this method is discussed. The authors believe that this procedure is better than the other methods.

Traumatic ulnar physeal arrest after distal forearm fractures in children

A review of the orthopaedic literature suggests that traumatic ulnar physeal arrest associated with radial fracture is a rare occurrence. Twenty-three cases of traumatic ulnar physeal arrest have been reported in patients with distal radius fractures, and we report five additional cases. A classification system for the distal ulnar growth deformities is proposed, and the compensatory radial changes are reviewed. Surgical indications for treatment include cosmetic deformity, progressive carpal subluxation, and decreased range of motion. Surgical options for treatment are discussed and include epiphysiodesis, ulnar lengthening, radial osteotomy, and the Suave-Kapandji procedure.

Epiphysiodesis of the lower extremity: results of the percutaneous technique

The results of 42 percutaneous epiphysiodeses of the lower extremity in 26 patients are reported. All patients achieved physeal arrest radiographically and clinically. No patient developed angular deformity from incomplete arrest. No neurovascular complications or fractures occurred. The average hospital stay for patients undergoing epiphysiodesis alone was 1 day. Percutaneous epiphysiodesis of the lower extremity provides a reliable and safe technique for growth plate arrest. The advantages of this technique include a cosmetic scar, short hospital stay, low incidence of complications, and reliable physeal arrest.

Surgical treatment of Madelung disease by the Sauvé-Kapandji technique

The Madelung deformity, a congenital alteration of growth in the distal radial epiphysis, becomes evident during adolescence, producing serious esthetic and functional disturbances. From 1982 to 1991, 15 patients ranging from 16 to 23 years old, suffering from Madelung deformity were operated by the Sauvé-Kapandji surgical technique (a pseudarthrosis is created on the ulna and an arthrodesis on the distal radio ulnar joint). The esthetic appearance and grip strength were improved. Pain was eliminated and the incidence of complications was very low.

Anterior thoracoscopic epiphysiodesis in the treatment of a crankshaft phenomenon

We report our first performance of a multiple anterior thoracoscopic epiphysiodesis in the treatment of a crankshaft phenomenon. In the last 2 years, video-assisted thoracoscopy has been introduced as a new therapeutic technique in the field of spinal diseases. Its use has been most documented in the treatment of vertebral abscesses and disc herniations, while its performance in treating deformities is less known. The patient in our case was an 11-year-old boy with a 7-year history of aggressive left thoracic idiopathic scoliosis that had previously needed three subcutaneous instrumentations and finally a Cotrel-Dubousset-instrumented arthrodesis. Following these operations, a continuous clinical and radiographical evolution of the curve was recorded and an anterior T6-T11 video-assisted thoracoscopic epiphysiodesis was therefore performed. The patient did not need postoperative narcotics; Argyle chest tubes were removed after 48h with only 150ml of serohaematic drainage, no blood transfusion was required. One year after the intervention, we found a well-consolidated T6-T11 arthrodesis with no evolution of the deformity. The endoscopic technique allowed us to perform an extensive anterior arthrodesis using only three small incisions, with a reduction of bed-confinement to 3 days and reduced postthoracotomy pain.

Metaphyseal dissociation fractures of the proximal tibia. An analysis of treatment and complications

A study was done of 44 metaphyseal dissociation fractures of the proximal tibia in 42 patients (27 men and 15 women, aged 22 to 77 years; mean, 42 years). Follow-up ranged from 6 months to 4 years. There were 2 study groups: a retrospective group (group 1, 22 fractures) given a variety of treatments ranging from casts to dual plates, and a prospective group (group 2, 22 fractures) treated by combining external fixation and optional minimal internal fixation. There were 12 comminuted fractures in group 1 and 20 in group 2 (P < 0.01). All fractures eventually healed, with an average healing time in group 1 of 3.8 months, and 5.3 months in group 2. There was one delayed union in group 2. Results were graded from poor to excellent, based on pain, range-of-motion, and malunion. There were 6 poor and 4 fair results in group 1, and no poor and 3 fair results in group 2. Complications included 6 deep infections, 5 in group 1 (1 requiring a free-flap procedure); and 1 pin-tract infection resulting in septic arthritis in group 2. There were 7 gastrocnemius flaps required in group 1, and 1 in group 2. The results of this study suggest that patients treated with external fixation had better results with less infection and soft-tissue complications than those treated with conventional internal fixation.

Slipped capital femoral epiphysis associated with hyperparathyroidism. A case report

A case of slipped capital femoral epiphyses is reported which occurred in association with primary hyperparathyroidism. Only two similar cases have been found in the English literature. The patient was a man, 16 years of age, who presented with bilateral slipped epiphyses. Investigation showed that he had primary hyperparathyroidism due to a parathyroid adenoma. At a single operation, the epiphyses were pinned in situ, and the adenoma removed. The result was satisfactory.

Long-term results of combined anterior and posterior convex epiphysiodesis for congenital scoliosis due to hemivertebrae

STUDY DESIGN

Retrospective review of patient records with recent clinical and radiologic assessment.

OBJECTIVE

To evaluate the long-term result of anterior and posterior convex ephiphysiodesis in the management of congenital scoliosis resulting from fully segmented nonincarcerated hemivertebra.

SUMMARY OF BACKGROUND DATA

Thirty patients (16 male/14 female patients) were reviewed. Follow-up was a minimum of 3 years (average, 8 years 10 months; range, 3-22.5 years). Nineteen patients were skeletally mature, and the mean age of the remaining 11 was 11.75 years.

METHOD

Clinical evaluation and sequential measurements of Cobb angle was made independently by two observers.

RESULTS

Compared with preoperative values, the rate of change in Cobb angle was reversed in 23 patients, arrested or slowed in five patients, and unchanged or progressed in two patients. The annual rate of change in Cobb angle was +1.9 degrees before surgery and -1.2 degrees after surgery, a difference of 3.1 degrees. This is highly statistically significant (P < 0.001). Total correction in Cobb angle correlates with age at time of surgery (P < 0.03). The rate of correction in Cobb angle after surgery correlates with the total correction achieved (P < 0.001) and with age at time of surgery (P < 0.05). The greater correction is achieved when surgery is performed at a young age. The preoperative rate of increase in Cobb angle does not correlate with correction (P < 0.76). The site of the hemivertebrae influenced final outcome with best results in the lumbar spine.

CONCLUSION

Combined anterior and posterior convex epiphysiodesis is a reliable method for the correction of deformity resulting from hemivertebrae.

Painful olecranon physeal nonunion in an adult weight lifter. A case report

Only 3 cases of persistent olecranon physes in adults have been reported previously in literature. In each case, physeal nonunion was present bilaterally and either unilateral, bipartite, or tripartite patellae were present. A case of painful unilateral physeal nonunion in an adult weight lifter is presented. The patient had begun competitive weight lifting when he was 14 years old. Radiographs of the contralateral olecranon and patellae were normal. After failure of conservative treatment, surgical union was achieved, using tension band wiring augmented with autologous iliac crest bone graft. The author proposes that unilateral olecranon physeal nonunion has a mechanical etiology as opposed to a genetic etiology in individuals with bilateral physeal persistence. Surgical treatment in the former group is best delayed until after age 19, to allow adequate time for spontaneous union.

[Results of surgical treatment for intraarticular fracture of the distal humeral epiphysis]

The paper deals with modalities and results of surgical treatment for intraarticular fracture of distal humeral epiphysis. Nineteen patients out of 22 operated in the department between 1982 and 1992 were reviewed. There were 6 good results, 11 fair and 2 poor ones.

[Thermographic examination of the hip and distal femoral epiphysis in children after surgery of the proximal femur]

The authors present preliminary results of thermographic examination of the hip and distal epiphysis of the femur after surgery of the proximal end of the femoral bone with the use of AGA 680 apparatus and IBM 486 PC data processing. The material included 10 children aged 3-11 years and evaluated 1 month to 3 years postoperatively. In 9 patients remarkable temperature increase within operated hip, less evident in bilateral surgery due to the smaller temperature difference. In 7 cases ipsilateral distal femoral epiphysis showed temperature increase; the phenomenon less perceptible in bilateral surgery again. The more time passed between surgery and examination the smaller was the temperature increase.

[Osteosynthesis using intra-focal pins of anteriorly dislocated fractures of the inferior radial epiphysis]

The authors describe two anterior approaches to intra-focal pinning of distal radius fractures, with anterior tilt, Smith type and anterior margin type. They demonstrate that this fixation mode is as reliable as anterior plate osteosynthesis, with less anatomic cost. It allows immediate mobilization and affords good functional results. Performed with regular K. Wire or better with "Arum" Pins, this procedure was used in ten Smith's fractures, six anterior margin fractures, one two-margins fractures, and twelve multi-fragment fractures. Anterior pins are also used when excessive anterior reduction is feared in Colle's fractures. Secondary displacements are rare, except radius shortening which is possible with all types of fracture and treatment. As cast is prohibited, early rehabilitation provides good and excellent functional results. Complications are exceptional, occurring at the beginning of the authors' experience. Thanks to some precaution, such as the "open approach" and protecting the pin ends, this technique is simple, reliable, economic and effective.

[Experimental studies in effect of limb lengthening using metaphyseal osteotomy on epiphyseal growth plate]

The experimental results in effect of limb lengthening using metaphyseal osteotomy at proximal tibia on epiphyseal growth plate in 28 young sheep were reported. Radiographic, microscopic and electronmicroscopic findings showed that lengthening of 7.5% the growth plate resulted in narrowing in varying degrees in one third of the sheep with a lengthening rate of 0.25 mm every six hours. Narrowing of epiphyseal growth plate was seen in half of sheep with lengthening of 10% and in all sheep with lengthening of 12.5% and 15%. Degeneration and necrosis of chondrocytes happened in one sheep of lengthening of 15%. Thickening of growth plate was seen in all sheep of the control group. Our conclusion from this series of experimental studies was that depression caused by compression stress effect in limb lengthening of less than 7.5% on epiphyseal growth plate is minimal.

Cure of the limp in children with congenital dislocation of the hip and ischaemic necrosis. Fifteen cases treated by trochanteric transfer and contralateral epiphysiodesis

Fifteen patients who limped and had early fatigue on walking caused by ischaemic necrosis after treatment for congenital dislocation of the hip had distal and lateral transfer of the greater trochanter. Nine of them in whom the predicted leg-length discrepancy was more than 3 cm also had epiphysiodesis of the contralateral leg. At skeletal maturity the limp was eliminated and walking distance was significantly improved in them all. In those who had epiphysiodesis the average leg-length discrepancy was 0.7 cm at maturity. Two of those not treated by epiphysiodesis used a heel raise of 1.5 cm. In seven cases the two operations were performed simultaneously without serious complications. This procedure is recommended at about the age of 12 years.