First dorsal metatarsal artery perforator flap to cover great toe defect

BACKGROUND

There were very few options available for distal foot and toe defects that required a vascularized flap for coverage. As such, the use of a free flap was often justified in this region of the foot. The use of perforator flaps has created a new subset of local tissue transfer alternatives that increases the potential that the difficulties associated with microvascular tissue transfers could be avoided. The first dorsal metatarsal artery (FDMA) perforator flap was one variant of this new type of tissue transfer. The aim of this report was to describe our experience using FDMA perforator flap to cover great toe defect.

METHODS

A standard FDMA flap from the dorsum of the foot was raised in reversed fashion based on the distal communicating branch or "perforator" from plantar foot circulation in two patients with great toe defect.

RESULTS

Salvage of the great toe was achieved in both patients. FDMA perforator flap achieved both reconstructive goals, and the donor site closure can be successfully performed without tension. Donor site healing was achieved in both patients with no associated complications by the 1-year follow-up.

CONCLUSIONS

FDMA flap can be successfully used as a local flap to cover distal foot and toe wounds. However, direct donor site closure can be problematic and may need skin graft.

Prediction of Callus Subsidence in Distraction Osteogenesis Using Callus Formation Scoring System: Preliminary Study

OBJECTIVE

To develop the scoring system which describes both quality and quantity of callus formation to predict the callus subsidence.

METHODS

Forty-seven bony segments with an average lengthening of 5.17 ± 2.83 cm were included. The score was calculated based on the amount of callus classified in five patterns and the summation with the density of the callus classified in four patterns; the total score was 9. Bony subsidence >10% or >10° angulation were considered significant. We analyzed all of the data to find the most appropriate score that would prevent callus subsidence <10% and prevented angulation of the regeneration bone <10 degrees. Data was analyzed by using the receiver operating characteristic (ROC) curve. An area under the curve of 0.9-1 indicated an excellent test, 0.8-0.9 indicated a good test, 0.7-0.8 indicated a fair test, 0.6-0.7 indicated a poor test, and 0.5-0.6 indicated a fail test. The appropriate score for Ilizarov removal was selected from the highest sensitivity and specificity.

RESULTS

Twenty-two tibia segments and 25 femur segments were included. The mean of bone lengthening was 5.17 ± 2.83 cm (range, 1.6-13.5 cm) and the mean of percentage lengthening was 16.58% ± 10.03% (range, 4.63%-56.84%). The mean distraction period was 5 months. The average months of follow-up for measurement of bony subsidence was 4.2 months. Mean subsidence was 21.06% (1.54%-57.44%). The mean of callus subsidence was 1.29 ± 1.17 cm (range, 0.03-4.72 cm). There were 32 segments (68%) with callus subsidence greater than 10% and 15 segments (32%) with subsidence less than 10%. The callus subsidence ranged from 0.3 mm to 4.72 cm, with 68% of bony fragments having significant subsidence. Type 5 callus diameter was statistically significant (P < 0.0001) in preventing callus subsidence compared to the other types. Type 4 callus density was statistically significant in preventing callus subsidence compared to the other types (P < 0.0001). The ROC curve with area under the curve 0.961 and sensitivity 0.933 showed that a callus scoring system score >7.5 was effective in preventing significant callus subsidence. When using score 8 as a result from the ROC curve, 73.3% of bony fragment subsidence was <10% with sensitivity 93.3 and specificity 83.2.

CONCLUSION

Callus diameter 81%-100% and callus density type 4 could prevent significant callus subsidence. Based on the results of the present study we suggest using callus score > 8 to determine the time of Ilizarov removal.

Molecular identification of Gnathostoma spinigerum (Nematoda: Gnathostomatidae) as causative agent of human gnathostomiasis in Thailand

A 43-year-old male residing in Prachin Buri Province, Thailand, was admitted to the Siriraj University Hospital of Mahidol University, Thailand, in July 2014 with right eyelid swelling and serpiginous lesion for three weeks. A nematode specimen was accidentally recovered from his upper right eyelid area. The body of the worm was cylindrical and measured 11.0 × 1.4 mm. The head bulb had eight circles of transverse spines. Anterior half of the body was covered with rows of comb-like pointed spines. The tail part was rounded dorsally and flattened ventrally and no copulatory spicule was observed at the posterior end. It was morphologically identified as an immature female worm of gnathostome species. Sequence analysis for partial cytochrome c oxidase subunit I (COI) gene revealed this recovered nematode as Gnathostoma spinigerum.

Evertor muscle activity as a predictor for recurrence in idiopathic clubfoot

BACKGROUND

Clubfoot is a complex three-dimensional deformity. Although brace compliance after initial correction was previously found to be significantly associated with recurrence in clubfoot, few previous studies have specifically examined evertor muscle function as a factor that contributes to recurrence in children with idiopathic and non-idiopathic clubfoot. The aim of this study was to investigate the relationship among brace compliance, evertor muscle grading, and recurrence rate in pediatric clubfoot patients.

METHODS

Children with idiopathic clubfoot who were treated and followed for a minimum of 2 years were included. Patients who used their brace <20-23 h a day for the first 3 months and then <8-10 h per day during sleep and nap times thereafter were classified as group I. Patients who complied fully by using the brace 23 h a day for the first 3 months and then 8-10 h per day during sleep and nap times thereafter were classified as group II. Demographic and clinical data including age, gender, follow-up time, recurrence, evertor muscle grading, types of surgery, brace compliance, severity of initial deformity, age at onset, number of casts required for initial correction, and the need for Achilles tenotomy were collected and analyzed.

RESULTS

Seventy-nine children with clubfoot were included. There were 47 males and 32 females, mean age was 3.2 years (range 2.1-6.3), and the mean follow-up time was 31.4 months. All patients had follow-up of at least 2 years. Primary correction was obtained in all children. There was no significant difference in mean age, mean follow-up time, or recurrence rate between groups. There was, however, a statistically significant difference in mean brace time between groups (p = 0.002). The recurrence rate was 26.2% in group I and 22.2% in group II. The recurrence rate in group a (Pirani score 0) was 3.9%, group b (Pirani score 0.5) 43.8%, and group c (Pirani score 1) 75% (p < 0.001). No significant association was found between severity of the initial deformity, age at the onset of treatment, number of casts required for correction, or reported brace compliance and recurrence or rates of surgery. Only poor or absent evertor muscle activity was found to be statistically significantly associated with risk of recurrence.

CONCLUSION

Good evertor muscle grading was found to be a significant protective factor against recurrence of idiopathic clubfoot. Thus, improvement in muscle balance around the ankle, especially the evertor muscle, should be emphasized to parents after the casting regimen is completed and correction is achieved.

Free non-vascularized fibular graft for treatment of large bone defect around the elbow in pediatric patients

BACKGROUND

Large bone defect is a challenging problem in orthopedics practice. Several methods are available for bridging of these bone defects, including cancellous bone graft, free vascularized fibula graft, and bone transport with external ring fixator. The aim of this study was to describe our experience in nine pediatric cases of free non-vascularized autogenous fibular strut bone graft in which large bone defect and bone loss of >7 cm was caused by open fracture and infective nonunion around the elbow joint.

OBJECTIVE

To describe our experience in nine pediatric cases of free non-vascularized autogenous fibular strut bone graft in which large bone defect and bone loss of >7 cm was caused by open fracture and infective nonunion around the elbow joint.

METHOD

This retrospective review was conducted in patients with large bone defect with bony gap >7 cm. Time to union, range of motion, complications, Mayo Elbow Performance Score, and Foot and Ankle Disability Index (FADI) were recorded.

RESULT

The large bone defects included in this study were managed by free non-vascularized fibular strut bone grafts (FNVFG) that were harvested subperiosteally. Nine patients with a mean age of 11 years (range: 6-17) underwent this procedure. Nine grafts (100%) united at both ends within an average of 9 weeks (range: 8-14). Mean length of defect was 9.3 cm (range: 8-13 cm). Mean postoperative Mayo Elbow Performance Score was significantly higher than the mean preoperative score (98.33 vs. 64.44, respectively; p < 0.001). Three fibulae were observed for hypertrophy. Mean Foot and Ankle Disability Index score was 100 both preoperatively and postoperatively in all patients.

CONCLUSION

Free non-vascularized fibular graft is a simple procedure and a reliable method for bridging large bone defect or loss caused by open fracture and/or infection around the elbow in pediatric patients.

Does the parental stretching programs improve metatarsus adductus in newborns?

BACKGROUND

Metatarsus adductus (MA) is a common pediatric foot deformity. Current recommendations suggest observation until 4-6 months, then casting if the deformity persists. Based on our review of the literatures, no randomized controlled trial has been conducted to study the effectiveness of parental stretching in the correction of MA in newborn.

MATERIAL AND METHODS

Ninety-four newborn feet that were diagnosed as MA by clinical examination were enrolled. Feet were randomized into two groups: observation group and stretching group. Outcome measurements were performed to compare success rate between groups.

RESULTS

According to Pearson's χ² test, there were no statistically significant differences between groups with regard to the overall success of the parental stretching program ( p = 0.191). There was also no significant difference between groups for mild degree or moderate-to-severe degree ( p = 0.134, p = 0.274, respectively). A more rapid success rate was observed in the stretching group at the first month follow-up, but rate of improvement then decreased. The stretching group tended to have a lower success rate compared to the observation group in moderate-to-severe feet, but the difference was not statistically significant.

CONCLUSIONS

Parental stretching program found no benefit over observation group in this study. Parental stretching program should not be applied for newborn babies with moderate-to-severe MA as the result from the study appeared to have lower success rate compared to observation group. Observe until 4-6 months, then corrective casting for the persisting deformity is recommended.

Complications Associated with Ponseti Serial Casting and Surgical Correction via Soft Tissue Release in Congenital Idiopathic Clubfoot

BACKGROUND

The current standard treatment used worldwide for management of congenital idiopathic clubfoot is serial casting by Ponseti method. Prior to 2006, standard treatment for congenital idiopathic clubfoot at Siriraj Hospital involved major soft tissue release by any of the following release techniques, modified posteromedial release, complete subtalar release, and posterior release.

OBJECTIVE

To evaluate the complications and recurrence of deformity associated with treatment of congenital idiopathic clubfoot by Ponseti serial casting and major soft tissue release at Siriraj Hospital.

MATERIAL AND METHOD

This retrospective review of medical charts and records was conducted in congenital idiopathic clubfoot patients who underwent primary treatment by either Ponseti serial casting or major surgical soft tissue release between 2000 and 2012 at Siriraj Hospital. Patient demographic, clinical, diagnostic, and surgical procedure-related data were reviewed. All associated complications were recorded and analyzed.

RESULTS

One hundred sixty one patients were included, of which 46 had treatment by Ponseti method and 115 had treatment by major soft tissue release. In the Ponseti group, there were 26 males and 20 females (73 feet), with an average age at the beginning of treatment of 10.70 weeks (range 0.86 to 42.86). The complication rate was 17.8% (13 feet in 11 patients). The most common complications were cast loosening in four feet (5.48%) and cast-associated skin irritation in four feet (5.48%). In patients treated with Ponseti method, second surgery for recurrent deformity was performed in 26 feet (35.61%). In the soft tissue release surgical intervention group, there were 69 males and 46 females (171 feet), with an average age at the beginning of treatment at 52.05 weeks (range 9.86 to 248.71). The complication rate was 12.87% (22 feet in 18 patients). The most common complications were wound infection in nine feet (5.26%), followed by cast loosening in seven feet (4.09%). In soft tissue release patients, second surgery for recurrent deformity was performed in 26 feet (15.20%).

CONCLUSION

In this study, complication rates relating to clubfoot treatment by Ponseti serial casting and major soft tissue release were 17.8% and 12.87%, respectively. The two most common complications of Ponseti serial casting were cast loosening (5.48%) and cast-associated skin irritation (5.48%). The most common complication of major soft tissue release was wound infection (5.26%), followed by cast loosening (4.09%).

The Comparison between Computer-Assisted Hexapods and Ilizarov Apparatus in Gradual Tibial Deformity Correction: A Preliminary Study

BACKGROUND

The Hexagonal external fixator (Hexapods) is known to have the ability to correct complex multi-planar deformities faster than the Ilizarov apparatus. However, the difficulty of achieving deformity correction by Hexapods seems to limit its popularity.

OBJECTIVE

This study aims to compare the advantages and disadvantages of Hexapods and Ilizarov in the gradual correction of complex tibial deformities.

MATERIAL AND METHOD

A retrospective review was performed in patients with complex tibial deformities treated with Hexapods or with Ilizarov apparatus from 2000 to 2014. Magnitude of deformity, length of time in Hexapods or Ilizarov apparatus, Lengthening Index, and complications were recorded. Statistical analysis was used to compare the two methods.

RESULTS

Six patients were treated with Ilizarov apparatus and seven patients were treated with Hexapods. Patients in Hexapods group had more coronal plane angulation before surgery than in the Ilizarov group with statistical significance (p = 0.02). The differences of the sagittal and the axial plane angulations were not statistically significant. The difference of leg length was also not statistically significant. After completion of treatment, no statistical significance of residual deformities was found between the two methods. Lengthening Index had trends toward significance in Hexapods group (p = 0.051).

CONCLUSION

Computer-assisted Hexapods may reduce the Lengthening Index compared to the conventional Ilizarov method. The hexapods device could be beneficial for faster correction of complex deformity if the patients or family members understand how to manipulate the apparatus.

The Results of Lengthening in Congenital Posteromedial Angulation of Tibia

BACKGROUND

Congenital posteromedial bowing of the tibia (PMBT) is a rare deformity with limb length discrepancy (LLD) with or without significant angular deformity. Some patients need only limb length equalization while many patients require additional angular correction. Limb length equalization may be achieved by either limb lengthening, epiphysiodesis or acute shortening of the long leg. Limb lengthening is the preferred treatment option in PMBT patients with significant angular deformity.

OBJECTIVE

The presented study is to evaluate the results of lengthening with Ilizarov fixator in these patients.

MATERIAL AND METHOD

PMBT patients treated with Ilizarov lengthening were retrospectively reviewed. Progression of angular deformity and LLD were assessed. Residual deformity after Ilizarov lengthening and complications were also evaluated.

RESULTS

Limb lengthening with Ilizarov external fixator was performed in 4 PMBT patients. Mean age at surgery was 3.7 years. Expected LLD (using multiplier method) of tibia ranged from 5.1 to 9.9 cm. Younger patients had more angular deformity than older patients. One patient had pin tract infection requiring Ilizarov removal. Lengthening index varied from 1.2 to 2.1 month/centimeter. LLD after the lengthening was -1.4 to 0.4 cm. Mean progression of LLD was 1.8 mm/year.

CONCLUSION

Ilizarov lengthening for posteromedial angulation shown good result with average residual LLD 0.4 to 1.4 cm which is not clinically significant.

Geographical distribution and incidence of Angiostrongylus lungworms (Nematoda: Angiostrongylidae) and their rodent hosts in Thailand

The rat lungworm Angiostrongylus cantonensis, a zoonotic parasite, is known to be responsible for eosinophilic meningitis and meningoencephalitis in humans in many countries worldwide. Another congener A. malaysiensis is a potential pathogen. Rodents as natural definitive host of the parasites are abundant and globally widespread. In this study, the prevalence of Angiostrongylus infection in wild rats was investigated in twenty-four provinces of Thailand during the period December 2011 to June 2014. Of the 669 wild rats sampled, 46 (6.88%) were infected with Angiostrongylus lungworms. The rodents harbouring A. cantonensis worms included Bandicota indica, Bandicota savilei, Rattus exulans, Rattus norvegicus, Rattus rattus complex and Rattus tiomanicus, and those harbouring A. malaysiensis were B. savilei, Rattus losea, R. norvegicus and R. rattus complex. No parasite was recovered from Maxomys surifer (n=11), Mus musculus (n=1), Niviventer fulvescens (n=2), Rattus argentiventer (n=4), Rattus nitidus (n=3) and Sundamys muelleri (n=3). In positive rats, the incidence of infection with Angiostrongylus lungworms was variable among host species and provinces. There were also considerable variation in the proportion of male and female worms among rodent hosts and localities. Two hundred and thirty-five of the collected worms were male and 282 were female. The mean worm burden in the positive rats was 11.24 and ranged from 1 to 61. 81.82% (423/517) of the adult worms were morphologically identified as A. cantonensis, and 18.18% (94/517) were A malaysiensis. One R. rattus from Prachuap Khiri Khan had mixed infection of A. cantonensis and A. malaysiensis (10 worms of each species). The overall number of male (202) and female (221) A. cantonensis worms was not significantly different (χ² = 0.86, 0.50 > P > 0.30). However, the overall number of male (33) and female (61) A. malaysiensis worms was significantly different (χ² = 8.34, P < 0.01). The present study added one new definitive host (R. tiomanicus) for A. cantonensis and two new definitive hosts (B. savilei and R. losea) for A. malaysiensis in Thailand. Our data update and contribute significantly to existing knowledge of the geographical distribution of A. cantonensis in wild rats in Thailand and confirm the occurrence of A. malaysiensis throughout the country.

The Factor Causing Poor Results in Late Developmental Dysplasia of the Hip (DDH)

BACKGROUND

Treatment of DDH in walking-age children often resulting in persistent or recurrent hip dysplasia, AVN and/ or loss of reduction. The incidence of secondary procedures in this age group after closed or open reduction of the hip in DDH varies from 38% to 80% in longterm studies. The goal of this study was to determine the factors that will predict poor results in walking-age children with DDH.

MATERIAL AND METHOD

The study was a retrospectively study of 25 walking children with late DDH (22 female and 3 male) treated with closed or open reduction of the hips. The data were collected from medical records and radiographs. Tonnis and Severin classifications were used to evaluate the condition of the hips. Fisher exact test and student t-test were used to evaluate the factors related to the poor result.

RESULTS

Age > 28 months and > 30 months at the reduction is a factor resulting in poor results evaluated by Tonnis and Severin classification (p = 0.007), and (p = 0.008). Acetabular index (AI) and Center-edge angle (CE) at the time of index surgery are not statistical significant causing the poor results. Bilateral or unilateral of DDH are not statistical significant to cause poor results.

CONCLUSION

From our study, age at presentation is the most important factor predicting poor results in walking DDH, age > 28 months at presenting leading to secondary procedure and poor Tonnis and Severin Grades. National Health Policy for Hip Screening is the most important for early detectoing of children with DDH to improve the outcome and prevent the children from multiple operations.

Results of Primary Talectomy for Clubfoot in Infants and Toddlers with Arthrogryposis Multiplex Congenita

BACKGROUND

Equinovarus deformity in arthrogryposis multiplex congenita patients is rigid and difficult to treat. Radical soft tissue operations yielded good results though recurrence of deformity was high. Talectomy is a bony procedure recommended as either a salvage procedure or a primary operation.

OBJECTIVE

To evaluate the results ofprimary talectomy in infant and toddler patients retrospectively.

MATERIAL AND METHOD

Arthrogryposis multiplex congenita patients with rigid equinovarus deformity treated with talectomy initially were retrospectively reviewed. Pain score, residual foot deformity, shoe modification, and ambulatory status were assessed.

RESULTS

Talectomy were performed in 19 arthrogrypotic feet in 10 infants and toddlers. There were 6 males and 4 females. The mean age at surgery was 1.3 years old and the mean age of the follow-up time was 4.9 years. All patients had plantigrade foot without pain. One arthrogrypotic foot required posteromedial release 2 years after index surgery due to recurrent deformity.

CONCLUSION

Talectomy as theprimaryprocedure in arthrogrypotic infants and toddlers demonstrated good results withfew residual deformities and recurrence. Patients could achieve plantigrade position.

Evaluation of dot immunogold filtration assay (DIGFA) for rapid serodiagnosis of eosinophilic meningitis due to Angio-strongylus cantonensis (Nematoda: Metastrongyloidea)

Angiostrongylus cantonensis is the most frequent cause of eosinophilic meningitis in humans in Thailand and worldwide. Because of difficulty of recovering the Angiostrongylus larvae from infected patients, detection of parasite-specific antibodies is used to support clinical diagnosis. This study tested serum samples from eosinophilic meningitis patients and individuals at risk of infection with A. cantonensis to evaluate a recently developed simple and rapid dot-immunogold filtration assay (DIGFA) for detection of specific antibodies against A. cantonensis. Purified 31-kDa glycoprotein of A. cantonensis and protein A colloidal gold conjugate were employed to detect the 31-kDa anti-A. cantonensis antibody in patients sera from the parasite endemic areas of northeast Thailand. The results were compared with those obtained by dot-blot enzyme-linked immunosorbent assay (ELISA) with 31-kDa A. cantonensis antigen. The overall positivity rate of DIGFA and dot-blot ELISA for A. cantonensis infection in 98 clinically diagnosed cases from three highly endemic districts in Khon Kaen province were 39.79% and 37.75%, respectively. Among 86 sera of subjects at risk of infection with A. cantonensis, 24.41% were positive by DIGFA and 23.25% by dot-blot ELISA. There were good correlation between the visual grading of DIGFA and dot-blot ELISA in both groups of defined sera. DIGFA is as sensitive and specific as dot-blot ELISA for confirming eosinophilic meningitis due to A. cantonensis infection, with advantages of simplicity, rapidity and without the use of specific and expensive equipment, and can be used in field settings.

Eosinophilic meningitis caused by Angiostrongylus cantonensis--a neglected disease with escalating importance

The rat lungworm Angiostrongylus cantonensis, a food-borne zoonotic parasite, has been recognized as the primary pathogen associated with human eosinophilic meningitis or eosinophilic meningoencephalitis. This neurotropic nematode has a definitive rodent host and a molluscan intermediate host. The adult worms live in the pulmonary arteries of rats. Human is a non-permissive, accidental host. Transmission to humans is by eating of infected raw or undercooked snails, poorly cleaned contaminated vegetables or other infected paratenic hosts such as freshwater prawns, crabs, frogs or monitor lizards. Thousands of diagnosed cases of eosinophilic meningitis caused by A. cantonensis have been reported worldwide. Angiostrongyliasis is of increasing public health importance as globalization contributes to the geographical spread and more international travelers encounter the disease. The parasite is on the move. It has spread from its traditional endemic areas of Asia and the Pacific Basin to the American continent including the USA, Brazil and Caribbean islands. Recently, the incidence of human infections has increased rapidly. Most reports of the disease are from Thailand and Taiwan with increasing reports from mainland China. The rapid global spread of the parasite and the emerging occurrence of the infection pose challenges in clinical and laboratory diagnosis, and in epidemiology and basic biology. Enhanced understanding of the epidemiology of angiostrongyliasis, increased public awareness about the risks associated with eating raw or undercooked food, and enhanced food safety measures are needed. Therefore, current knowledge on various aspects of the parasite and the disease it causes, as well as recent epidemiological status together with significant progress in laboratory investigation of A. cantonensis infection, are overviewed to promote understanding and awareness of this emerging neglected disease.

Four-point molding: a new cast molding technique for closed reduction treatment of developmental dysplasia of the hip

BACKGROUND

In order to achieve added stability in a hip spica cast and decrease unnecessary open reduction, the authors have devised a new hip spica cast molding technique that has been named, "Four-point molding technique". Our aim was to evaluate the efficacy of this technique, in terms of its ability to deliver a stable, concentric reduction of the hip.

MATERIAL AND METHOD

The authors retrospectively reviewed the patients, aged 6-24 months, that were diagnosed with DDH and who had undergone closed reduction with a hip spica cast. The authors used the four-point molding technique on all patients. The authors evaluated radiographs for redislocation during the 12 weeks of cast treatment and followed-up to 1 year after hip spica cast removal. 15 children (15 hips) who were treated over a 14-year period were included in the present study to determine the success rate ofthis procedure.

RESULTS

From 1996-2010, there were 15 unilateral DDH patients who were treated with the four-point molding technique. The average age of the patients at the time of the reduction was 17 months (age range: 8-23 months). The treatment was 86.6% successful in 13 children (95% CI 0.62-0.96). The average duration in the hip spica cast was 12.5 weeks. Mean follow-up was 23.1 months. Two children were unable to be concentrically reduced with sufficient stability with closed reduction and therefore required open reduction and osteotomy.

CONCLUSION

Four-point molding is simple, gives good result, and with low complications. The authors propose this technique for use in closed reduction treatmentfor DDH.

Prevalence and patterns of fractures in children

OBJECTIVE

To study the prevalence, patterns, and causes of fractures in children at Siriraj Hospital in the years 2006, 2009, and 2012.

MATERIAL AND METHOD

Patient records, files, and radiographs of all children under 16 years of age who had sustained a fracture and came to Siriraj Hospital in the years 2006, 2009, and 2012 were collected. The prevalence and patterns of fractures were reviewed for details, such as age at time of injury, gender, side, location, types, and causes offractures.

RESULTS

The prevalence of the fractures in children seen in the trauma unit at Siriraj Hospital were 4.7% in 2006, 5.3% in 2009, and 5.8% in 2012. There were 716 children with 718 fractures in three one-year periods, as follows: 222 in 2006, 234 in 209, and 262 in 2012. The children consisted of 68% boys and 32% girls, of which boys represented a statistically significant difference (p = 0.013). The most common and dominant age group for fractures was 10-16 years for both boys and girls, at 47.4%. The mean age± +SD of the children was 7. ± +4.6 years old. The rate o ffracture increased with the age of the children-a statistically significant difference (p = 0.001). The rate o fopen fracture was 6.7%. The rate o fphyseal fracture was 12.4%, o fwhich type 2 was the most common at 11.3%. Fractures to the right side occurred in 53.8% o fcases, as compared to 46.2% on the left side (p = 0.031). The most common fracture in children was dista lforearm at 18.87%. The most common causes of fracture were falling (34.6%), road accident (28.4%), and falling from height (24.1%). These top three most common accounted for 87.1% o fall causes o ffractures.

CONCLUSION

The present study described the prevalence, types, patterns, and causes of fractures in children. The results of the present study may be useful in the planning of management and prevention of fractures in children.

Management of fibular hemimelia using the Ilizarov method at Siriraj Hospital in Thailand

BACKGROUND

Fibular hemimelia is one of the most common congenital longitudinal bone deficiencies. Previous treatment protocols called for amputation of the deficient limb; while others made attempts to save the limb. The objective of treatment is to restore function and achieve patient satisfaction. The authors evaluated the outcomes of the Ilizarov technique for the treatment of leg-length discrepancy and bone associated deformities in patients with fibular hemimelia. The present study also evaluated and assessed complications, knee and ankle function, and patient satisfaction with the treatment.

MATERIAL AND METHOD

Nine patients with fibular hemimelia who underwent tibial lengthening using the Ilizarov method were reviewed in the present study. Initial condition data, including age, gender type offibular hemimelia, initial limb-length discrepancy, predicted limb-length discrepancy, and the data were collected and analyzed. Activity level, patient satisfaction, complications, and residual leg-length discrepancy were assessed at the end of treatment.

RESULTS

According to Achterman and Kalamchi classification, there were 4 patients with Type IA, 3 patients with Type IB, and 2 patients with Type II. In Type IA, the affected leg-length discrepancy and mean age at the initial treatment were 3.25 cm and 7.75 years, respectively. In type IB, the affected leg-length discrepancy and mean age at the initial treatment were 5.83 cm and 4.3 years, respectively. In Type II, the affected leg-length discrepancy and mean age at the initial treatment were 5.5 cm and 5 years, respectively. The mean follow-up was 5 years (range: 7-10). The mean lengthening was 7.52 cm (range: 4-13). The lengthening index was 1.28 mo/cm. The mean residual leg-length discrepancy was 0.94 cm. There was ankle joint stiffness and mild equinous foot in type II cases, but patients could walk well without gait aid. No patients were experiencing pain by the end of treatment. All patients expressed satisfaction with this technique.

CONCLUSION

The Ilizarov technique for bone lengthening of the tibia has shown satisfactory results in the treatment of all types of congenital fibular hemimelia and should be considered an attractive alternative to amputation, as measureable functional improvement can be expected.

The most important risk factors for avascular necrosis and chondrolysis in patients with slipped capital femoral epiphysis

OBJECTIVE

To study the most important risk factors for avascular necrosis (AVN) and chondrolysis in children with slipped capital femoral epiphysis (SCFE).

MATERIAL AND METHOD

Thirty patients with SCFE, who were surgically treated by single-screw fixation with goodpositioning from 1998 to 2012, were reviewed (22 male and 8 female patients, 35 hips; bilateral involvement in 1 male and 4 female patients). The following clinical and radiographic data were analyzed: age, sex, weight, height, onset, grading, stability, severity, history of trauma, anterior physeal separation (APS), and major complications such as AVN and chondrolysis. The results were reported according to the Heyman and Herndon criteria as excellent, good, fair, poor or failure. Multiple logistic regression was used to identify multivariate predictors of osteonecrosis and chondrolysis.

RESULTS

The mean patient age was 11.9 years. The right and left sides were affected in 45.7% and 54.3% of patients, respectively. There were 2 acute (5.7%), 26 chronic (74.3%), 5 acute-on-chronic (14.3%), and 2 preslips (5.7%). Five hips were unstable (14.3%), and 30 were stable (85.7%). There were 14 mild slips (40%), 6 moderate slips (17.1%), and 15 severe slips (42.9%). Thirteen hips (37.1%) had a history oftrauma. APS waspresent in 12 hips (34.3%). Nine hips hadAVN (25.7%), 7 had chondrolysis (20.0%), and 10 had both AVN and chondrolysis (28.6%). Clinical results were excellent, good, fair, poor, and failure in 13 (37.1%), 12 (34.3%), 6(17.1%), 2 (5.7%), and 2 hips (5.7%), respectively. Univariate analysis revealed that the statistically significant risk factors (p < 0.05) for A VN and chondrolysis were the presence of APS (p = 0.000), acute and acute-on-chronic onset (p = 0.001), moderate and severe grades (p = 0. 002), instability (p = 0.17), and a history of trauma (p = 0.02). Multivariate analysis revealed that the presence of APS was the only risk factor for AVN and chondrolysis with the highest statistical significance (p = 0.000).

CONCLUSION

Single-screw fixation gave good and reliable outcomes in most cases. APS is the most important risk factor for AVN and chondrolysis in patients with SCFE. The optimal alternative treatment to reduce this major complication should be further studied, especially in patients with acute or acute-on-chronic slips, unstable hips, a history of trauma, or APS.

Results of surgical release in pediatric trigger thumb

OBJECTIVE

To observe and evaluate the treatment outcome of pediatric trigger thumb in patients who had undergone surgical release of the annular ligament with the oblique pulley partially released in patients who did not achieve full IP joint extension.

MATERIAL AND METHOD

From 2003 to 2010, 21 surgically operated thumbs in 17 patients were reviewed. Bowstringing, range of motion (ROM) of thumb interphalangeal joint, Notta's node resolution and assessment of patient/parent satisfaction were used as outcome parameters. The pulley pathology system was observed intra-operatively. The annular ligament was completely released, and in patients who were notfully corrected, a further procedure in which 50% of the oblique pulley was released was undertaken.

RESULTS

One thumb had recurrent triggering after 60 months of follow-up. No infection, neurovascular injury, excessive scarring, or bowstringing were detected. Notta's node was fully resolved in all operated thumbs. Mean follow-up was 64 months. Improved IP joint motion without flexion contracture was observed in all patients. The procedure was well tolerated by patients and both the patients and parents of patients expressed satisfaction with the results of the procedure.

CONCLUSION

Surgical release is recommended for children aged more than one year that are afflicted with trigger thumb. This procedure delivers satisfactory results with minimal complications. To achieve full FPL excursion, some patients need to release 50% of the oblique pulley after the first procedure.

Results of surgical treatment of coxa vara in children: valgus osteotomy with angle blade plate fixation

BACKGROUND

Coxa vara is a rare condition. Surgical correction of coxa vara has been challenging. A few reports present correction coxa vara in multiple causes. In this retrospective study, the authors reported the results of surgical treatment of coxa vara by valgus osteotomy with angle blade plate fixation in 11 children with 12 hips.

MATERIAL AND METHOD

Since 2002-2011, 11 children with 12 hips with coxa vara were reviewed retrospectively by medical chart and radiographic data after surgical treatment. All of them were operated by valgus osteotomy and fixation with angle blade plate. All of them had been hip spica cast between 8-12 weeks after surgery. Neck-shaft angle, Hilgenreiner-epiphyseal angle, leg-length discrepancy and Harris hip score were evaluated at preoperative, postoperative, and final follow-up.

RESULTS

Twelve coxa vara; 4 malunion femeral neck fracture, 4 congenital coxa vara, 2 spondyloepiphyseal dysplasia and 1 multiple epiphyseal dysplasia were operated on in 11 patients. One spondyloepiphyseal dysplasia had bilateral coxa vara. The average age at surgery was 9.5 years (range, 7-12 years). The average time of follow-up was 4.2 years (range, 3-7years). The average neck-shaft angle was changed significantly from 79.8 to 123.7 degrees, the Hilgenreiner-epiphyseal angle was changed significantly from 70 to 39.3 degrees and leg-length discrepancy was changed significantly from 2.2 to 1.7 centimeters at final follow-up. The average Harris Hip score was improved significantly from 68 at preoperative to 96 atfinalfollow-up. No complication or recurrence was found.

CONCLUSION

Surgical treatment of coxa vara is uncommon treatment. The aims of treatment were to change the stress in the neck femur from shearing force to compression force and also improving shortening that could reduce incidence of further fracture and osteoarthritis. The Hilgenreiner-epiphyseal angle should be closed to 38-40 degree or less after surgery.

Do we need to do overcorrection in Blount's disease?

PURPOSE

In order to prevent recurrent deformity, overcorrection in Blount's disease has been a common practice by most paediatric orthopaedic surgeons. However, some patients have persistent valgus alignment resulting in awkward deformity. The femoro-tibial angle (FTA) was measured in this series of cases to determine the necessity of such practice.

METHOD

During 1998-2010, patients with Blount's disease stage 2 by Langenskiold, aged from 30 to 40 months who had failed from bracing and underwent valgus osteotomy were included. Seventeen legs had postoperative FTA 7-13° (group 1) and 48 legs had postoperative FTA more than 13° (group 2). ROC curve was used to determine the appropriate FTA that was suitable to prevent recurrence.

RESULTS

Four legs had recurrence (28.6%) in group 1 and six legs (12.5%) had recurrence in group 2. Chi-square test between two groups were not statistically significant in recurrence (p = 0.434). Age and BMI were not statistically significant between recurrent and non-recurrent groups. The ROC curve shows that overcorrection more than 15° did not show benefit to prevent the recurrence in Blount's stage 2.

CONCLUSION

Our study showed that the overcorrection group had non-statistically significant recurrence compared to the non-overcorrection group, and overcorrection more than valgus 15° has no benefit to prevent recurrence.

Walking ability in patients with arthrogryposis multiplex congenita

BACKGROUND

Arthrogryposis multiplex congenita (AMC) is a multiple joint condition which affects both lower and upper extremities and thus affects ambulation. Multiple surgeries are needed to correct limb deformity in order to promote walking. The objective of this study is to identify the most critical residual deformity that diminishes the ambulatory status.

MATERIALS AND METHODS

51 patients were included in this study, 14 patients were nonambulatory. The mean age at first surgery was 4.1 years (range 2-16 years). The mean length of followup was 44.0 months (range 22-168 months). Type of procedures and number of operations, residual deformity and walking ability were recorded. Residual deformity including hip flexion contracture more than 30°, knee flexion contracture more than 30°, scoliosis, hip dysplasia or dislocation, knee extension contracture or recurvatum, active motion of hips and knees and upper limb involvement were evaluated. Statistical analysis was done to evaluate factors that were statistically significant to affect walking ability in AMC patients.

RESULTS

At the latest followup, 31 patients were community ambulators, 3 patients were household ambulators, 3 patients were nonfunctional ambulatory, and 14 patients were nonambulatory. There were an average of 4.3 surgeries per patient. Statistical analysis of all factors was done and the results were significant with a P < 0.037 in knee flexion contracture >30 degrees with odds ratio of 4.58. Hip flexion contracture >30° was a trend toward significant with a P value of 0.058 and odds ratio of 4.53. Multivariate analysis showed that knee flexion contracture was significant with 4.58 (95% CI 1.01-20.6).

CONCLUSION

AMC is a rare disease that causes disability, requiring multiple surgeries to correct deformities. Our study showed that residual knee flexion contracture was associated with nonambulatory status of patients with AMC.

Double dome osteotomy for the treatment of cubitus varus in children

PURPOSE

The purpose of this study was to report double dome osteotomy used to correct paediatric cubitus varus and to avoid lateral prominence after correction.

METHODS

Eighteen children with cubitus varus underwent double dome osteotomy. Preoperative templating created from radiographs was used to determine the bone cuts. Double dome osteotomy created a proximal and distal cut, then varus deformity and sagittal alignment were corrected. The osteotomies were fixed with K-wires and immobilised in a long-arm cast. Radiographics and clinical histories were evaluated. Ulno-humeral angle pre and postoperative, range of motion and lateral prominent index were evaluated.

RESULTS

The osteotomy was performed in 18 patients, with an average age of 7.5 years. All patients ended up with flexion of 130° or greater with full and symmetrical pronation and supination. The average ulno-humeral angle difference compared to the uninjured side was 3.27°. The mean of the lateral prominent index was -0.91. The mean follow up was 50.3 months (30-115 months). All of the patients had excellent clinical and radiographic alignment. No revisions were made in this series. One transient radial nerve palsy and one superficial infection occurred.

CONCLUSION

This series demonstrates that double dome osteotomy can provide reliable correction of varus deformity and prevent lateral prominence with a minimal complication rate.

Combined osteotomy in patients with severe Legg-Calve-Perthes disease

OBJECTIVE

The purpose of the present study was to describe the clinical and radiographic results obtained with the combined osteotomy in patients with severe Legg-Calve-Perthes disease.

MATERIAL AND METHOD

During 2000 to 2010 patients with Legg-Calve-Perthes disease who intervened with combined osteotomy at Siriraj Hospital were evaluated. Clinical evaluation was categorized by Ratliff classification and radiographic evaluation was performed by Moss index, Lloyd Roberts classification and Stulberg classification.

RESULTS

Twenty patients intervened with combined osteotomy. There were nineteen males and one female with a mean age of 7.7 years. The average follow-up was 49 months. Nine had a Catterall III and eleven had a Catterall IV. According to Herring classification, fourteen patients were Herring B and six were Herring C. In accordance with the Ratliff classification, the postoperative clinical results: fifteen good, three fair and two poor. According to Mose scale, eight patients had good results, nine had fair results and three had poor results. According to the Lloyd-Roberts classification eight patients had good results, nine had fair results and three had poor results. Based on the Stulberg classification, there were ten patients in class II, nine in class III and one in class V.

CONCLUSION

The surgical treatment for severe Perthes disease with the best expected outcome is still a challenge. According to the results reported here, the combined osteotomy is safe and effective procedure for patients with severe Perthes disease in whom the femoral head cannot be contained by conventional forms of treatment.