Cervico-thoracic kyphosis in a girl with Pierre Robin sequence

Congenital cervico-thoracic kyphosis has been encountered in a girl with Pierre Robin sequence. The constellation of the spine malformation complex such as incomplete development of the vertebral bodies associated with defective ossification of the cervico-thoracic pedicles causing effectively the development of complete spinal cord injury at the kyphotic level of C7/T1 were present. Congenital kyphosis secondary to vertebral body hypoplasia has not been reported in connection with Pierre Robin sequence.

[Complications after femoral lengthening with ring fixators in congenital femoral deficiency]

PURPOSE OF THE STUDY

Congenital femoral deficiency (CFD) is a rare and complex deformity. The results and complications of surgical correction of this deformity using ring fixators (Ilizarov/Taylor Spatial Frame) have been evaluated.

MATERIAL AND METHODS

We retrospectively reviewed a consecutive series of 30 patients with CFD, between the ages of 3.3 and 17 years (mean, 9.3 years), with 35 lengthening procedures. Ten cases were treated with an Ilizarov frame, 25 cases with a Taylor Spatial Frame (TSF).

RESULTS

The average lengthening at femoral osteotomy was 44.3 mm. Nine patients underwent an additional tibial lengthening by an average of 24.2 mm. The total lengthening was 50.5 mm (28-85 mm). A fracture after removal of the fixator occurred in 25.7% of the cases, and a pin-site infection with the subsequent need of operative revision was found in 8.5%. A subluxation of the knee joint was observed in 11.4% and a persistent limitation of the knee joint range of motion in 22.8%.

CONCLUSIONS

Despite several complications, the use of ring fixators, especially the TSF, is an effective method for treatment of this complex deformity. The complication rate was similar with the use of either ring fixator. Some complications can be decreased with experience. The risk of knee dislocation can be reduced by joint bridging and fractures after frame removal can be avoided by prophylactic rodding.

Sirenomelia (symelia apus) with Potter's syndrome in connection with gestational diabetes mellitus: a case report and literature review

We report one case of a fetus of sirenomelia sequence with Potters syndrome which showed oligohydramnios and symelia apus. The infant showed absent urinary tract and external genitalia, the legs were fused by skin and had separate bones associated with Potter's syndrome. The mother had a history of gestational diabetes mellitus.

Split hand/split foot deformity with focal dermal hypoplasia (Goltz syndrome)

We report on a-6-months-old girl who manifested the phenotypic features of focal dermal hypoplasia. Significant limb deformities in connection with typical skin changes were documented. The family history had a high frequency of spontaneous abortions and male stillbirths. Male stillbirths are a landmark in favour of X-linked dominant pattern of inheritance. Despite the severe hand/foot deformities, the skull base and the tubular bones were sclerotic.

Interobserver reliability of radiographic measurements of contralateral feet of pediatric patients with unilateral clubfoot

BACKGROUND

Radiographs have traditionally been used to describe and quantify foot deformities in infants and children. We hypothesized that the interobserver reliability of measurements obtained from radiographs of pediatric feet would be low, especially with regard to the infant foot, and that normal ranges and standard deviations would decrease in association with increasing patient age.

METHODS

We retrospectively reviewed 494 radiographs of 121 patients treated for unilateral clubfoot at our institution and studied the contralateral normal foot. All anteroposterior radiographs, lateral radiographs, and lateral radiographs made with the foot in maximum dorsiflexion were analyzed by three observers, and the values were recorded. The databases created by the three observers were statistically analyzed according to five predefined age groups (birth to less than three months, three months to less than twelve months, twelve months to less than three years, three years to less than seven years, and seven years to less than fourteen years).

RESULTS

The anteroposterior talocalcaneal angle was rated as having good interobserver reliability (i.e., an intraclass correlation coefficient of 0.61 to 0.80) for all patients in each age group. Other angles that were associated with good interobserver reliability were the anteroposterior calcaneus-fifth metatarsal angle in the twelve months to less than three-year age group, the three-year to less than seven-year age group, and the seven-year to less than fourteen-year age group; the lateral talocalcaneal angle in the three-year to less than seven-year age group; the lateral tibiotalar angle in the three-year to less than seven-year age group; and the lateral talus-first metatarsal angle in the seven-year to less than fourteen-year age group. All other angles were rated as having very good interobserver reliability (i.e., an intraclass correlation coefficient of 0.81 to 1). The mean difference and the maximum difference among the observers decreased for all angles in nearly all age groups.

CONCLUSIONS

Interobserver reliability with regard to the radiographic measurement of pediatric feet was higher than expected, although measurement discrepancies can be as great as 30° with the infant foot. Interobserver reliability tended to improve with increasing patient age. The standard deviation showed a trend toward a decrease as patient age increased, although the trend was less notable than expected.

Torsional profile versus gait analysis: consistency between the anatomic torsion and the resulting gait pattern in patients with rotational malalignment of the lower extremity

Measurements of femoral and tibial torsion obtained from radiographs or computed tomographic scans have been used to describe rotational malalignment of the lower extremities and to clarify indications for surgery. A weak relationship between anatomic torsion deformity and the resulting transverse plane gait pattern in patients with cerebral palsy has been described, but the observations have not yet been tested in an able-bodied patient population. We conducted a prospective study to investigate the correlation of femoral torsion and tibial torsion as measured by using computed tomography with transverse plane gait data for patients with rotational malalignment. Twenty-six lower limbs from 26 patients selected for surgery based on gait analysis were evaluated. Calculation of Pearson correlations showed that increase of femoral anteversion resulted in increase of pelvic range of motion. A very weak correlation between femoral torsion and hip rotation (determination coefficient, R(2)=0.22) was found in a linear regression model, whereas tibial torsion and knee rotation showed a strong correlation (determination coefficient, R(2)=0.71). The correlation between the foot progression angle and tibial torsion was higher than between the foot progression angle and femoral torsion. We conclude that there is a considerable dynamic influence of mechanisms of compensation, especially in the hip, that should be considered when evaluating the torsional profile. We therefore recommend conducting three-dimensional instrumented gait analysis for patients undergoing surgical correction of rotational malalignment.

Clinicoradiographic presentation of a girl with progressive pseudorheumatoid arthropathy

We report the case of a girl-child who manifested the clinicoradiographic features of pseudorheumatoid arthritis. 3D-CT scan of the craniocervical junction showed distinctive features of dystopic type of os odontoideum. The report highlights the necessity to explore the craniocervical junction in patients with progressive pseudorheumatoid arthropathy.

Evidence of reduced bone turnover and disturbed mineralization process in a boy with Stickler syndrome

We describe a tall-statured 14-year-old boy who illustrated the full phenotypic and radiographic features of Stickler syndrome type I. A bone biopsy showed evidence of reduced bone mass and bone turnover, such as reduced BV/TV (-43%), TbTh (-29%), and OS/BS (-48%), Ob.S/BS (-27%), and Oc/BS (-47%) compared to "age-matched" controls. Moreover, there was evidence that the mineralization process was severely disturbed. Quantitative backscattered electron imaging revealed that the bone mineralization density distribution (BMDD) of cancellous (Cn) as well as cortical (Ct) bone was shifted toward lower mineralization compared to a young control reference cohort. BMDD parameters of mean degree of mineralization, Cn Ca (-9.8%) and Ct Ca (-18.0%), were dramatically decreased. To the best of our knowledge this is the first clinical report describing bone biopsy findings in a boy with Stickler syndrome. Such a severe undermineralization of bone matrix might essentially contribute to the compromised mechanical competence of the skeleton found in this patient.

Tomographic assessment of the spine in children with spondylocostal dysotosis syndrome

OBJECTIVE

The aim of this study was to perform a detailed tomographic analysis of the skull base, craniocervical junction, and the entire spine in seven patients with spondylocostal dysostosis syndrome.

METHOD

Detailed scanning images have been organized in accordance with the most prominent clinical pathology. The reasons behind plagiocephaly, torticollis, short immobile neck, scoliosis and rigid back have been detected. Radiographic documentation was insufficient modality.

RESULTS

Detailed computed tomography scans provided excellent delineation of the osseous abnormality pattern in our patients.

CONCLUSION

This article throws light on the most serious osseous manifestations of spondylocostal dysostosissyndrome.

Correction of post-traumatic lower limb deformities using the Taylor spatial frame

Twenty-five post-traumatic leg length discrepancies combined with axial deviation in 22 patients were treated with the Taylor spatial frame. We retrospectively analysed the accuracy of correction, the complication rate and the clinical outcome including the duration of treatment. The cases were divided into three sub-groups according to the level of the osteotomy. The mean age at operation was 22.7 years; the mean follow-up was 21.1 months. The patients presented uniplanar and multiplanar deformities in combination with leg length discrepancy. Twenty-one of 25 cases showed a frontal plane malalignment preoperatively. Only three of those 21 cases continued to show minimal malalignment postoperatively. The preoperative mechanical axis deviation present in 15 of 17 lower extremities was fully corrected in 13 extremities. The 25 lengthening and correction procedures were associated with a total of 61 difficulties, including 44 problems, seven obstacles and ten complications. In conclusion, the Taylor spatial frame allows accurate results in correction of complex post-traumatic deformities with minimal morbidity.

[Congenital club foot]

Congenital talipes equinovarus is the most common deformity of the lower limb. The adequate treatment of clubfeet is still a challenge for orthopaedic surgeons and requires well-founded knowledge of pathoanatomy and established therapeutical options. This refresher, in addition to pathoanatomical fundamentals, provides an update on diagnostic and therapeutical facilities. By reviewing the results of conservative and surgical treatment concepts and their discussion it shall contribute to optimal individual management of congenital talipes equinovarus.

Atlanto-axial segmentation defects and os odontoideum in two male siblings with opsismodysplasia

We report two siblings aged 11 and 7 years, respectively, who presented with the clinical and radiographic features of opsismodysplasia (non-lethal type). 3D computed tomography scans of the craniocervical region revealed a split atlas and os odontoideum in both siblings. To the best of our knowledge, this is the first clinical report detailing craniocervical malformations in two siblings with opsismodysplasia.

Professional awareness is needed to distinguish between child physical abuse from other disorders that can mimic signs of abuse (Skull base sclerosis in infant manifesting features of infantile cortical hyperostosis): a case report and review of the literature

Background

Infantile cortical hyperostosis is characterised by hyperirritability, acute inflammation of soft tissue, and profound alterations of the shape and structure of the underlying bones, particularly the long bones, mandible, clavicles, or ribs.

Case presentation

We report on a clinical case of a 3-months-old baby girl of non-consanguineous parents. Multiple long bone swellings were the motive of referral to our department for clinical evaluation. Radiographic documentation was consistent with infantile cortical hyperostosis (Caffey disease). Interestingly, skull base sclerosis associated with excessive thickening was the most unusual malformation. We report a baby with mixed endochondral and intramembraneous ossification defects.

Conclusion

Bone dysplasias, mucopolysaccharidoses, and metabolic diseases are a group of disorders that cause abnormal growth, density, and skull base shape. Skull base sclerosis/thickening is a well-known malformation in connection with other forms of sclerosing bone disorders such as dysosteosclerosis, frontometaphyseal dysplasia, and progressive diaphyseal dysplasia with skull base involvement. It is noteworthy that our present patient had an unusually sclerosed/thickened skull base. Narrowing of skull foramina due to sclerosis of skull base is likely to result in cranial nerves deficits. In this baby, the pathology has been judged to be the result of child abuse and it is not, in this case considerable harm to his parents, and the doctor-parent relationship was the outcome.

Osteochondritis dissecans and Osgood Schlatter disease in a family with Stickler syndrome

PURPOSE

Stickler syndrome is among the most common autosomal dominant connective tissue disorders but is often unrecognised and therefore not diagnosed by clinicians. Despite much speculation, the cause of osteochondrosis in general and osteochondritis dissecans (OCD) and Osgood Schlatter syndrome (OSS) in particular remain unclear. Etiological understanding is essential. We describe a pair of family subjects presented with OCD and OSS as a symptom complex rather than a diagnosis.

METHODS

Detailed clinical and radiographic examinations were undertaken with emphasis on the role of MRI imaging. Magnetic resonance imaging may allow early prediction of articular lesion healing potential in patients with Stickler syndrome.

RESULTS

The phenotype of Stickler syndrome can be diverse and therefore misleading. The expectation that the full clinical criteria of any given genetic disorder such as Stickler syndrome will always be present can easily lead to an underestimation of these serious inheritable disorders. We report here two family subjects, a male proband and his aunt (paternal sister), both presented with the major features of Stickler syndrome. Tall stature with marfanoid habitus, astigmatism/congenital vitreous abnormality and submucus cleft palate/cleft uvula, and enlarged painful joints with early onset osteoarthritis. Osteochondritis dissecans (OCD) and Osgood Schlatter syndrome (OSS) were the predominating joint abnormalities.

CONCLUSION

We observed that the nature of the articular and physeal abnormalities was consistent with a localised manifestation of a more generalised epiphyseal dysplasia affecting the weight-bearing joints. In these two patients, OCD and OSS appeared to be the predominant pathologic musculoskeletal consequences of an underlying Stickler's syndrome. It is empirical to consider generalised epiphyseal dysplasia as a major underlying causation that might drastically affect the weight-bearing joints.

Advanced ossification of the carpal bones, and monkey wrench appearance of the femora, features suggestive of a propable mild form of desbeqious dysplasia: a case report and review of the literature

Intoduction

Advanced bone maturation is a radiographic feature that might be encountered in a number of different forms of skeletal dysplasias such as Desbuquois dyspalsia, Larsen syndrome, the Reunion Island form of Larsen syndrome, diastrophic dysplasia, acrodysostosis, Catel-Manzke syndrome, a variant of metatropic dysplasia and Maroteaux-lamy syndrome.

Case presentation

We report on a 2-year- old boy from Slovakia was born to non-consanguineous parents. Prenatal and postnatal growth parameters were normal. Clubfoot and genu valgum were the most prominent orthopaedic abnormalities. Radiographic documentation showed bone age of 4 years and 8 months associated with the appearance of accessory ossification centers. Monkey wrench appearance of the proximal femora was a characteristic finding associated with significant vertebral changes.

Conclusion

The major skeletal changes in our patient include advanced carpal ossification, monkey wrench appearance of the proximal femora associated with significant vertebral changes. No joint dislocations, no hitchhiker thumbs and or dysmorphic facial features were present. The normality of his growth, facial features, intelligence, and palate as well as the characteristic radiographic features were to certain extent in favour of a mild form of Desbuquois dysplasia. Additional laboratory findings allowed us to exclude other disorders with abnormal metabolic parameters such as mucopolysaccharoidosis.

Progressive acetabular dysplasia in a boy with mucopolysaccharoidosis type IV A (Morquio syndrome): a case report

BACKGROUND

Morquio syndrome is an autosomal recessive lysosomal storage disorder, a mucopolysaccharidosis (PMS), characterized by abnormal metabolism of glycosaminoglycans. Major treatable concerns in patients with MPS type IV involve C1 to C2 instability, genu valgum, and hip subluxation. All patients demonstrate characteristic acetabular dysplasia and failure of ossification of the superolateral femoral head.

CASE PRESENTATION

We report on a 6-year-old boy whose prime presentation was a waddling gait associated with pain since early childhood. Radiographic documentation showed progressive acetabulo-femoral dysplasia associated with additional skeletal deformities. Laboratory investigations showed increased urinary keratan sulfate and reduced leukocyte enzymatic activity of N-Acetyl-Galaktosamin-6-sulfate-sulfatase. Mucopolysaccharoidosis type IV A (Morquio syndrome) has been identified.

CONCLUSION

Patients with Morquio syndrome usually appear normal at birth but exhibit growth failure and spondyloepiphyseal dysplasia as infants. Most children are brought to a physician for investigation of what the parents perceive as an abnormal appearance by 12 to 18 months of age and thoracic kyphosis is supposed to be the first appearing deformity. In our present patient progressive acetabular dysplasia was the prime orthopaedic presentation causing effectively the development of a painful waddling gait.

[When is the optimal time for hip ultrasound screening?]

The perfect time for hip screening is when every pathologically deformed hip can be diagnosed by sonography and after spontaneous resolution of immature, dysplastic hips. In addition, the beginning of therapy should be early enough to provide the best possible outcome concerning the anatomically correct healing of the patient's hip. Even though every child should be screened by sonography in the first few days of life, a reasonable way could be ultrasound screening in the first week for clinically unstable hips or newborns with risk factors such as breech position combined with ultrasound screening of every newborn between the fourth and sixth week.