Labral Support Shelf Acetabuloplasty for Late Presenting Perthes Disease: Outcomes in Indian Patients

Introduction

The treatment of late-presenting Perthes disease with extrusion is controversial and debatable. One of the options available is the labral shelf acetabuloplasty (LSA).

Aim

The aim of the study was to evaluate the results of LSA in late-presenting Perthes disease in terms of clinic-radiological outcome measures.

Materials and Methods

A retrospective analysis of prospectively collected data of patients with late presenting Perthes disease (Elizabethtown stage 2B onwards) treated by LSA by 2 experienced paediatric orthopaedic surgeons was performed. Data was collected of clinical parameters such as hip range of motion(ROM) and Harris Hip score and radiological parameters such as acetabular height, width and volume, shelf width, Centre Edge angle(CEA) and the lateral extrusion.

Results

Thirty-five patients (28 males and 7 females) treated between 2012 to 2019 were analyzed. Majority were in Elizabethtown stage 3A (23) followed by 2B and 3B (12 each). At a mean follow up of 36 months, the hip ROM and the Harris Hip Score (from 65 ± 3.5 to 81.33 ± 7.12) improved significantly and there was a statistically significant improvement in terms of all radiological parameters. Majority of the hips were in Stulberg grade 3 (20) followed by grade 1 and 2 (7 each) and Stulberg 4 (1). There were no major complications in any of the patients of the series.

Conclusion

Labral support shelf acetabuloplasty is a valuable surgery for late presenting Perthes disease and helps in maintenance of good coverage and allows restoration of range of motion over time.

Technique and Interpretation of Arthrogram for Developmental Dysplasia of the Hip

Closed reduction, arthrography and hip spica application is the treatment of choice for DDH between 6 and 18 months. There is a lot of controversy about what exactly constitutes an "acceptable" closed reduction and arthrogram and the arthrography findings are often difficult to interpret. In this video, the authors describe the technique to perform the arthrogram as well as the interpretation of the same. Various static parameters such as the femoral head coverage, the medial dye pool and the hourglass constriction are shown. In addition, the validity of the safe zone is discussed. With this video technique article, the authors hope that it becomes easy for the budding paediatric orthopaedic surgeon to perform and interpret the DDH arthrogram with ease.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00493-4.

Lower-Limb Ischemia at Birth Because of Spontaneous Arterial Thrombosis: A Case Report

CASE

A full-term neonate presented with right lower extremity ischemia at birth because of spontaneous thrombosis of the right common iliac artery. He was initially managed with supportive treatment, anticoagulation, and dressings; however, advanced gangrenous changes precluded salvage of the ischemic limb. A guillotine amputation was performed at day 15 of life, and the stump went on to heal well by secondary intention.

CONCLUSION

Thromboembolic events occurring in infancy are well-recognized phenomena; however, it is far rarer to encounter a neonate born with "congenital gangrene". We discuss the etiology, approach to diagnosis, and treatment of this rare but devastating condition.

Preparation of cement spacer in treatment of segmental bone defects in children by the induced membrane technique: A technical note

The Masquelet Induced Membrane Technique (IMT) is one of the tools in the surgeon's armamentarium for the management of segmental bone defects. The first stage of the IMT includes the insertion of a cement spacer, which is typically fashioned by the free-hand technique. We propose a novel technique for preparation of the cement spacer using a split syringe barrel as a mould. This technique produces a uniformly cylindrical spacer with minimum cement spillage, while also minimizing thermal damage to the surrounding soft tissues. It is a simple and cost-effective method that can be adapted for use in any long bone in children.

Bone age delay patterns in Legg-Calvé-Perthes disease: an analysis using the Tanner and Whitehouse 3 method

To study the bone age delay patterns in different stages of Perthes disease, 140 hand and corresponding hip radiographs in 83 patients were assessed. In the hand radiographs, the radius, ulna, metacarpals and phalanges (RUS) and carpal bone ages were calculated using the Tanner and Whitehouse 3 method and the Greulich and Pyle (G and P) bone age was assessed using the G and P atlas. From corresponding hip radiographs, the modified Elizabethtown stage was assessed. The RUS and carpal bone age as well as G and P bone age were found to lag behind the chronological age. The 95% confidence interval for the difference between RUS and G and P bone ages was 0.19 to 0.43 years and between carpal and G and P bone ages was -0.516 to -0.14 years, indicating a close agreement between the Tanner and Whitehouse 3 and G and P methods. The RUS bone age delay was maximum in stage Ia (2.00 +/- 1.08 years), whereas carpal delay was maximum in stage IIa (2.15 +/- 1.28 years). Bone maturation acceleration was observed in later stages of the disease as bone age tried to catch up with chronological age. Carpal delay was significantly greater than RUS delay from stage Ib to IIIb (P<0.05), but no significant difference was observed between carpal and RUS delays in stage IV (P=0.21), implying that bone maturation acceleration occurs in the RUS in the earlier stages, and carpal bone age tends to catch up with RUS bone age in the healed stage of the disease. The RUS and carpal bone age delays in stage I were significantly greater in severe (Catterall groups 3 and 4) disease than in mild (Catterall groups 1 and 2) disease. All patients in whom RUS or carpal bone age delay in stage I was greater than 2 years subsequently developed severe disease, indicating a positive correlation between bone age delay in stage I and subsequent extent of involvement of capital femoral epiphysis.

Bifocal tibial corrective osteotomy with lengthening in achondroplasia: an analysis of results and complications

The results and complications of bifocal tibial osteotomies with gradual correction and lengthening by Ilizarov ring fixator performed in 47 tibiae in 24 achondroplastic patients were analyzed. Comparison was made between the parameters of angular and torsional deformities of the tibia preoperatively, at fixator removal, and at last follow-up. Of these parameters, statistically significant change was seen postoperatively in the values of medial proximal tibial angle, lateral distal tibial angle, mechanical axis deviation, and tibial torsion, which changed from 78.8 +/- 7.05 degrees, 103.2 +/- 11.8 degrees, 25.1 +/- 14.6 mm (medial), and 22.7 +/- 10 degrees (internal) preoperatively to 87.3 +/- 6.3 degrees, 90.9 +/- 5.4 degrees, 5.3 +/- 10 cm (medial), and 15.8 +/- 4.2 degrees (external), respectively, at the time of fixator removal; and this correction was maintained during the follow-up period. Mean total tibial lengthening was 6.84 +/- 1.3 cm. Average healing index was 26.06 days/cm. Complications observed were 15 pin tract infections, 1 residual varus, 1 overcorrection into valgus, 2 recurrence of varus, 22 equinus contractures, 2 premature consolidations, and 3 fibula malalignments. Recurrence of varus was observed in limbs with a residual abnormal medial mechanical axis deviation due to femoral deformity. A hundred percent incidence of equinus was observed in limbs with tibial lengthening of more than 40%, with distal tibial lengthening of more than 15%. To minimize the risk for occurrence of equinus, we recommend restriction of distal tibial lengthening in achondroplasia to less than 15%, although total tibial lengthening may exceed 40%. Fibula malalignment was not observed after double fibula osteotomy. This procedure is safe and efficacious if performed with strict adherence to prescribed technique.

Morphometric Determinants of the Sagittal Dimensions of the Cervical Spinal Canal in Achondroplasia

This study was undertaken to evaluate the accuracy of the Torg ratio for predicting the spinal canal stenosis in achondroplasia, by trying to establish its correlation with the corresponding effective sagittal canal diameter (ESCD) and dural sac ratio (DSR) on the MRI of the cervical spine. Lateral radiographs and the sagittal and axial MRI study of the cervical spine from C3 to C7 level were carried out in 18 asymptomatic achondroplasia subjects. A total of 90 levels were evaluated on the lateral radiographs and on the mid sagittal T2 MR images. On statistic analysis, the highest correlation coefficient for the Torg ratio compared with the ESCD was 0.74 at C6 level and the least was 0.45 at the C5 level. The highest correlation coefficient between the Torg ratio and the DSR was 0.79 at C3 level and the least was 0.42 at the C5 level. The highest coefficient of determination for the ESCD was 54% at C6 which translates into a poor correlation. The highest coefficient of determination for the DSR was 62 at C3 level, indicating a variable correlation. These results clearly show that the Torg ratio is of limited value in the assessment of the true sagittal spinal canal diameter in achondroplasia and its reliability as an indicator of severe cervical canal stenosis is questionable.

A Large Adolescent Idiopathic Scoliosis Curve in a Skeletally Immature Patient: Is Early Surgery the Correct Approach?

The goal of this study was to determine whether the available studies provide enough evidence that, in a borderline case of adolescent idiopathic scoliosis with a large (35 to 50 degrees) curve in a skeletally immature patient (Risser 0 to 2) with significant growth potential left, a conservative line of management in the form of bracing can be considered, rather than to rush into a potentially unnecessary major spinal surgery. We reviewed the literature spanning the last 20 years for the results of bracing in this specific group of patients. From the 9 studies selected, a group-specific data extraction was carried out. Three hundred and five patients with a 36 to 50 degrees scoliosis curve and Risser stages 0 to 2 were treated by bracing and the treatment was termed successful in 160 patients. Thus, more than half (52.5%) of the patients were successfully managed with a brace and were spared surgery. The current trend for management of these curves is early surgical intervention, the rationale being the ineffectiveness of bracing in preventing the progression of such a large curve and the difficulty in obtaining satisfactory correction by postponing surgery to a later date. On the basis of our results, we propose a conservative line of management for these curves, in contrast with current views, rather than to rush into a major spine surgery, expecting a favorable outcome with a well-supervised bracing program. If the curve progresses, surgery can always be considered later, keeping in mind the excellent correction obtained with the pedicle screw systems even for large curves of 70 to 100 degrees.

Silastic replacement of metacarpal after resection of giant cell tumour. A case report

Giant cell tumours are aggressive lesions, albeit benign. Lesions in the hand, especially those arising from metacarpals require resection with adequate margins and definitive structural reconstructions to ensure preservation of hand architecture, function and cosmesis. Almost all the described reconstructive procedures require a stump of tumour free metacarpal base after resection, for reconstruction of the metacarpal. This report describes replacement of the entire metacarpal with a silastic prosthesis, in a case of giant cell tumour involving the entire metacarpal head and shaft to within 7 mm of the base.

An age- and sex-controlled matched pair analysis of T scores in ethnic Indians with hip fractures

OBJECTIVE

The first study to predict peritrochanteric fractures by the use of T scores amongst the Indian population was performed. This study aimed to assess the risk of fracture around the hip in peri-menopausal and postmenopausal women, and in men over the age of 35 years using dual energy X-ray absorptiometry, and to analyse whether the result, i.e. the T score, can predict an impending hip fracture.

METHODS

T scores of the unaffected hip in 30 patients with peritrochanteric fractures were determined, and matched pair analysis was done using a control group without fracture. All patients were from a single centre and were evaluated using the same scanner.

RESULTS

The mean T score of the 30 patients in the fracture group was -3.34 (range, -1.2 to -5.1; standard deviation [SD], 1.032), compared with the mean T score of the 30 control subjects which was -2.41 (range, 0.6 to -5.0; SD, 1.378). T scores of patients from the fracture group were significantly lower than those in the control group.

CONCLUSION

We infer that T scores are the best predictors for fracture risk. A score of -2.5 or lower effectively defines patients at risk and is useful for predicting fracture risk in the Indian population. In patients with osteoporosis, whether a fall precedes the fracture or the fracture precedes a fall may not be an issue of debate, but can serve as a basis for prevention of additional fractures by instituting appropriate measures in patients at risk.

Anthropometric measurements to design total knee prostheses for the Indian population

An anthropometric computed tomography scan study was undertaken to design femoral components in 86 knees (47 osteoarthritic Indians-21 men, 26 women) who matched standards suggested by the Indian Council of Medical Research, 1990. Patients were classified into 3 random groups based on anteroposterior diameter (<55 mm, 55-59 mm, >59 mm). Most Indian men (86.8%) could have the femoral component satisfactorily replaced by available designs. A statistically significant number of women (60.4%, P < .001) had femoral anteroposterior diameters smaller than the smallest available (55 mm) femoral component. Splaying in mediolateral dimension (> 10 mm) in a given anteroposterior size was noted in all 3 groups. This pilot study representative of the Indian population can be used to manufacture prosthetic inventories suitable for most of the Asian-Pacific population having smaller anthropometric measurements than Western populations.

Irreducible lateral dislocation of the elbow

A rare case of an irreducible post-traumatic lateral dislocation of elbow is presented. The mechanism of injury was fall on a flexed elbow with trauma on its medial aspect resulting in pronation of the forearm. At open reduction, the brachialis muscle was in the form of a tight band which prevented reduction. The ulnar nerve was entrapped in the joint.

Results of Austin Moore replacement

Forty cases of Austin Moore Replacement done for transcervical fractures of the femur in patients were reviewed after a period of 12 to 48 months postoperatively (mean 26 mth). 30 cases (75%) had mild to severe pain of non-infective origin, starting as early as 6 months postoperatively. This was irrespective of the make, size or position (varus/valgus) of the prosthesis. Though the Aufranc and Sweet clinical scoring was satisfactory in 65% cases, radiological evidence of complications like sinking, protrusion, etc. were seen in majority of the cases. Calcar resorption was seen in 34 cases (85%) as early as 4 months postoperatively. Results of THR and bipolar replacement done for transcervical fractures in recent literature show 85% pain-free cases at 5 years. We feel that Austin Moore Replacement should be reserved for patients more than 65 years of age and those who are less active or debilitated because of other factors, because of increased acetabular wear with time in the younger individual. This is corroborated by unsatisfactory results in patients less than 65 years of age (p < 0.05).

Left ventricular aneurysm: angiographic determinants

To determine antiographic factors involved in left ventricular aneurysm formation after myocardial infarction, 50 patients with a first anterior wall myocardial infarction who underwent cardiac catheterisation within 6 months of infarction were evaluated. Extent of coronary artery disease and status of collateral circulation were studied in detail. Thirty patients had aneurysm in apical region while 20 patients showed aneurysm in anteroapical region. Coronary angiography revealed single-vessel disease in 17 patients, double-vessel disease in 17 patients and triple-vessel disease in 15 patients while in one patient coronary angiogram was normal. Fortynine patients showed significant involvement of left anterior descending artery which was poorly collateralised. Left anterior descending artery disease in association with inherent poor collateral blood supply may predispose for aneurysm formation after anterior wall myocardial infarction.