Predicting Rates of Angular Correction After Hemiepiphysiodesis in Patients With X-Linked Hypophosphatemic Rickets

PURPOSE

Patients with X-linked hypophosphatemic rickets (XLH) often develop coronal plane knee deformities despite medical treatment. Hemiepiphysiodesis is an effective way to correct coronal plane knee deformities in skeletally immature patients, but a full understanding of the rate of angular correction after hemiepiphysiodesis in XLH patients, compared with idiopathic cases is lacking.

METHODS

We retrospectively reviewed charts of 24 XLH patients and 37 control patients without metabolic bone disease who underwent hemiepiphysiodesis. All patients were treated with standard-of-care medical therapy (SOC=active vitamin D and phosphate salt supplementation) in our clinical research center and had a minimum of 2-year follow-up after hemiepiphysiodesis. Demographic data as well as complications, repeat procedures, or recurrence/overcorrection were recorded. Standing lower extremity radiographs were evaluated before the surgical intervention and at subsequent hardware removal or skeletal maturity, whichever came first. Mean axis deviation, knee zone, mechanical lateral distal femoral angle (mLDFA), and medial proximal tibial angle were measured on each radiograph. The rate of angular correction was calculated as the change in mLDFA and medial proximal tibial angle over the duration of treatment.

RESULTS

The magnitude of the initial deformity of the distal femur was greater in XLH patients as compared with control for varus (XLH mLDFA 97.7 +/- 4.9 vs. Control mLDFA 92.0 +/- 2.0 degrees) and valgus (XLH mLDFA 78.7 +/- 6.2 vs. Controls mLDFA 83.6 +/- 3.2 degrees). The rate of correction was dependent on age. When correcting for age, XLH patients corrected femoral deformity at a 15% to 36% slower rate than control patients for the mLDFA (>3 y growth remaining XLH 0.71 +/- 0.46 vs. control 0.84 +/- 0.27 degrees/month, <3 y growth remaining XLH 0.37 +/- 0.33 vs. control 0.58 +/- 0.41 degrees/month). No significant differences were seen in the rate of proximal tibia correction. XLH patients were less likely to end treatment in zone 1 (55.0% XLH vs. 77.8% control). XLH patients had longer treatment times than controls (19.5 +/- 10.7 vs. 12.6 +/- 7.0 mu, P value <0.001), a higher average number of secondary procedures than controls (1.33 +/- 1.44 vs. 0.62 +/- 0.92 number of procedures), a higher rate of overcorrection than controls (29.2% vs. 5.4%), and a higher rate of subsequent corrective osteotomy than controls (37.5% vs. 8.1%). There was no significant difference in the rate of complications between groups (8.3% vs. 5.4%).

CONCLUSIONS

Patients with XLH undergoing hemiepiphysiodesis have a 15% to 36% slower rate of femoral deformity correction that results in longer treatment times, a higher likelihood to undergo more secondary procedures, and a lower likelihood to reach neutral mechanical alignment.

SIGNIFICANCE

This study provides important information to guide the timing and treatment of patients with XLH and coronal plane knee deformities. In addition, results from this study can be educational for families and patients with respect to anticipated treatment times, success rates of the procedure, complication rate, and likelihood of needing repeat procedures.

Failure of Hip Reconstruction in Children With Cerebral Palsy: What Are the Risk Factors?

BACKGROUND

The rates and risk factors contributing to failure after hip reconstruction among patients with cerebral palsy (CP) are not well established. In analyzing a large cohort of children with CP who underwent hip reconstruction, the objectives of this study are to establish (1) the failure rates and (2) associated risk factors.

METHODS

This retrospective study included chart and radiographic review of patients between the ages of 1 to 18, with a diagnosis of CP, who underwent a hip reconstructive procedure at a single children's hospital over a 9-year period (2010 to 2018). Patients without at least 2 years of follow-up were excluded. Age at time of surgery, sex, Gross Motor Function Classification System (GMFCS), procedure(s) performed, preoperative migration percentage (MP), neck-shaft angle, and acetabular index (AI) were recorded. Failure was defined as need for revision surgery or a MP >50% on follow-up radiographs. Logistic regression and multiple-variable regression-type models were used to test for significance of risk factors.

RESULTS

Of the 291 hips in 179 patients (102 males, 77 females) that met inclusion criteria, 38 hips (13%) failed. Significant differences in the failure group were seen in age at time of surgery (6.2±3.2 vs. 8.1±3.2; P<0.001), preoperative MP (62.3±28.7 vs. 39.9±24.1%; P<0.001) and preoperative neck-shaft angle (164.9±8.2 vs. 157.3±15.6 degrees; P<0.001). Age below 6 at time of surgery significantly increased failure rate (26% vs. 6.3%, P<0.001) as did preoperative MP >70% (28.9% vs. 9.9%, P<0.001). Receiving an acetabular osteotomy was protective against failure (9.1% vs. 16.9%, P=0.048), particularly in patients with a preoperative AI >25° (odds ratio=0.236; confidence interval: 0.090-0.549).

CONCLUSIONS

In this case series, failure after hip reconstruction for children with CP was determined to be 13.1%. There was a higher risk associated with age under 6 at time of surgery or a preoperative MP >70%. Correction of acetabular dysplasia when AI is more than 25 degrees with acetabular osteotomy at time of hip reconstruction, exerted a protective effect against subsequent failure.

LEVEL OF EVIDENCE

Level III-retrospective case series.

Limb lengthening in the treatment of posteromedial bowing of the tibia

PURPOSE

Posteromedial bowing of the tibia is an uncommon but recognized congenital lower extremity deformity in children that can lead to limb length discrepancy (LLD) and residual angulatory deformity. The purpose of this study is to report a series of children at a single institution with posteromedial bowing treated by lengthening.

METHODS

A retrospective review was carried out at our institution identifying 16 patients who were treated with limb lengthening for posteromedial bowing of the tibia and followed to skeletal maturity. Projected LLD was a mean of 7.7 cm (range 5.0 cm to 14.2 cm). Three patients were treated in a staged fashion with lengthening and deformity correction at age three to four years and subsequent definitive tibial lengthening. The remaining 13 patients were treated with limb lengthening approaching adolescence using circular external fixation.

RESULTS

All patients were pain free and ambulated without a limp at final follow-up. The mean final LLD was 0.3 cm short. In spite of correction of distal tibial shaft valgus in 11 of the 16 patients, eight of the 16 (50%) required later correction of persistent, symptomatic ankle valgus by either hemiepiphyseodesis (seven patients) or osteotomy (one patient).

CONCLUSIONS

Children with posteromedial bowing of the tibial with projected LLD over 5cm can be effectively treated with lengthening. Patients with severe valgus of more than 30° of shaft valgus and difficulty ambulating at age three years can be successfully treated with a two-stage lengthening procedure. Attention should be paid in patients with posteromedial bowing to ankle valgus.

LEVEL OF EVIDENCE

IV.

Treatment of femoral fractures in children aged two to six

Aims

Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group.

Methods

Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years.

Results

All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia.

Conclusion

Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061.

Descriptive Epidemiology of Adolescent Clavicle Fractures: Results From the FACTS (Function after Adolescent Clavicle Trauma and Surgery) Prospective, Multicenter Cohort Study

Background:

The majority of previous investigations on operative fixation of clavicle fractures have been related to the adult population, with occasional assessments of the younger, more commonly affected adolescent population. Despite limited prospective data for adolescents, the incidence of operative fixation of adolescent diaphyseal clavicle fractures has increased.

Purpose:

To detail the demographic features and descriptive epidemiology of a large pooled cohort of adolescent patients with diaphyseal clavicle fractures presenting to pediatric tertiary care centers in the United States through an observational, prospective, multicenter cohort study (Function after Adolescent Clavicle Trauma and Surgery [FACTS]).

Study Design:

Cross-sectional study; Level of evidence, 4.

Methods:

Patients aged 10 to 18 years who were treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at 1 of 8 geographically diverse, high-volume, tertiary care pediatric centers were screened. Treatment was rendered by any of the pediatric orthopaedic providers at each of the 8 institutions, which totaled more than 50 different providers. Age, sex, race, ethnicity, fracture laterality, hand dominance, mechanism of injury, injury activity, athletic participation, fracture characteristics, and treatment decisions were prospectively recorded in those who were eligible and consented to enroll.

Results:

A total of 545 patients were included in the cohort. The mean age of the study population was 14.1 ± 2.1 years, and 79% were male. Fractures occurred on the nondominant side (56%) more frequently than the dominant side (44%). Sport was the predominant activity during which the injury occurred (66%), followed by horseplay (12%) and biking (6%). The primary mechanism of injury was a direct blow/hit to the shoulder (60%). Overall, 54% were completely displaced fractures, defined as fractures with no anatomic cortical contact between fragments. Mean shortening within the completely displaced group was 21.9 mm when measuring the distance between fragment ends (end to end) and 12.4 mm when measuring the distance between the fragment end to the corresponding cortical defect (cortex to corresponding cortex) on the other fragment (ie, true shortening). Comminution was present in 18% of all fractures. While 83% of all clavicle fractures were treated nonoperatively, 32% of completely displaced fractures underwent open reduction and internal fixation.

Conclusion:

Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. Slightly more than half of these fractures were completely displaced, and approximately one-fifth were comminuted. Within this large cohort, approximately one-third of patients with completely displaced fractures underwent surgery, allowing for future prospective comparative analyses of radiographic, clinical, and functional outcomes.

Gnathodiaphyseal dysplasia: Severe atypical presentation with novel heterozygous mutation of the anoctamin gene (ANO5)

Gnathodiaphyseal dysplasia (GDD; OMIM #166260) is an ultra-rare autosomal dominant disorder caused by heterozygous mutation in the anoctamin 5 (ANO5) gene and features fibro-osseous lesions of the jawbones, bone fragility with recurrent fractures, and bowing/sclerosis of tubular bones. The physiologic role of ANO5 is unknown. We report a 5-year-old boy with a seemingly atypical and especially severe presentation of GDD and unique ANO5 mutation. Severe osteopenia was associated with prenatal femoral fractures, recurrent postnatal fractures, and progressive bilateral enlargement of his maxilla and mandible beginning at ~2months-of-age that interfered with feeding and speech and required four debulking operations. Histopathological analysis revealed benign fibro-osseous lesions resembling cemento-ossifying fibromas of the jaw without psammomatoid bodies. A novel, de novo, heterozygous, missense mutation was identified in exon 15 of ANO5 (c.1553G>A; p.Gly518Glu). Our findings broaden the phenotypic and molecular spectra of GDD. Fractures early in life with progressive facial swelling are key features. We assessed his response to a total of 7 pamidronate infusions commencing at age 15months. Additional reports must further elucidate the phenotype, explore any genotype-phenotype correlation, and evaluate treatments.

An analysis of suboptimal outcomes of medial malleolus fractures in skeletally immature children

We retrospectively analyzed cases of intra-articular medial malleolar fractures in skeletally-immature patients (Salter-Harris III and IV) with suboptimal outcomes at St. Louis Children's Hospital and Shriner's Hospital for Children. Common causes of poor outcome were frac­ture malunion or malreduction and physeal damage. Malreductions of only 2 mm does not appear to be toler­ated and the concept of "remodeling" does not apply to these fracture patterns. Based on this study, we "recom­mend" fracture reduction and fixation if there is greater than 1 mm of fracture step-off..

Use of femoral nerve blocks in adolescents undergoing patellar realignment surgery

The purpose of this study was to analyze the efficacy of femoral nerve blocks (FNBs) in decreasing postoperative narcotic use in adolescents undergoing patellar realignment surgery (PRS). All patients who underwent PRS at 2 children's hospitals between 1998 and 2002 were included in the study. Patients were grouped according to postoperative analgesia: FNB (n = 14), as-needed intravenous morphine (PRN-IV; n = 16), or patient-controlled analgesia using morphine (PCA; n = 13). Total postoperative i.v. morphine use was statistically significantly different among the 3 groups: 9.0 mg for FNB, 26.43 mg for PRN-IV, and 64.7 mg for PCA. FNB use was effective in significantly decreasing postoperative i.v. narcotic use.

Arthroscopic findings at the time of patellar realignment surgery in adolescents

Articular cartilage injuries and loose bodies have been associated with patellar dislocations. At the time of patellar realignment surgery (PRS), direct intraarticular visualization of the structures of concern may be limited with the use of a small arthrotomy. Concomitant diagnostic arthroscopy can improve the identification of intraarticular abnormalities, both patellofemoral and nonpatellofemoral, because of the better field of view.

PURPOSE

This report details the findings from knee arthroscopy performed concomitantly with PRS in adolescents.

METHODS

All patients underwent knee arthroscopy and open PRS for patellar instability, performed by a single surgeon, during a 4-year period. Patient demographics, knee history, clinical examination, operative findings, and treatment details were collected on all patients.

RESULTS

: Thirty-eight patients (mean age, 14.9 years; 41 knees) were included in this analysis. Patellar osteochondral lesions were present in 30 knees (73%; mean size, 112 mm). Femoral lesions were documented in 11 knees (23%; mean size, 81 mm). Loose bodies were present in 6 knees (15%). In 8 patients (20%), an additional 11 nonpatellofemoral diagnoses were made at the time of arthroscopy: lateral tibiofemoral chondroses (n = 4), medial meniscal tear (n = 2), lateral meniscal tear (n = 2), discoid lateral meniscus (n = 1), partial anterior cruciate ligament tear (n = 1), and medial tibiofemoral chondrosis (n = 1). Because of these findings, 5 additional procedures were performed in 4 patients: partial lateral meniscectomy (n = 2), medial meniscal repair (n = 1), discoid meniscus saucerization (n = 1), and staged distal femoral valgus-correcting osteotomy (n = 1).

CONCLUSIONS

By performing concomitant knee arthroscopy at the time of PRS, we were able to identify significant tibiofemoral abnormality in 4 patients, which would have been missed with direct inspection by a limited arthrotomy at the patellofemoral joint. In addition, precise evaluation of the patellofemoral joint permits customization of the PRS and aids in establishing appropriate patient expectations postoperatively. We advocate diagnostic knee arthroscopy at the time of PRS in adolescents to identify all intraarticular abnormalities and to optimize discussions with the patient and the caregivers on the long-term prognosis of the knee.

SIGNIFICANCE

Arthroscopic inspection of the knee at the time of PRS permits identification of abnormality that is not routinely visual by using open arthrotomy. Twenty percent of patients had additional pathological findings; of these patients, 50% underwent an additional surgical procedure.

A new dynamic foot abduction orthosis for clubfoot treatment

Recurrent clubfoot deformity after successful initial correction with the use of the Ponseti method continues to be a common problem and is often caused by noncompliance with wear of the traditional foot abduction brace. The purpose of this study was to assess the results of a newly designed dynamic foot abduction orthosis in terms of (1) parental compliance and (2) effectiveness in preventing recurrent clubfoot deformities. Twenty-eight patients (49 clubfeet) who were treated with a dynamic foot abduction orthosis in accordance with the Ponseti method were included in this study. Of the 28 patients, 18 had idiopathic clubfeet (31 clubfeet), 2 had complex idiopathic clubfeet (4 clubfeet), 5 had myelodysplasia (8 clubfeet), and 3 were syndromic (6 clubfeet). The mean duration of follow-up was 29 months (range, 24-36 months). Noncompliance was reported in only 2 (7.1%) of the 28 patients in the new orthosis compared with the authors' previously reported 41% (21/51) noncompliance rate in patients treated with the use of the traditional foot abduction brace. The two patients in this study, in which parents were noncompliant with orthosis wear, developed recurrent deformities. There were 2 patients (7%) who experienced skin blistering in the new orthosis compared with 12 (23.5%) of 51 patients who experienced blistering with the use of traditional abduction brace in the authors' previously reported study. Logistic regression modeling compliance and recurrence revealed that noncompliance with the foot abduction orthosis was most predictive of recurrence of deformity (odds ratio, 27; 95% confidence interval, 2.2-326; P = 0.01). The articulating foot abduction orthosis is well tolerated by patients and parents and results in a higher compliance rate and a lower complication rate than what were observed with the traditional foot abduction orthosis.

Complications after titanium elastic nailing of pediatric tibial fractures

A retrospective review of 60 diaphyseal tibia fractures (31 closed and 29 open fractures) treated with flexible intramedullary fixation was conducted. All charts and radiographs were reviewed. Children ranged in age from 5.1 to 17 years. Fifty patients with 51 fractures were followed up until union and comprised the study group. The mean follow-up period for these 50 patients was 79 weeks. Forty-five fractures achieved bony union within 18 weeks (mean, 8 weeks). Five patients (11%) had delayed healing (3 had delayed unions that ultimately healed with casting or observation, and 2 had nonunions that required secondary procedures to achieve union [1 patient underwent a fibular osteotomy, and 1 underwent exchange nailing with a reamed tibial nail]). These 5 fractures ultimately healed, with a mean time to union of 41 weeks. Patients with delayed healing tended to be older (mean age, 14.1 years) versus the study population as a whole (mean age, 11.7 years). In addition to delayed union, other complications were observed in the study population. One patient healed with malunion (13-degree valgus), requiring corrective osteotomy. One patient with a grade II open fracture was diagnosed with osteomyelitis at the fracture site after attaining bony union. Two patients developed nail migration through the skin, requiring modification or nail removal. The fixation of pediatric diaphyseal tibia fractures with titanium elastic nails is effective but has a substantial rate of delayed healing, particularly in older patients.

Soft-tissue distraction with a ring external fixator before centralization for radial longitudinal deficiency

PURPOSE

To review the techniques and evaluate the use of soft-tissue distraction with a ringed fixator for radial longitudinal deficiency (RLD) before centralization.

METHODS

Eight extremities in 6 patients with severe RLD were treated with ring fixator distraction followed by centralization. A clinical examination was performed and radiographic data were obtained prospectively and at an average follow-up period of 17 months. The techniques and the early objective (range of motion, position) and radiographic outcome were evaluated.

RESULTS

The preoperative ring fixator accomplished an average of 16 mm of distraction and allowed the centralization procedure to be performed effectively and without tension. Clinical alignment was improved markedly. The hand-forearm angle improved from 72 degrees radial to 8 degrees ulnar after surgery. The volar carpal subluxation improved by an average of 6 mm.

CONCLUSIONS

Precentralization ring fixator distraction allows the performance of a tensionless centralization procedure with good early radiographic and clinical outcome in patients severely affected with RLD.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Obstructive sleep apnoea syndrome in morbidly obese children with tibia vara

Morbid obesity and its association with obstructive sleep apnoea syndrome have been increasingly recognised in children. Orthopaedic surgeons are often the primary medical contact for older children with tibia vara, which has long been associated with obesity, but are unfamiliar with the evaluation and treatment of sleep apnoea in children. We reviewed all children with tibia vara treated surgically at one of our institutions over a period of five years. Thirty-seven patients were identified; 18 were nine years of age or older and 13 of these (72%) had morbid obesity and a history of snoring. Eleven children were diagnosed as having sleep apnoea on polysomnography. The incidence of this syndrome in the 18 children aged nine years or older with tibia vara, was 61%. All these patients required pre-operative non-invasive positive-pressure ventilation; tonsillectomy and adenoidectomy were necessary in five (45%). No peri-operative complications related to the airway occurred. There is a high incidence of sleep apnoea in morbidly obese patients with tibia vara. These patients should be screened for snoring and, if present, should be further evaluated for sleep apnoea before corrective surgery is undertaken.

Periacetabular osteotomy in the treatment of severe acetabular dysplasia. Surgical technique

BACKGROUND

The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients.

METHODS

Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively.

RESULTS

Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures.

CONCLUSIONS

The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

Femoral deformity in tibia vara

BACKGROUND

Previous studies have suggested that compensatory valgus deformity of the femur is common in patients with tibia vara, or Blount disease. The availability and routine use of standing long-cassette radiographs of the lower extremities to assess angular deformities has allowed quantitative evaluation of this hypothesis.

METHODS

The cases of all patients with tibia vara, two years of age or older, seen at our institution prior to treatment, over a thirteen-year period, were reviewed. Seventy-three patients with a total of 109 involved lower limbs were identified and were classified as having either infantile tibia vara (thirty-seven patients with fifty-six involved limbs) or late-onset tibia vara (thirty-six patients with fifty-three involved limbs). Standardized standing radiographs of the lower extremity were examined to assess the deformity at the distal part of the femur and the proximal part of the tibia by measuring the lateral distal femoral angle and the medial proximal tibial angle.

RESULTS

The distal part of the femur in the children with infantile tibia vara either was normal or had mild varus deformity, with a mean lateral distal femoral angle of 97 degrees (range, 82 degrees to 129 degrees). The mean medial proximal tibial angle in these children was 72 degrees (range, 32 degrees to 84 degrees). Older children with infantile tibia vara were noted to have little distal femoral deformity, with no more than 4 degrees of valgus compared with either normal values or the contralateral, normal limb. Children with late-onset tibia vara had a mean lateral distal femoral angle of 93 degrees (range, 82 degrees to 110 degrees) and a mean medial proximal tibial angle of 73 degrees (range, 52 degrees to 84 degrees). On the average, the varus deformity of the distal part of the femur constituted 30% (6 degrees of 20 degrees) of the genu varum deformity in these patients.

CONCLUSIONS

Patients with infantile tibia vara most commonly had normal alignment of the distal parts of the femora; substantial valgus deformity was not observed. Distal femoral varus constituted a substantial portion of the genu varum in children with late-onset disease. When correction of late-onset tibia vara is planned, the surgeon should be aware of the possibility that distal femoral varus is a substantial component of the deformity.

Limit on the electron electric dipole moment in gadolinium-iron garnet

A new method for the detection of the electron electric dipole moment (EDM) using a solid is described. The method involves the measurement of a voltage induced across the solid by the alignment of the sample's magnetic dipoles in an applied magnetic field, H. A first application of the method to GdIG has resulted in a limit on the electron EDM of 5 x 10(-24)e cm, which is a factor of 40 below the limit obtained from the only previous solid-state EDM experiment. The result is limited by the imperfect discrimination of an unexpectedly large voltage that is even upon the reversal of the sample magnetization.

Variable hand and foot abnormalities in family with congenital vertical talus and CDMP-1 gene mutation

Isolated foot anomalies, including congenital vertical talus, were shown recently to occur in heterozygous carriers of CDMP-1 (cartilage-derived morphogenetic protein-1) gene mutations. Six families with isolated congenital vertical talus with apparent autosomal dominant inheritance were ascertained. DNA was isolated from 17 affected individuals and 24 unaffected individuals from these families and subjected to mutational analysis of the CDMP-1 gene. A missense mutation was identified (1312C>T) that results in an R438C substitution in the CDMP-1 active domain. This segregated with disease in one Northeren American family. Phenotypic variability in this family includes brachydactyly type C, clinodactyly, calcaneo valgus deformity, and congenital vertical talus. Metacarpophalangeal profiles (MCPPs) confirm incomplete penetrance in one family member. Hence, CDMP-1 mutations may be found in individuals with apparently isolated CVT, although careful examination of family members may reveal additional, subtle hand and foot abnormalities. However, mutations in CDMP-1 do not appear to be a frequent cause of isolated congenital vertical talus.

Diaphyseal derotational osteotomy with intramedullary fixation for correction of excessive femoral anteversion in children

Nearly all children with femoral anteversion spontaneously remodel by age 8. Femoral derotational osteotomies are performed in older children with persistent excessive femoral anteversion when children or adolescents are limited in activities of daily living or sports. Procedures for correction of the anteversion vary, and no one procedure has been shown to be superior. Since 1997 the authors have corrected idiopathic excessive femoral anteversion thorough a diaphyseal osteotomy with fixation using a rigid intramedullary pediatric femoral nail. The purpose of this study was to describe the technique and results of this new technique. A retrospective study was conducted of all femoral derotational osteotomies performed with a pediatric femoral nail in 13 consecutive patients and 21 affected limbs. All patients complained preoperatively of frequent tripping during sports and activities of daily living. The mean preoperative rotation included internal rotation of 77 degrees and external rotation of 15 degrees. Standing AP radiographs of all patients were obtained at final follow-up. All patients were evaluated clinically and radiographically at a minimum of 1 year after surgery. All patients noted improvement in the ability to participate in activities without tripping. No patient limped at final follow-up. No intraoperative or postoperative complications occurred. Healing of the osteotomy was present at a mean of 6 weeks. All osteotomies healed in anatomic alignment. Mean final hip rotation included internal rotation of 40 degrees and external rotation of 57 degrees. No patient had substantial changes of valgus or femoral neck narrowing at final follow-up. Femoral derotational osteotomy with fixation using a small-diameter rigid intramedullary nail placed through the lateral aspect of the greater trochanter is a safe, accurate, and effective method of correcting excessive femoral anteversion in symptomatic children.

Outcome of hemiepiphyseal stapling for late-onset tibia vara

BACKGROUND

The results of hemiepiphysiodesis for the treatment of late-onset tibia vara have been reported to be favorable, but the technique requires careful timing and an accurate estimation of skeletal age. Hemiepiphyseal stapling does not require a careful estimation of skeletal age, and it has been reported to yield good results with low morbidity. However, we are not aware of any study evaluating the intermediate-term radiographic results or complications of this procedure.

METHODS

Twenty-six patients with thirty-three extremities with late-onset tibia vara were treated with proximal tibial hemiepiphyseal stapling. Fourteen extremities had substantial concomitant distal femoral varus and also had hemiepiphyseal stapling of the distal part of the femur. Eighteen patients (twenty-three involved extremities) had juvenileonset tibia vara and eight patients (ten involved extremities) had adolescent-onset tibia vara. The mean age at the time of stapling was 11.8 years. The mean duration of follow-up was 3.8 years. We reviewed standardized standing radiographs to determine the mechanical axis deviation, the medial proximal tibial angle, the lateral distal femoral angle, and the zone of the knee through which the mechanical axis passed.

RESULTS

The mean mechanical axis deviation improved from 58 mm (range, 27 to 157 mm) preoperatively to 22 mm (range, -33 to 117 mm) at the time of the last follow-up, and the mean medial proximal tibial angle improved from 77 degrees (range, 50 degrees to 85 degrees ) to 85 degrees (range, 48 degrees to 95 degrees ). In the fourteen lower extremities in which distal femoral hemiepiphyseal stapling was performed, the mean lateral distal femoral angle improved from 96 degrees (range, 92 degrees to 100 degrees ) to 86 degrees (range, 79 degrees to 97 degrees ). At the time of the final follow-up, seven extremities were considered to be in moderate varus; four, in mild varus; twenty, in normal alignment; and two, in valgus. No differences in radiographic outcome were noted between the juvenile and adolescent forms of tibia vara. Only one of the four extremities with severe preoperative varus was corrected to normal alignment; the remaining three were left with moderate varus.

CONCLUSIONS

Hemiepiphyseal stapling of the lateral aspect of the proximal tibial physis and, as needed, the lateral aspect of the distal femoral physis is safe and effective in children with late-onset tibia vara if the physes are sufficiently open and the varus deformity is mild to moderate. Hemiepiphyseal stapling is particularly effective in patients who are ten years of age or younger.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Flexor digitorum accessorius longus muscle is associated with familial idiopathic clubfoot

The etiology of idiopathic and familial clubfoot remains elusive. The purpose of this study was to document the prevalence of the flexor digitorum accessorius longus muscle in a large series of children treated with an extensive soft tissue release for idiopathic clubfoot deformity and compare those patients with and without this anomalous muscle in terms of various demographic data, including a positive family history of clubfoot. A retrospective review was conducted to identify infants treated with an extensive soft tissue release for idiopathic clubfoot deformity at the authors' institutions between 1980 and 2000. Patient characteristics and family demographic data were analyzed using multiple logistic regression analysis modeling the probability of having the anomalous flexor muscle. A flexor digitorum accessorius longus muscle was identified in 55 (6.6%) of the 835 patients at the time of surgical correction of the clubfoot deformity. It was present in 4.5% of patients without a family history (33/741) and 23.4% of patients with a family history (22/94) (P < 0.0001). Children with first-degree relatives with clubfoot are 6.6 times more likely to have the anomalous flexor muscle than children without first-degree relatives with clubfoot (odds ratio 6.6; 95% confidence interval 3.63-11.84; P < 0.0001).

Comprehensive treatment of late-onset tibia vara

BACKGROUND

Late-onset tibia vara (Blount disease) can be difficult to treat because of frequent morbid obesity and associated deformities, including distal femoral varus, proximal tibial procurvatum, and distal tibial valgus, that contribute to lower extremity malalignment. We present a comprehensive approach that addresses all components of the deformity and allows restoration of the anatomic and mechanical axes.

METHODS

Fifteen consecutive patients (nineteen lower extremities) with late-onset tibia vara were managed with this comprehensive approach. The mean age of the patients at the time of surgery was 14.9 years, and the mean weight was 113 kg. Standing anteroposterior and lateral radiographs were made preoperatively and at the time of the final follow-up. Preoperatively, the mean mechanical axis deviation was 108 mm, the mean lateral distal femoral angle was 95 degrees , and the mean mechanical medial proximal tibial angle was 71 degrees . In all nineteen extremities, the proximal tibial varus deformity was corrected by means of a valgus osteotomy and application of an Ilizarov ring external fixator. Distal femoral varus was corrected by means of either hemiepiphyseal stapling or valgus osteotomy with blade-plate fixation in thirteen of the nineteen extremities. Distal tibial valgus was treated either with hemiepiphyseal stapling or with varus osteotomy and gradual correction with use of the Ilizarov external fixator in eleven of the nineteen extremities.

RESULTS

After a mean duration of follow-up of 5.0 years, the mean mechanical axis deviation had improved to 1 mm (range, 20 to -30 mm), the lateral distal femoral angle had improved to 87 degrees (range, 83 degrees to 98 degrees), and the mechanical medial proximal tibial angle had improved to 88 degrees (range, 83 degrees to 98 degrees ). The mean time required for correction of the proximal tibial varus deformity was thirty-one days, and the external fixator was removed at a mean of 4.5 months postoperatively. All patients had development of one or more superficial pin-track infections (mean, 1.9 pin-site infections per patient). No wound infections, nonunions, or neurovascular complications occurred. Eighteen of the nineteen extremities were pain-free at the time of the final follow-up.

CONCLUSIONS

This comprehensive approach allowed restoration of the mechanical and anatomic axes of the lower extremity in patients with late-onset tibia vara, resulting in a resolution of symptoms as a result of normalization of the weight-bearing forces across the knee and ankle. We believe that this approach will decrease the risk of early degenerative arthritis of the knee.

Use of an intramedullary rod for the treatment of congenital pseudarthrosis of the tibia. Surgical technique

BACKGROUND

The treatment of congenital pseudarthrosis of the tibia remains difficult and controversial. The purpose of this study was to evaluate the long-term results of a technique consisting of excision of the pseudarthrosis, autologous bone-grafting, and insertion of a Williams intramedullary rod into the tibia.

METHODS

Twenty-one consecutive patients with congenital pseudarthrosis of the tibia were managed with this technique between 1978 and 1999, and the results were retrospectively reviewed. The mean age of the patients at the time of the latest follow-up was 17.2 years (range, seven to twenty-five years), and the mean duration of postoperative follow-up was 14.2 years (range, three to twenty years).

RESULTS

Initial consolidation occurred in eighteen of the twenty-one patients. Refracture occurred in twelve patients; five fractures healed with closed treatment, five healed after an additional surgical procedure, and two ultimately required amputation. Ten patients had an ankle valgus deformity after tibial union. Eleven patients had a residual limb-length discrepancy of >2 cm; six required a contralateral distal femoral and/or proximal tibial epiphyseodesis, two had a tibial lengthening, and one used a shoe-lift. Five patients had an amputation: two, because of a recalcitrant fracture; two, because of a limb-length discrepancy (6 and 9 cm); and one, because of a chronic lower-extremity deformity.

CONCLUSIONS

This technique produced a satisfactory long-term functional outcome in sixteen of twenty-one patients and should be considered for the management of congenital pseudarthrosis of the tibia.

Magnetic resonance imaging of the knee in children and adolescents. Its role in clinical decision-making

BACKGROUND

Recent studies have questioned the utility of magnetic resonance imaging in the diagnosis of pediatric knee disorders because of the morphologic changes during growth and the low accuracy of the formal interpretation of the magnetic resonance imaging scan by a radiologist. The purpose of this study was twofold: (1) to report the accuracy of formal interpretations of magnetic resonance imaging scans of the knee in children and adolescent patients by a radiologist, and (2) to determine the benefit, if any, of a personal review of the magnetic resonance imaging scan of the knee by the orthopaedic surgeon, as a routine part of the diagnostic evaluation.

METHODS

A three-year prospective study of all patients who underwent knee arthroscopy performed by a single surgeon, at two children's hospitals, was completed. The analysis focused on the six most common diagnoses: anterior cruciate ligament tear, lateral meniscal tear, medial meniscal tear, osteochondritis dissecans, discoid lateral meniscus, and osteochondral fracture. The preoperative diagnosis of the surgeon was determined by integrating the history and the findings on the clinical examination, plain radiographs, and magnetic resonance imaging scans (including the radiologist's interpretation).

RESULTS

Ninety-six patients with ninety-six abnormal knees were included. The mean age was 14.6 years at the time of surgery. Relative to operative findings, kappa values for the formal interpretations of the magnetic resonance imaging scans by a radiologist were 0.78 for an anterior cruciate ligament tear, 0.76 for a medial meniscal tear, 0.71 for a lateral meniscal tear, 0.70 for osteochondritis dissecans, 0.46 for discoid lateral meniscus, and 0.65 for osteochondral fracture. Relative to operative findings, kappa values for the preoperative diagnoses by the surgeon were 1.00 for an anterior cruciate ligament tear, 0.90 for a medial meniscal tear, 0.92 for a lateral meniscal tear, 0.93 for osteochondritis dissecans, 1.00 for discoid lateral meniscus, and 0.90 for osteochondral fracture. The preoperative diagnosis by the surgeon was better (p < 0.05) than the formal interpretation of the magnetic resonance imaging scans by the radiologist with respect to an anterior cruciate ligament tear, lateral meniscal tear, osteochondritis dissecans, and discoid lateral meniscus.

CONCLUSIONS

Integration of patient information with an orthopaedic surgeon's review of the magnetic resonance imaging scan of the knee in children and adolescent patients improves the identification of pathological disorders in four of the six categories evaluated. This study questions the necessity for and appropriateness of a routine interpretation of a magnetic resonance imaging scan of the knee in children and adolescents by a radiologist.

Primary and delayed closure after open irrigation and debridement of septic arthritis in children

Seventy-one patients with 83 septic joints due to idiopathic septic arthritis were investigated retrospectively. Forty-three joints were closed primarily while 40 underwent delayed primary closure. Two joints in each group failed treatment and had to be reopened after definitive closure. Joints in patients 7 years of age or older had a substantially higher failure rate (12%), with either primary or delayed closure, than joints in patients younger than 7 years (1.7%). Two of 13 patients with a polymorphonuclear leukocyte count in the synovial fluid greater than 100,000 required repeat debridement after final closure. Three of the four patients who required repeat debridement showed evidence of osteomyelitis. The average length of stay was longer in the delayed primary closure group (7.0 days) than in the primary closure group (5.6 days). This study suggests that primary closure is a viable alternative to delayed primary closure with shorter hospital stays and similar outcomes in children with idiopathic septic arthritis. Care should be taken in children aged 7 and older or when concurrent osteomyelitis exists.

Periacetabular osteotomy for the treatment of severe acetabular dysplasia

BACKGROUND

The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients.

METHODS

Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively.

RESULTS

Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees ) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees ) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees ) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures.

CONCLUSIONS

The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

Smoking and socio-economic status in the etiology and severity of Legg-Calvé-Perthes' disease

BACKGROUND

The etiology of Legg-Calvé-Perthes disease is poorly understood. An association has been found in the past between Legg-Calvé-Perthes disease and smoking as well as low socio-economic status.

METHODS

A prospective study was carried out in which families with a child diagnosed with Legg-Calvé-Perthes' disease were interviewed about the presence and duration of household second-hand smoke exposure to children. A control group of randomly selected families seen at our institution were interviewed with identical questions. The radiographs of children with Legg-Calvé-Perthes disease were reviewed and classified according to the Herring lateral pillar classification system.

RESULTS

Thirty-eight of the 60 patients (63.3%) with Legg-Calvé-Perthes disease were noted to have at least one smoker living in the child's household with a mean of 1.03 smoker-years per year of life exposure to smoke. The median income of the patients with Legg-Calvé-Perthes disease was USD 20,300. The median income of the patients in the control group was USD 17,000. Thirty-eight of the 96 control patients (39.6%) were noted to have at least one smoker living in the child's household with a mean of 0.48 smoker-years per year of life. A significant association was noted between living with a smoker and Legg-Calvé-Perthes disease as well as between increasing smoke exposure and increased risk of developing Legg-Calvé-Perthes disease. No significant association was noted between lower income and Legg-Calvé-Perthes disease. There was no association between increased smoke exposure and increased severity of Legg-Calvé-Perthes disease as measured by the lateral pillar classification.

CONCLUSIONS

The presence of second-hand smoke seems to be a significant risk factor in the development of Legg-Calvé-Perthes disease. The presence of second-hand smoke may represent the 'unknown industrial factor' that has been discussed.

Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of clubfoot deformity

Ponseti demonstrated correction of most clubfeet in infants using proper manipulative techniques followed by application of well-molded long-leg plaster casts and a percutaneous tendoachilles tenotomy to correct residual equinus contracture. Medical complications occurring as a result of this technique have not to our knowledge been reported. The authors retrospectively reviewed 134 consecutive infants with 219 idiopathic clubfeet treated with the Ponseti method. A percutaneous tendoachilles tenotomy was performed on 200 clubfeet (91%) at a mean age of 16 weeks (range, 6-77 weeks) when less than 10 degress of ankle dorsiflexion was present after casting. A total of 4 patients had serious bleeding complications following the percutaneous tendoachillis tenotomy--3 due to presumed injury to the peroneal artery and 1 due to injury to the lesser saphenous vein. The authors detail the technique of performing a percutaneous tendoachilles tenotomy and offer guidelines that may help others avoid this same complication.

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children

OBJECTIVES

To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents.

DESIGN

A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail.

PATIENTS/PARTICIPANTS

Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes.

INTERVENTION

Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter.

MAIN OUTCOME MEASUREMENTS

Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing.

RESULTS

Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications.

CONCLUSIONS

The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.

Use of an intramedullary rod for treatment of congenital pseudarthrosis of the tibia. A long-term follow-up study

BACKGROUND

The treatment of congenital pseudarthrosis of the tibia remains difficult and controversial. The purpose of this study was to evaluate the long-term results of a technique consisting of excision of the pseudarthrosis, autologous bone-grafting, and insertion of a Williams intramedullary rod into the tibia.

METHODS

Twenty-one consecutive patients with congenital pseudarthrosis of the tibia were managed with this technique between 1978 and 1999, and the results were retrospectively reviewed. The mean age of the patients at the time of the latest follow-up was 17.2 years (range, seven to twenty-five years), and the mean duration of postoperative follow-up was 14.2 years (range, three to twenty years).

RESULTS

Initial consolidation occurred in eighteen of the twenty-one patients. Refracture occurred in twelve patients; five fractures healed with closed treatment, five healed after an additional surgical procedure, and two ultimately required amputation. Ten patients had an ankle valgus deformity after tibial union. Eleven patients had a residual limb-length discrepancy of >2 cm; six required a contralateral distal femoral and/or proximal tibial epiphyseodesis, two had a tibial lengthening, and one used a shoe-lift. Five patients had an amputation: two, because of a recalcitrant fracture; two, because of a limb-length discrepancy (6 and 9 cm); and one, because of a chronic lower-extremity deformity.

CONCLUSIONS

This technique produced a satisfactory long-term functional outcome in sixteen of twenty-one patients and should be considered for the management of congenital pseudarthrosis of the tibia.

Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms

BACKGROUND

Differentiation between septic arthritis and transient synovitis of the hip in children can be difficult. Kocher et al. recently developed a clinical prediction algorithm for septic arthritis based on four clinical variables: history of fever, non-weight-bearing, an erythrocyte sedimentation rate of >or=40 mm/hr, and a serum white blood-cell count of >12000/mm(3) (>12.0 x 10(9)/L). The purpose of this study was to apply this clinical algorithm retrospectively to determine its predictive value in our patient population.

METHODS

A retrospective review was performed to identify all children who had undergone a hip arthrocentesis for the evaluation of an irritable hip at our institution between 1992 and 2000. One hundred and sixty-three patients with 165 involved hips satisfied the criteria for inclusion in the study and were classified as having true septic arthritis (twenty hips), presumed septic arthritis (twenty-seven hips), or transient synovitis (118 hips).

RESULTS

Patients with septic arthritis (true and presumed; forty-seven hips) differed significantly (p < 0.05) from patients with transient synovitis (118 hips) with regard to the erythrocyte sedimentation rate, differential of serum white blood-cell count, total white blood-cell count and differential in the synovial fluid, gender, previous health-care visits, and history of fever. If the four independent multivariate predictors of septic arthritis proposed by Kocher et al. were present, the predicted probability of the patient having septic arthritis was 59% in our study, in contrast to the 99.6% predicted probability in the patient population described by Kocher et al. Statistical analyses demonstrated that the best model to describe our patient population was based on three variables: a history of fever, a serum total white blood-cell count of >12000/mm(3) (>12.0 x 10(9)/L), and a previous health-care visit. When all three variables were present, the predicted probability of the patient having septic arthritis was 71%.

CONCLUSIONS

Although the use of a clinical prediction algorithm to differentiate between septic arthritis and transient synovitis may have improved the utility of existing technology and medical care to facilitate the diagnosis at the institution at which the algorithm originated, application of the algorithm proposed by Kocher et al. or of our three-variable model does not appear to be valid at other institutions.

Complications and outcomes of open pediatric forearm fractures

Few reports have documented the complications and outcomes of open pediatric forearm fractures. The authors completed of all patients (1987-1999) with open forearm fractures. Sixty-five patients with 65 injured extremities were identified, with an average age of 10.3 years. Fifty-two open fractures were grade I, 12 were grade II, and 1 was grade IIIA. Implants stabilized 40 extremities (62%), which improved alignment but not outcome. Forearms initially stabilized with implants did not undergo additional realignment procedures (0%), compared with 18.5% of forearms without stabilization. Eleven patients (16.9%) experienced complications. Overall, 47 (72%) were classified as having excellent results, 11 (17%) as good, and 7 (11%) as fair. Open pediatric forearm fractures have a high percentage of excellent and good outcomes. Early, thorough surgical débridement produces a low frequency of deep infections, and bony stabilization can be a safe technique, permitting more anatomic alignment and preventing the need for reoperation due to malalignment.

Medial translation of the hip joint center associated with the Bernese periacetabular osteotomy

This study assessed medial translation of the hip joint achieved by the Bernese periacetabular osteotomy (PAO) in correcting residual acetabular dysplasia deformities. 86 hips in 75 patients with an average age of 25 years (range, 12-50) were treated for symptomatic acetabular dysplasia with a periacetabular osteotomy. Radiographic analysis was performed to assess correction of the acetabular deformity with specific attention to the horizontal position of the hip joint center. All hips were followed until bony union of the iliac osteotomy and the average follow-up was 28 months. The lateral center edge angle improved an average 31.6 degrees (-0.4 degrees preoperative, 31.2 degrees at follow-up). The anterior center edge angle improved 39.3 degrees (-4.5 degrees to 34.8 degrees). The acetabular roof obliquity improved an average 21.8 degrees (25.1 degrees to 3.3 degrees). Preoperatively, the average distance from the medial aspect of the femoral head to the ilioischial line was 17.6 mm. This distance was decreased to an average 7.8 mm postoperatively. This change resulted in an average medial translation of the hip joint center of 9.8 mm, (range -6 to 31mm). Overall, some degree of medial translation of the hip joint center was obtained in 79 (92%) of the hips. Four (5%) were maintained in the same horizontal position, and 3 (3%) had slight lateral repositioning. For the hips translated medially, the average change was 10.0 mm, and 72% of all hips had an optimal correction with the distance between the medial aspect of the femoral head and the ilioischial line being between 0 and 10 mm. This study demonstrates that in addition to optimizing femoral head coverage, a major and distinct advantage of the periacetabular osteotomy is reproducible and consistent medial translation of the hip joint center.

A comparison of monolateral and circular external fixation of unstable diaphyseal tibial fractures in children

Forty-six tibial fractures in 44 children, which were treated by external fixation at our institution between 1 January 1991 and 31 December 1999, were retrospectively identified. Twenty-nine fractures were treated with monolateral fixation and 16 were treated with circular fixation. The average age of the patients was 11 years 8 months (range 3 years 11 months-17 years 7 months). External fixators were left in place for a mean of 13.7 weeks (range 9-33 weeks). Eleven significant complications occurred. Loss of reduction necessitating return to the operating room occurred in four patients (13%) and malunion occurred in an additional patient with monolateral fixators. Four of these patients had comminuted fracture patterns. All of the patients with loss of reduction were 12 years of age or older. No patient with a circular fixator developed mal-alignment. Final alignment in 45 of the 46 fractures was acceptable. External fixation is a safe and effective method of treating unstable diaphyseal tibia fractures in children. Patients over the age of 12 years, particularly with comminuted fracture patterns may be more effectively treated with circular external fixation or, if treated with monolateral fixation, require close observation.

Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children

BACKGROUND

Recent reports have described osteonecrosis of the femoral head after intramedullary nailing of the femur through the piriformis fossa in children. Other reports have raised concerns about the development of femoral neck narrowing and valgus deformity of the proximal part of the femur after intramedullary nailing through the tip of the greater trochanter. We evaluated the radiographic changes in the proximal part of the femur following intramedullary nailing through the lateral trochanteric area at a minimum of two years postoperatively in twenty-five affected extremities. The mean age of the patients at the time of the index procedure was ten years and six months.

METHODS

A retrospective radiographic review was performed to look for proximal femoral changes. Specifically, the radiographs were examined for evidence of osteonecrosis. The articulotrochanteric distance, femoral neck diameter, and neck-shaft angle were measured on the initial and final radiographs.

RESULTS

No patient had evidence of osteonecrosis of the femoral head. The articulotrochanteric distance decreased by a mean of 0.4 mm, the femoral neck diameter increased by a mean of 4.9 mm, and the neck-shaft angle decreased by a mean of 1.4 degrees. Compared with a group of seventeen patients with adequate initial and final radiographs of the contralateral side, the final mean articulotrochanteric distance was 4.5 mm less on the involved side than on the uninvolved side, the mean femoral neck diameter was 0.7 mm less on the involved side than on the uninvolved side, and the mean neck-shaft angle was 3.2 degrees less on the involved side than on the uninvolved side. No patient had development of clinically important femoral neck narrowing or valgus deformity. Statistically, the likelihood that these data represent a group with a mean 3-mm increase in the articulotrochanteric distance is <1%. The likelihood that these data represent a group with a mean 3.2-mm decrease in the ultimate femoral neck diameter is <1%. The likelihood that these data represent a group with a mean 5 degrees increase in the neck-shaft angle is <1%.

CONCLUSIONS

Lateral transtrochanteric intramedullary nailing in children who are nine years of age or older does not produce clinically important femoral neck valgus deformity or narrowing, and we did not observe osteonecrosis of the femoral head after this procedure.

Complications of titanium elastic nails for pediatric femoral shaft fractures

Limited data exist about complications of titanium elastic nails (TNs) for femur fracture management in pediatric patients. Thirty-nine patients with 43 femoral shaft fractures were identified whose average age was 6.0 years. There were 21 complications (1 intraoperative, 20 postoperative) in 43 femur fractures (49%). There were two major postoperative complications: one septic arthritis after nail removal and one hypertrophic nonunion. Minor postoperative complications were pain at the nails in 13 extremities, nail erosion through the skin in 4, and one delayed union. There was an association between the prominence of TNs and nail pain or skin erosion. Fracture angulation and outcome were associated with the patient's weight and size of the nails implanted. Technical pitfalls exist with this implant and can be minimized by leaving less than 2.5 cm of nail out of the femur and by using the largest nail sizes possible.

Septic arthritis of the hip in infancy: long-term follow-up

At a mean 15-year follow-up, the authors evaluated five hips in five patients who had complete destruction of the femoral head and neck from septic arthritis when they were 3 months old. All patients were treated with a trochanteric arthroplasty in combination with a proximal femoral varus osteotomy at a mean age of 30 months in an attempt to salvage a femoral-pelvic articulation. Results suggest this treatment can provide a stable, painless, and functional hip, with an improved gait and less leg-length discrepancy than predicted if no reconstructive effort were attempted.

Severely displaced proximal humeral epiphyseal fractures

The purpose of this study was to document the late outcome of a group of patients with Neer grade III/IV proximal humeral physeal fractures who were treated with reduction of the fracture and maintenance of reduction until fracture consolidation. A total of 28 patients treated between 1984 and 1999 at a large children's hospital were included in this study. Nineteen of the 28 patients were 15 years or older (range 5-16 y). All patients were treated in the operating room with closed reduction followed by immobilization (n = 3), closed reduction and pin fixation (n = 20), open reduction and screw fixation (n = 3), or open reduction and pin fixation (n = 2). Postoperatively, all had Neer grade I or II displacement, which was maintained until fracture union. No operative or postoperative complications occurred. At an average follow-up of 4 years, all patients had near-normal glenohumeral motion and excellent strength and uniformly reported regaining full preinjury functional use of the involved extremity. Achieving and maintaining reduction in Neer grade III/IV proximal humeral epiphyseal fractures can be safely performed and results in excellent long-term shoulder function. This is of particular significance in the older adolescent who has minimal remodeling potential.

Reduction of a dislocation of the hip due to developmental dysplasia. Implications for the need for future surgery

BACKGROUND

Recent reports on the treatment of a dislocation of the hip due to developmental dysplasia have documented conflicting data on the importance of the ossific nucleus in the development of postreduction ischemic necrosis. Delaying reduction until the ossific nucleus is present bypasses the time-period of maximal osseous remodeling of the hip, thereby possibly increasing the need for future operations. We hypothesized that hips with an ossific nucleus are more likely to have subsequent reconstructive procedures.

METHODS

A retrospective review of the medical records at two tertiary-care children's hospitals was completed to identify all patients who had had reduction of a dislocation of the hip due to developmental dysplasia, performed between 1979 and 1993, when they were less than two years old. Patients were excluded if the medical records or radiographs were inadequate, the duration of follow-up was less than three years after the final reduction, a previous reduction had been performed at an outside facility, or the patient had a neuromuscular disease or a teratologic dislocation. We identified 124 patients (153 hips) who satisfied the criteria for inclusion. The average age at the time of the reduction was eleven months, and the average duration of follow-up was 7.2 years.

RESULTS

Overall, fourteen of the sixty-three hips without an ossific nucleus had a reconstructive procedure: thirteen had a varus rotational osteotomy of the proximal part of the femur and one had a combined pelvic and varus rotational femoral osteotomy. Forty of the ninety hips with an ossific nucleus had a reconstructive procedure: twenty-seven had a varus rotational osteotomy, eight had a pelvic osteotomy, and five had a combined pelvic and varus rotational osteotomy (p < 0.05). In addition, secondary reconstructive procedures were performed in 17% (ten) of the fifty-nine patients who were less than six months old and in 35% (thirty-three) of the ninety-four patients who were at least six months old, which was a greater than twofold increase. The effect of age was further emphasized at the other age cutoff points.

CONCLUSION

Delaying the reduction of a dislocated hip until the appearance of the ossific nucleus more than doubles the need for future surgery to make the hip as anatomically normal as possible. Despite finding a slight increase in the rate of ischemic necrosis after reduction of the hips without an ossific nucleus, we advocate early reduction of a dislocation of a hip due to developmental dysplasia to optimize the development of the hip with the minimum number of operations

Combined midfoot osteotomy for severe forefoot adductus

A one-stage procedure combining a closing wedge osteotomy of the cuboid with an opening wedge of the medial cuneiform was used for the treatment of severe forefoot adductus. Results were reviewed in 33 patients (50 feet) followed-up for at least 2 years postoperatively. Clinical and radiographic improvement in forefoot position was achieved in 90% of cases. The mean calcaneo-second metatarsal angle improved from 37 degrees preoperatively to 18 degrees at final follow-up. The mean talo-first metatarsal angle improved from 15 degrees preoperatively to 3 degrees at final follow-up. The medial to lateral column ratio demonstrated 33% improvement after surgical treatment. Two feet were unimproved because of graft migration. Patients younger than age 5 years without a well-defined medial cuneiform ossific nucleus had a high rate of medial graft extrusion with loss of correction. This procedure should be reserved for patients aged 5 years or older. Ten patients followed-up for more than 6 years had no deterioration in results. This procedure provides effective, safe, predictable, and lasting correction of forefoot adductus.

Treatment of rigid hypertrophic posttraumatic pseudarthrosis of the tibia in children using distraction osteogenesis

Posttraumatic tibial pseudarthrosis is a relatively uncommon complication of tibia fractures in children. Although reported as a successful method of treating tibial nonunions in adults, distraction osteogenesis through a nonunion site via ring external fixation has not been described in children. The authors report three consecutive cases of distraction through an angulated, shortened, hypertrophic, posttraumatic nonunion to achieve successful union and concurrent correction of deformity. Distraction was carried out using a ring fixator with computer-guided correction. Union was achieved in each of the three patients with complete correction of deformity and length. Lengthening of 8 to 31 mm was achieved. The length of time in the external fixator ranged from 7 to 27 weeks. Pin tract infections developed in all patients; they were treated successfully using oral antibiotics. No deep infections or other significant complications developed. Each patient was followed up for at least 1 year.

Femoral lengthening over a humeral intramedullary nail in preadolescent children

BACKGROUND

Femoral lengthening over an intramedullary nail has been described in adults. A technique of femoral lengthening over a humeral intramedullary nail in children is described, and the results and complications are presented.

METHODS

Nine preadolescent patients (average age, nine years and ten months) with femoral length discrepancy were treated with femoral lengthening over a humeral intramedullary nail. After nail insertion, a monolateral external fixator was placed with half-pins either anterior or posterior to the intramedullary nail, and lengthening was performed through a proximal osteotomy.

RESULTS

The femora were lengthened a mean of 6.1 cm (range, 5.0 to 8.0 cm), 19.5% (range, 15.9% to 26.2%) of the preoperative femoral length. Patients had a mean lengthening index of 12.2 days/cm of length (range, 9.5 to 16.9 days/cm of length). Five complications including osteomyelitis, failure of the distal interlocking site, and femoral fracture at the distal end of the nail occurred in four patients; four of the complications led to surgical intervention. No case of proximal femoral valgus secondary to nailing through the greater trochanter had developed by the time of final follow-up. All patients were followed for a minimum of two years postoperatively, with a mean of 128 weeks (range, 111 to 161 weeks).

CONCLUSIONS

The technique is effective but has a high rate of complications, including osteomyelitis, which developed in two of the nine patients. No avascular necrosis or proximal femoral valgus was noted.