Prognostic evaluation of Legg-Calvé-Perthes disease by MRI. Part I: the role of physeal involvement

Twenty-eight unselected hips affected by Legg-Calvé-Perthes disease (LCPD) in 24 patients from 1987 to 1994 had magnetic resonance imaging (MRI) performed. The patients were retrospectively reviewed at a mean follow-up of 5.4 years. An interobserver blind analysis was made to establish the reliability of four MRI parameters: extent of epiphyseal necrosis (EXT), lateral extrusion of the femoral head (LAT), physeal involvement (PHY), and metaphyseal changes (MET). The interobserver analysis resulted in a good reliability for all MRI parameters (concordance, >80%; K index, >0.45). A statistical correlation study (Spearman test) was then done between each MRI parameter and the condition of the hips at follow-up evaluated by Stulberg class and a personal scored system (total score) of clinical-radiographic condition. All MRI parameters appeared well correlated to the Stulberg class and to the total score (S > 0.66; p < 0.05). PHY resulted the strongest correlated parameter (S = 0.84 for Stulberg class; S = 0.91 for total score). Finally our statistical correlation study demonstrates physis involvement to have a high predictive value in LCPD; therefore it can be assumed as the main risk factor in formulating prognosis.

Prognostic evaluation of Legg-Calvé-Perthes disease by MRI. Part II: pathomorphogenesis and new classification

The most widely used system of grading Legg-Calvé-Perthes disease (LCPD) is still the radiographic grouping by Catterall, although it lacks interobserver reliability, especially in the early stages. The predictive value of Salter-Thompson classification and Herring's "lateral pillar" classification are still being studied. In Part 1, we demonstrated the good reliability and the predictive value of four magnetic resonance imaging (MRI) indices (extension of necrosis, lateral extrusion, physeal involvement, metaphyseal changes) through their correlation to clinical and radiographic conditions of the hips at follow-up. The same good results were obtained by submitting to statistical analysis a second group of 31 patients (French series). On the basis of these statistical studies, a new classification has been proposed. It takes into account the extent of necrosis and two MRI risk signs: lateral extrusion and physeal involvement. The extent of necrosis up to or more than 50% separates two main groups, A and B. The associated MRI risk factors distinguished six classes with different prognoses. Appropriated treatment also is suggested for each class. Our experience on MRI in LCPD led us to draw a pathomorphogenetic model called "packed capsule." According to this biomechanical model, the femoral head is considered a segment of a sphere made of viscoelastic material and hermetically sealed. The deformation of the head depends on the behavior of the necrotic fluid collected inside the capsule under the weight-bearing forces. Finally, our suggestion in the treatment of Perthes disease is to relieve weight bearing up to the fragmentation stage, whether the diagnosis has been made by the use of MRI or without it. During the fragmentation stage, MRI is extremely useful in performing prognosis; at this time our classification can be applied, and the corresponding treatment can be followed.

Distal tibial and fibular epiphyseal fractures in children: prognostic criteria and long-term results in 158 patients

From 1974 to 1993, 158 injuries of the ankle joint were treated at the Department of Orthopedics and Traumatology of Santobono Children's Hospital. One hundred thirty-two patients were treated conservatively; 26 patients underwent surgical treatment. Fibular fractures of the malleolus without epiphyseal separation or dislocation (68 patients) were excluded from this review. Of the 158 patients, 113 (70%) were available for follow-up. The mean age of patients was 11 years. The mean follow-up was 6 years (range 3-15 years). In this review, the authors compare, based on the degree of epiphyseal separation or dislocation, the Carothers-Crenshaw classification, which is based on the mechanism of trauma, with the Salter-Harris classification, which is based on anatomical-radiographic criteria. The aim is to review the authors' patients based on these classifications, to verify the prognostic ability of these criteria and thus to establish a better and more viable treatment for these injuries. Therefore, two fundamental factors should be considered for the prognosis: the mechanism of trauma and damage to the epiphyseal plate. Compressive trauma and adduction-supination trauma are the most dangerous types of injury, and any damage or gap in the physis should be perfectly reduced, by open means if necessary, to prevent a bone bridge from forming.

Juvenile hyaline fibromatosis: a case report

The authors present a 9-year-old girl with a juvenile hyaline fibromatosis observed before any treatment and after surgical releases. The disorder showed impressive clinical features both concerning the size of the dermal nodules and the degree of limitation of involved joints. Although the follow-up was short, we emphasize the great role surgery can play in reaching very satisfying results, both aesthetically and functionally.

Eosinophilic granuloma of C4 causing spinal cord compression

A rare case of vertebral eosinophilic granuloma (C4) causing spinal cord compression is reported. The clinical, histological and radiological features of this pathological entity are discussed. After surgery a complete neurological recovery was observed. The value, in selected cases, of surgical treatment with total removal of the tumour and reconstruction of the spine to ensure spinal stability and to prevent irreversible neurological deficit is emphasized.

The use of external fixators in femur fractures in children

Between 1988 and 1993, 81 children with 82 femur fractures were treated with external fixators at the Santobono Children's Hospital of Naples. This technique was reserved for children older than 6 years with open fractures, multiple fractures, multiple trauma, and unstable fractures. The patients were placed in skin traction on admission, and after 24-48 h, the external fixator was applied under general anesthesia. Therefore, within 1 week the children were able to take care of themselves and to attend school. The fixator was very well tolerated and was removed 8-9 weeks later. The fractures healed with good alignment, no complications with few cases of superficial infections, and less overgrowth. The use of external fixation is recommended for its simplicity and lack of complications.

New rationale in management of tibial agenesis type II: a maturity review of its functional, psychological, and economic value

It is now 3 years since we published a new surgical approach to type II tibial agenesis. All three patients have reached the end of growth, and we have been able to conduct a maturity review of the functional, psychological, and economic value of this method of treatment. All three patients were very satisfied with the treatment they had received, although it was long and often arduous. We have attempted to compare the costs of primary amputation without complication in the first year of life, followed by supply of at least 10 prostheses, until age 18 years, with that of the reconstructive technique, which is liable to require five operations and considerable periods of inpatients and outpatient care until age of 18 years.

Is gentle manipulative reduction and percutaneous fixation with a single screw the best management of acute and acute-on-chronic slipped capital femoral epiphysis? A report of 70 patients

We report the results of the management of acute and acute-on-chronic slipped capital femoral epiphysis (SCFE) for 70 patients (81 hips) with an average follow-up of 6 years (range 1-15 years). We clinically reviewed 51 patients (55 hips) with acute or acute-on-chronic slip treated in our department from 1978 to 1993 with clinical and radiographic examination. Of these, 10 patients (11 hips) underwent a three-dimensional computed tomography (CT) scan to provide more details of the remodeling process. Percutaneous pinning with one cannulated screw appears to offer significant advantages. It is stable, safe, and reliable; there is no blood loss; the scar is small; hospital stay is brief; and early weightbearing is possible 2 weeks after the procedure, with low incidence of complications. Last, but not least, children can soon return to school. We conclude that preoperative reduction with very gentle manipulation and percutaneous pinning with a single screw is the best treatment for SCFE.

Gluteoperineal gangrene and sciatic nerve palsy after umbilical vessel injection

Thirteen patients with gluteoperineal necrosis of the skin and subcutaneous tissue without muscle involvement associated with palsy of the peroneal branch of the sciatic nerve were examined at the authors' institution. This syndrome was a complication after umbilical vessel catheterization for injection of medications mainly for respiratory distress and apnea. Skin and subcutaneous damaged tissues required debridement without sedation or anesthesia. Local antibiotic application and ultraviolet rays helped heal the lesions, leaving a star-like scar that did not cause cosmetic disfigurement or fistulae formation. For the residual peroneal nerve palsy with involvement of peroneal, toe extensor, and anterior tibialis musculature, the therapeutic approach initially consisted of physical therapy to the involved muscles of the foot. Surgery was required only to correct the deformity of the foot secondary to muscular deficits. In this series, the final results of the muscles involved secondary to nerve palsy were good in 4 patients, fair in 6, and poor in 3. No excellent result was noted.

Infantile type of Blount's disease: considerations concerning etiopathogenesis and treatment

The proper treatment of the infantile type of Blount's disease is still a controversial issue. We postulate the hypothesis of the etiopathogenesis of the infantile type of Blount's disease as a disease related to a dysplastic linkage between epiphysis and metaphysis. Therefore, considering the radiographic observations of a 26-month-old girl admitted in our department in 1986 with the infantile type of Blount's disease (type II Langenskiold--tibial femoral angle 24 degrees), the consequential optimal management of this condition is the need to apply a treatment consisting of the epiphyseal distraction capable of interrupting this dysplastic linkage, avoiding recurrences and damage to the growth cartilage. This child was treated with early, slow, and monocompartmental distraction by Ilizarov apparatus for 11 weeks. When the Ilizarov apparatus was removed, full recovery was achieved, the leg was clinically straight, and the mechanical axis was restored. The long-term follow-up (7 years) confirms this operation as a definitive treatment. It was less traumatic for the child, without recurrences or disorders of growth cartilage, supporting the dysplastic origin of infantile type of Blount's disease and the efficacy of this type of treatment.