Preventing of nonunion in congenital pseudarthrosis of the tibia cases of Crawford Type I and II through the use of allograft bypass and a brace: Midterm findings

Background

Congenital pseudarthrosis of the tibia is a limb deformity, which can be distressing for the affected patients and the pediatric orthopedic surgeons involved. We hypothesized that the modified McFarland procedure would avoid fractures and even have a corrective effect on the affected tibia in congenital pseudarthrosis of the tibia patients. Toward this end, we evaluated the midterm results of treating congenital pseudarthrosis of the tibia patients of Crawford Type I and II with allograft bypass combined with long-term bracing.

Methods

This study retrospectively evaluated 7 patients with congenital pseudarthrosis of the tibia who were treated with allograft bypass combined with long-term bracing between 2009 and 2018. The median follow-up was 7.0 years (range 3.8-10.0 years). The medical records and radiographs were reviewed for demographic data, clinical characteristics, outcomes, and complications.

Results

At the time of the last follow-up, all allografts revealed complete consolidation in the patients' tibiae at both ends. All patients presented no functional restriction of the lower limbs and no amputation or non-union has occurred. Most of the obvious deformities of the tibia diaphysis or ankle joint were corrected. Two complications occurred that required successful revision surgery.

Conclusion

In this series of seven congenital pseudarthrosis of the tibia patients, the allograft bypass technique showed satisfactory midterm results and validated our hypothesis. For congenital pseudarthrosis of the tibia patients of Crawford Type I and II, this procedure combined with long-term bracing, which involves the affected leg only, can delay or possibly prevent fractures, decrease tibial malalignment, and preserve leg length.

Level of evidence

level IV.

Hamartoma of the soft palate: Case report and review of literature

INTRODUCTION

Hamartoma is a tumor-like malformation that represents a focal proliferation of normal cells. Hamartoma of the soft palate is a rare entity, which can lead to serious, life-threatening clinical manifestations, given its anatomical location. However, if properly treated surgically, their prognosis is excellent.

CASE PRESENTATION

The literature reports very few similar cases. So, we report a case of hamartoma of the soft palate, which presented as a sessile velar outgrowth arising on the midline of a 12-day-old newborn. The final diagnosis was based on histopathology. The patient was treated surgically and had excellent evolution. Clinical Discussion. Clinical examination shows hamartomas of the palate to be polyploid lesions, with a firm surface. A CT scan and magnetic resonance imaging (MRI) are indicated to establish the extent of the tumor. The diagnosis of certainty is determined by a histopathological examination. The only treatment is surgery, generally via the transoral approach. Prognosis is excellent.

CONCLUSION

Hamartomas of the palate are diagnosed histologically, with imaging being of great help in assessing extension, and their therapeutic management is exclusively surgical. The prognosis after successful surgery is practically always good, with no recurrence.

Neglected bilateral triphalangeal of the thumb delta type in adult case: A case report

INTRODUCTION

In rare case, thumb has extra phalanges known as triphalangeal of the thumb (TPT). Patients with TPT can have difficulty doing work/activities that require high precision. Therefore, surgical intervention is essential. This report provides an approach for a patient with TPT.

PRESENTATION OF CASE

A patient with TPT who underwent removal of extra phalanges and arthrodesis of interphalangeal (IP) joints is presented. The left thumb deviated 25o to ulnar while the contralateral part deviated 15o to radial. X-ray revealed both thumbs had extra delta-shaped middle phalanges. Complete excision of extra phalanges and simple arthrodesis of IP joints with two K-wires in 10° to 15° flexion was performed. Healing process ended without any complications and the patient had an improvement.

DISCUSSION

Productive-age patients with TPT can have difficulty doing work and activities that require high precision, especially in the non-opposable type of the right hand. Furthermore, the female patient is highly emphasizing the cosmetics of her hand to increase her self-confidence. Therefore, surgical intervention is essential for this patient. We performed complete excision of extra phalanges and simple arthrodesis of IP joints with two K-wires in 10° to 20° flexion. The first K-wire is introduced intramedullary as a primary fixator for longitudinal alignment, and the second wire is inserted obliquely as an anti-rotation wire. Functional outcome was assessed after 6 months post-removal of the wire which gave a satisfying result.

CONCLUSION

TPT is a rare anomaly which surgical intervention can improve the appearance and the precision of the hand.

Posterior hemivertebra resection and short-segment fusion with lateral mass screws in congenital scoliosis: a novel strategy for the resource-limited setting

Background

Posterior hemivertebra resection and short-segment fusion with pedicle screws are an established treatment in congenital scoliosis, which require pediatric-specific instrumentation. The purpose of this study was to report the results of utilizing cervical lateral mass screws instead of pedicle screws in the treatment of congenital scoliosis in children younger than 5 years old.

Methods

In an IRB-approved retrospective chart review study, patients <5 years old with congenital scoliosis who underwent posterior hemivertebra resection and fusion with lateral mass screws from 2013 to 2017 were included. Demographic information, pre- and post-operative radiographs, complications, and outcomes were extracted from the charts.

Results

Twenty-three patients were included in the final analysis with a mean age of 40 months, of which 14 were female. Patients were followed for a mean of 51.3±13.2 months. The mean blood loss was 210ml, and patients were hospitalized for a mean of 4 days post-operatively. The correction rate of the main coronal curve, compensatory cranial curve, compensatory caudal curve, and segmental sagittal curve was 74.8%, 68%, 65.2%, and 68.9%, respectively. Three complications were observed: one intra-operative pedicle fracture, one case of implant failure, and one deep surgical-site infection, all of which were successfully managed.

Conclusions

Our findings suggest that adult lateral mass screws can be used for transpedicular fixation of the thoracic and lumbar vertebrae in low-resource settings where pediatric-specific pedicle instruments are not readily available. The correction rate, outcomes, and complications are similar and comparable to pediatric-specific pedicle screws, in addition to being low-profile and less bulky compared to adult implants.

Revision risk after pediatric spinal deformity surgery: a nationwide study with 2-year follow-up

BACKGROUND CONTEXT

Revision risk after pediatric spine surgery is not well established and varies between deformity etiologies.

PURPOSE

To report the 2-year revision risk following surgery for primary pediatric spinal deformity in a nationwide cohort and to evaluate potential risk factors and reasons for revision surgery.

DESIGN

Retrospective nationwide cohort study.

PATIENT SAMPLE

A national registry study of all pediatric spinal deformity patients undergoing surgery during 2006-2015 (n=1310).

OUTCOME MEASURES

Two-year revision risk.

METHODS

All patients ≤21 years of age undergoing spinal deformity surgery in Denmark during 2006-2015 were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on revision surgery were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Medical records were reviewed for reason for revision in all patients. Potential risk factors for revision were assessed with multiple logistic regression analyses and included age, etiology, sex, Charlson comorbidity index (CCI), and growth-preserving treatment.

RESULTS

Patients were categorized according to etiology: idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann's kyphosis (5%), and syndromic deformity (3%). Of 1,310 included patients, 9.2% underwent revision surgery within 2 years and 1.5% was revised more than once. Median time to revision was 203 (interquartile range 35-485) days. The multivariable logistic regression found significantly higher odds ratio (OR) for revision in patients with growth-preserving treatment (OR=5.1, 95% confidence interval [CI] 2.6-10.1), congenital deformity (OR=2.7, 95% CI 1.3-5.3), spondylolisthesis (OR=3.5, 95% CI 1.9-6.7), Scheuermann kyphosis (OR=3.9, 95% CI 1.9-8.3), and CCI score ≥3 (OR=2.5 95% CI 1.1-5.6). The most common reason for revision was implant failure (32.5%) followed by residual deformity and/or curve progression (15.8%).

CONCLUSIONS

In this nationwide study, the 2-year revision risk after primary pediatric spinal deformity surgery is 9.2%. Risk factors for revision are etiology of congenital deformity, spondylolisthesis, Scheuermann kyphosis as well as patients with growth-preserving treatment and higher CCI. The most common reason for revision is implant failure.

Congenital Deformities of the Hands

Evaluation of the pediatric musculoskeletal system may be difficult because of differences between children and adults. As children mature, their physical structure approaches that of an adult. However, in the meantime, varying stages of ossification and developmental timelines may confuse the average clinician. Congenital abnormalities of the upper extremity are extremely numerous, but here we present 10 that often are seen in clinical practice. The article discusses the diagnosis, evaluation, treatment, and outcomes of each condition.

Cornelia de Lange syndrome: A rare case, presented with unilateral pes equinovarus

Cornelia de Lange syndrome is a genetic disorder with multiple system abnormalities. It is especially characterized by typical facial appearance and hirsutism. Growth and mental retardation, gastrointestinal, cardiovascular, and orthopedic abnormalities are other important features of this syndrome. In this case, we present a rare manifestation of Cornelia de Lange syndrome with a unilateral pes equinovarus deformity without other more specific orthopedic manifestations. Ponseti method's was applied as the initial procedure. Afterwards, complete subtalar release was performed. After four years follow-up, clinical and radiological results were satisfactory. Unilateral pes equinovarus deformity may be a part of this syndrome as well as a sporadic presentation. The discrimination is important for anesthetic procedures and surgical outcomes.

Assessing public awareness of clubfoot and knowledge about the importance of early childhood treatment: a cross-sectional survey

BACKGROUND

Clubfoot is a treatable abnormality that can be managed with early intervention. However, there is a lack of public knowledge regarding clubfoot, which can delay treatment. This study aimed to assess the public awareness of clubfoot and knowledge regarding the importance of treatment in early childhood.

METHODS

This cross-sectional survey spanned 6 months, from June through November 2018, and involved persons living in Saudi Arabia. To collect data on public awareness of clubfoot risk factors, treatment, and prognosis, a questionnaire was developed by orthopedic experts and disseminated online. The target population included people of both genders and all age groups from the general population, regardless of their knowledge of someone with clubfoot.

RESULTS

By the end of the study period, 746 participants completed the online survey. In total, 520 of the respondents (69.7%) had never heard about clubfoot syndrome. Among the participants, 5.4% had a child with clubfoot syndrome and 4.6% were aware of clubfoot because they had an affected child. The top resource accessed by respondents for obtaining knowledge about clubfoot was social media channels (38.4%), followed by obtaining knowledge from relatives and friends (19.9%). The most reported perceived cause of clubfoot was hereditary and genetic disorders (58.4%), followed by neurological disorders (39.9%).

CONCLUSIONS

Results show that there is low public knowledge of clubfoot which may be attributed to a lack of awareness campaigns. We recommend increasing awareness regarding clubfoot through social media platforms and public campaigns in key locations, such as malls, as this may encourage people to seek early treatment. This is important because early management of clubfoot is less invasive and with regular follow-up, leads to better patient outcomes.

How should congenital absence of cruciate ligaments be treated? A case report and literature review

BACKGROUND

Hypoplasia of bilateral cruciate ligaments is a rare congenital malformation. The diagnosis of such diseases and indications for the various treatment options require further analysis and discussion.

CASE SUMMARY

The patient is a 26-year-old Chinese woman who has been suffering from knee pain since the age of 8 years, 2-3 episodes a year. Three years ago, due to the practice of advanced yoga poses, the frequency of left knee pain increased, requiring prompt medical treatment. Magnetic resonance imaging demonstrated an absence of both anterior and posterior cruciate ligaments of both knees with abnormal posterior tilting of the tibial plateau. Bilateral subluxation of the knee joint was also found, therefore tibial osteotomy was performed. The patient reported at the 24 mo follow-up that the frequency of pain and instability had been reduced and function restored.

CONCLUSION

Osteotomy may be an effective method to treat patients with congenital cruciate ligament deficiency with posterior tibial plateau tilting. The diagnosis of congenital cruciate ligament deficiency shall be based on the combination of patient’s medical history, clinical manifestations, and findings from imaging to avoid possible misdiagnosis. Based on the symptoms, frequency of attacks, and intent of the individual, appropriate treatment options shall be identified.

Surgical Correction of Pectus Excavatum by the Nuss Procedure: A 15-Year Experience Study

Pectus excavatum is the most common congenital deformity of the chest. The Nuss procedure is minimally invasive surgical correction of this defect, using retrosternal metal bars. The purpose of the present study was to describe a 15-year experience with the Nuss surgery, and to evaluate the long-term clinical results of the procedure. We retrospectively evaluated 239 patients, aged 14-34, who underwent the Nuss surgery in the years 2002-2016. Postoperative complications were observed in 40/236 (16.9%) patients. The most common complication was pneumothorax in 14/239 patients. Less common were the following: wound infection in 4, pleural effusion in 3, allergy to nickel in 1, lung atelectasis in 1, and ventricular failure in 1 patient. Three patients were treated because of severe postoperative pain, and in one case the implant had to be removed. Postoperative complications associated with the number of bars inserted, but not with the patient age or gender. A satisfactory and long lasting corrective effect of surgery was observed in 231/239 (96.7%) of patients. There was no perioperative mortality. We conclude that the Nuss surgery is a safe surgery that demonstrates excellent and long-lasting esthetic results, with a low risk of severe complications.

Pediatric musculoskeletal ultrasound

The expanding applications of musculoskeletal ultrasound include many examinations that are new to pediatric radiologists but are well known to our adult colleagues. In this review we present an introduction and guide to some of these entities for pediatric radiologists making inroads into the world of musculoskeletal ultrasound.

Surgical Treatment of Thoracolumbar Segmental Spinal Dysgenesis: Optimal Type of Fusion

OBJECTIVES

We sought to evaluate long-term results of surgical treatment of thoracolumbar segmental spinal dysgenesis (SSD).

METHODS

We analyzed 8 patients with thoracolumbar SSD treated in our institution. Each case was evaluated for specific clinical and radiologic criteria and types and outcomes of treatment.

RESULT

The average age of primary surgery was 3.4 years (median 3.4 years, range 1.7-7 years). The average correction of kyphosis was 49.3° (mean 45°, from 25°-75°) and scoliosis 10.6° (mean 10°, from 0°-25°). Average follow-up time was 3.2 years (mean 2.6 years, from 1.8-5.6 years). Neurologic improvement was also achieved in all patients. The Japanese Orthopaedic Association scale score (Benzel's modification) was increased by 2.5 points on average (mean 2.5 points, from 2-5 points). One patient had complications: pseudarthrosis and rod fracture followed by refusion.

CONCLUSIONS

Our treatment strategy provides favorable deformity correction and neurologic improvement. It is limited by immature vertebral structures in newborns and infants, who should be carefully monitored from birth with braces until they reach the age when a fixing tool can be used.

Congenital deformity of the distal extremities in three dogs

Congenital limb deformities are very rare conditions and the knowledge about etiology, pathogenesis, clinical presentation and treatment is still poor. Moreover, many defects are still not reported in veterinary literature. This report documents clinical and radiographic findings in three dogs with congenital deformity involving the distal extremities. Case 1 was affected with bilateral aphalangia of the pedes, case 2 presented a combination of brachydactyly and syndactyly, whereas in case 3 a unilateral ectrodactyly was observed. To the authors’ knowledge, brachydactyly, as well as aphalangia, are very uncommon anomalies and have been rarely documented. Moreover, association between syndactyly and brachydactyly has still not been reported.

Assessment of potential confounders when imaging pectus excavatum with chest radiography alone

BACKGROUND

Chest radiography (CXR) has emerged as an attractive alternative imaging option for objective pre-operative assessment of pectus excavatum (PE) with comparable accuracy, reduced cost, and less radiation exposure when compared to computed tomography (CT). This study asked whether image quality, scoliosis, and asymmetry of the PE deformity would decrease the accuracy of CXR as compared to CT.

METHODS

A database of PE patients receiving preoperative CXR and CT was created, and Haller-indices (HI) and correction-indices (CI) were calculated using each imaging modality. Each potential confounding variable were analyzed using Spearman correlations the Fisher r-to-z transformation test.

RESULTS

The database was comprised of 77 patients. Image quality, scoliosis and the 'eccentric type' of asymmetry did not demonstrate any significant worsening of measurement accuracy. However, the correlation coefficients for CIs for those with and without the 'unbalanced type' of asymmetry were 0.593 and 0.890, respectively, with a Fisher r-to-z of 2.16 (p=.031).

CONCLUSIONS

The accuracy of CXR-derived pectus indices remains quite favorable despite the heterogeneity from radiographic quality, scoliosis and chest wall asymmetry. Nonetheless, the unbalanced type of chest wall asymmetry did emerge as a significant confounder. As such, use of CXR alone in cases of gross chest wall asymmetry should be cautioned.

Surgical treatment for far-out syndrome associated with abnormal fusion of the L5 vertebral corpus and L4 hemivertebra: a case report

BACKGROUND

Far-out syndrome was reported by Wiltse et al. in 1984, which is a condition characterized by L5 spinal nerve radiculopathy due to nerve compression between the L5 transverse process and sacral alar. Although many cases of far-out syndrome have been reported, to our knowledge, the present case firstly showed far-out syndrome due to assimilated L4 hemivertebra and L5 vertebra through which abnormal nerve root passed.

CASE PRESENTATION

A 71-year-old man presented with left lower back pain and intermittent claudication accompanied by severe left buttock pain. Radiological examination showed assimilation between the L4 hemivertebra and L5 vertebra, which had two pedicles on the right side, with no canal stenosis. However, computed tomography and magnetic resonance imaging of coronal sections showed extraforaminal stenosis between the L5 transverse process and sacral alar, whereby the L5 spinal nerve was pinched ("far-out lesion"), and an abnormal nerve root passage in the assimilated vertebral corpus. We performed transforaminal lumbar interbody fusion, then resected the L5 transverse process to decompress the extraforaminal stenosis, and finally installed pedicle screws, but not at the one of pedicles of the assimilated vertebra in order to prevent nerve injury. Postoperatively, the patient had no symptoms up to 1.5 years after the surgery.

CONCLUSION

The current case suggests the importance of detailed preoperative examination of patients with anatomical abnormalities such as assimilated vertebrae, which may result in incorrect diagnosis and failed surgery.

The case for using the correction index obtained from chest radiography for evaluation of pectus excavatum

BACKGROUND

We previously reported the use of a computed tomography (CT)-based Correction Index (CI) as a more accurate assessment of pectus excavatum (PE) severity than the historically used Haller Index (HI). This study examines the diagnostic capabilities of the CI as assessed by lateral chest radiography (CXR).

METHODS

A database of PE patients receiving preoperative CXR and CT was created. For each patient, a radiologist calculated a CT-based CI, while two pediatric surgeons independently calculated CXR CIs.

RESULTS

The database was composed of 69 patients. Significant correlations were found between CXR CI estimates of the two observers and between the CXR and CT CI for each observer. Per our previous work, CT CIs were used in this study for identifying patients meeting surgical criteria (CT CI≥28%). Observed CXR CIs demonstrated good interrater reliability. The sensitivity (0.83) and specificity (0.77) of CXR in diagnosing severe PE (CT CI≥28%) was high. However, sensitivity (0.89) markedly improved when only considering measured CXR CIs≤26%, and combined specificity rose to 0.86 when only considering measured CXR CIs≥30%.

CONCLUSIONS

We recommend the CI as measured by lateral CXR for the preoperative evaluation of PE, with CT used as a confirmatory test in patients measured to have a CXR CI between 26% and 30%.

Supramalleolar Osteotomies: An Algorithm for the Deformed Ankle

Supramalleolar osteotomies are powerful osteotomies that realign the tibiotalar and optimize hindfoot position in the presence of varus, valgus, procurvatum, recurvatum, as well as internal and external rotation of the tibia. Although used in the pediatric and hemophilic population earlier, supramalleolar osteotomy is a relatively new reconstructive surgical technique that was introduced in 1995. Conducted primarily in cancellous bone, supramalleolar osteotomies offer rapid, reliable bony consolidation compared with dome osteotomies and complex arthrodesis.

Congenital cervical kyphosis in two young sighthounds

INTRODUCTION

Cervical vertebral (C) malformation is rarely reported in large breed dogs. Congenital cervical kyphosis (CCK) may result from defects of vertebral segmentation, failure of formation or both. This report describes two cases of C3-C4 CCK in young sighthounds, treated surgically.

CASE DESCRIPTION

An 18-month-old female Deerhound and a six-week-old female Borzoi dog were presented because of the complaints of reluctance to exercise and signs of of neck pain. Both dogs were neurologically normal. Diagnostic imaging revealed C3-C4 deformity, moderate kyphosis, and spinal canal stenosis associated with chronic spinal cord pressure atrophy. Both dogs underwent surgical treatment.

RESULTS

A staged two-step surgery starting with dorsal decompression was elected in the Deerhound. After the first surgical procedure, the dog developed focal myelomalacia and phrenic nerve paralysis and was euthanatized. A ventral distraction-fusion technique with two locking plates was performed in the Borzoi. This patient recovered uneventfully and long-term follow-up computed tomography revealed complete spondylodesis.

CLINICAL SIGNIFICANCE

Until now, CCK has only been described in sighthounds. Congenital cervical kyphosis might be considered a differential diagnosis in these breeds that are presented with signs of cervical pain. Ventral realignment-fusion and bone grafting may be considered for surgical treatment, although the earliest age at which this procedure can and should be performed remains unclear.

Restoration of the central slip in congenital form of boutonniere deformity: case report

We present a case of a congenital form of a boutonniere deformity involving both little fingers with a poorly differentiated extensor mechanism and the absence of the tendinous attachment on the dorsal aspect of the middle phalanx. This complex deformity was evaluated histologically followed by successful reconstruction of the central slip.

Median facial cleft with a frontoethmoidal encephalocele treated with craniofacial bipartition and free radial forearm flap: a case report

We describe a patient with a median facial cleft with a frontoethmoidal encephalocele, hypertelorism, hydrocephalus, and cerebrospinal fluid (CSF) leakage referred to our department due to numerous complications after previous surgical treatments. An 8-year-old girl, born with median cleft syndrome, underwent neurosurgical repair of the encephalocele at another hospital and cleft lip/palate repair later in the same year. Her hydrocephalus was treated with a ventriculoperitoneal shunt, but she underwent numerous shunt revisions due to recurrent intracerebral infections. In 2008, she was rehospitalized due to a gram-negative meningitis and cerebral abscess. She underwent surgery where part of her frontal bone was removed due to osteomyelitis. She was referred to our department due to persistent CSF leakage, recurrent infections, and significant dura defect. In addition, she had hypertelorism and a strongly reduced vision. We performed a monobloc and facial bipartition osteotomy where 15 mm of her frontal and nasal bone was removed after facial bipartiton. The dura defect was closed using a free fasciocutanous flap. The patient had no CSF leakage or infections postoperatively, and her hypertelorism was reduced. The case represents the first monobloc and facial bipartition osteotomy performed in Norway as a part of the treatment of median cleft syndrome with a nasoethmoidal encephalocele.