Paediatric Orthopaedic Society of India

Abstracts

Faculty Talk

1. Degenerativ Scoliosis With Stenosis – Do We Fuse ? If So, How Long ?

Dr. Dilip K. Sengupta, MD
Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI 48073, USA

Synopsis:

Degenerative scoliosis with spinal stenosis is a disease of the elderly. They usually have co-morbid medical problems. There are two clinical problems; a) leg pain or neurogenic claudication from spinal stenosis, and b) mechanical back pain from instability of the scoliotic spine. Isolated deformity without pain or neurodeficit is not a candidate for treatment. Symptoms are gradually progressive and surgery is indicated only after failed conservative treatment. The goal for surgery is to end up with a stable spine, balanced over the sacrum, and the neural elements adequately decompressed. Appropriate balance of the spine at the end of the procedure is more important than the absolute amount of correction obtained. Two types of deformity exist. Type I is a degenerative scoliosis, with minimal rotation, and usually involve a short segment and lateral listhesis. A posterior short-segment fusion, with distraction of the concave side is indicated in this group. Type II is a pre-existing scoliosis with superimposed degenerative stenosis, and usually involves a longer segment, and significant rotation. These cases require a longer instrumentation, and rod rotation technique. Anterior surgery is rarely indicated, except to fuse the lumbosacral disc, which is common site of pseudoarthrosis in patients with long fusion to sacrum. A third subgroup is flat back or sagittal plane deformity. If the deformity is fixed, pedicle subtraction osteotomy is often indicated. In relatively flexible deformity, posterior correction of kyphotic deformity along may result in undesirable narrowing of nerve root forearm. Therefore they may require anterior surgery, with restoration of the disc height with interbody cage or structural allograft, before posterior instrumentation. Complication rates after surgery for degenerative scoliosis or kyphosis with spinal stenosis are high and should be performed only by experienced surgeons.

Introduction:

Lumbar spinal stenosis is a common problem in elderly individuals. It results from degenerative changes of the disc, facet joints with hpertrophic osteophytes and buckled ligamentum encroaching into the central canal, the lateral recess or the nerve root forearm. The typical clinical presentation is neurogenic claudication with radicular pain. (1) In many instances there may be presence of instability, listhesis or deformity like scoliosis or kyphosis. (2-8) These associated conditions may contribute to the nerve root impingement, and in addition, may cause mechanical back pain form the degenerated segment and muscular fatigue due to deformity. The deformity associated with spinal stenosis may be in the sagittal plane with flat back or kyphotic lumbar spine, or in the coronal plane, the degenerative scoliosis. Often they are combined with a predominant kyphosis or scoliosis component. Degenerative scoliosis (Type I), which is often associated with lateral listhesis or deformed vertebral body, and minimal rotation involving a short segment. Or it may be secondary, as a result of degenerative changes and stenosis superimposed on a pre-existing lumbar scoliosis, which is often associated with significant rotation of vertebrae over a longer segment (Type II). The sagittal plane deformity may often be associated and sometimes that may be the predominant feature. The goal for treatment is relief of pain rather than correction of deformity. The symptoms are usually gradual in onset and slowly progressive. The elderly patient population often have co-morbid medical problems. Therefore, the initial treatment is always conservative. The indications for surgery are progressive neurological deficit or pain refractory to conservative treatment. (7-10) Progressive deformity alone, in absence of the other symptoms may not constitute an indication for surgery in these elderly patients. (8) Correction of deformity is necessary in as much as required to achieve a balanced spine and at times, to achieve indirect decompression of the foremen in the concavity of the curve. The goal for surgical treatment is to obtain a stable spine, balanced over the sacrum, and the neural components adequately decompressed. Absolute correction of deformity or cosmetic appearance is not important. (8, 10). The surgery is extensive and complications are frequent. Appropriate preoperative medical evaluation must be done. Preoperative blood donation, hypotensive general anaesthesia, use of cell-salvage, use of sensory evoked potential to monitor nerve roots, and meticulous surgical technique to prevent excessive blood loss, neurological damage, and dural tear are a few important points to remember to avoid complications. (8, 11-14).

Clinical presentation:

The patients are often elderly, of either sex, presenting with progressively increasing leg pain. There usually have associated mechanical low back pain, and fatigue pain due to spinal imbalance. The neurogenic claudication must be differentiated from vascular claudication. (1, 5, 8, 15, 16) In vascular claudication the peripheral pulses are diminished, the pain never arises if the patient is standing still, and the pain relief is slower after resting. The neurogenic claudication on the other hand frequently arises even with the patient standing still, and is relieved after stooping forward, and pain relief is usually fast. Walking uphill, produces vascular claudication faster but much slower in neurogenic claudication because of the flexed attitude of the spine. Vascular claudication often produces calf pain and neurogenic claudication while it may produce calf pain, more typically produces tingling, numbness and weakness in the distribution of the roots involved. Patients often will state they feel relief if they can hold onto a shopping cart, the “shopping cart” sing. (8). The stationery bicycle test can be used to differentiate between vascular and neurogenic claudication. When the patient sits on a bicycle, the lumbar spine is in flexion and patients with spinal stenosis will tolerate the position well without symptoms while pedaling; however, the patient with vascular claudication will become symptomatic while pedaling. The low back pain from sources other than the spine needs to be examined, which include abdominal aortic aneurysm, pelvic tumors, and hip osteoarthrosis. Patients must be examined standing. Frequently, they stand with hyperextension of hips and slight flexion of the knees to compensate any flat back or kyphotic deformity. In the presence of hip arthrosis and stiffness, such postural compensation may not be possible. The gait pattern may include a broad-based gait with instability. Trendelenburg lurch, or antalgic. There may not be any neurologic defiit at rest, but it may appear after symptoms are reproduced by walking a distance on a treadmill.

Pathogenesis:

The cause of neurogenic claudication is not fully understood. (17- 20). It is thought to be attributable to narrowing of the spinal canal, which constricts the thecal sac. The nerve roots of the cauda equina experience external pressure that causes venous congestion, root edema, and decreased microcirculation of the neural elements. The ischemia of the nerve roots is worsened when the patient is in the lordotic posture. Neural impingement can occur centrally and in the lateral recess and foramina. Facet joint hypertrophy and pedicular kinking caused by collapse of disc space height frequently are present. Asymmetric collapse, rotation and frequently associated rotary and lateral listhesis, and spondylolisthesis or retrolisthesis problems that are present within the degenerative scoliotic curve all compromise the neural elements additionally. In presence of lateral listhesis, the nerve root may be compressed between the adjacent pedicle in the concavity of the curve. In spondylolistheis the nerve root is usually compressed between the pedicle of the vertebra above, and the disc and superior endplate of the vertebra below. The presence o deformity makes the direction of the pedicle screw placement difficult. Osteopenia is frequently associated in elderly patients.

Surgical options: Decompression:

There are two principle components in the surgical procedures, decompression and Instrumented stabilization. In the decompression, care needs to be taken because the dura often is thinned and atrophic and can tear easily. The dura also can be adherent to overlying bone and careful dural dissection from the bone is necessary. Ural tears can occur during the decompression portion of the surgery. Careful inspection is done using dural dissectors and seekers. Any tear in the dura should be repaired primarily. Occasionally, disc herniation also is present; however, this is rare in this elderly age group. Fusion without instrumentation can be done; however, the overall fusion rate will be less and correction of deformity cannot be performed. (4, 8, 10). If a discectomy needs to be performed, it adds to further instability of the segment and makes instrumented fusion of that segment mandatory. (21) The same is true if any destabilization is created by the decompression procedure.

Instrumented stabilization :

Instrumentation allows correction of deformity, and stabilization of the segment. Deformity correction is not the primary goal of surgery, and it should be limited to what is necessary to achieve indirect decompression of the neural element, and restoring the sagittal and coronal balance of the spine. Because of the decompressive laminectomy and associated osteopenia, pedicle screw fixation is the only satisfactory method o anchorage to the spine. The deformity makes finding of the pedicle screw direction difficult, and tactile sensation of the pedicle walls, with additional sensory evoked potential monitoring is necessary to ensure safe screw placement.

In Type I deformity, patients usually have a short degenerative collapsing curves with reasonably well-maintained lumbar lordosis or minimal loss of lordosis. This involves some distraction on the concave side with the rod carefully contoured to maintain lordosis and a neutralization rod on the convex side.

In Type II deformity, where pre-existing scoliosis involves significant rotation of the vertebrae, a rod derotation maneuver may be necessary. This technique is useful for patients with longer degenerative curves and for patients with curves with more significant loss of lumbar lordosis. In these patients, the derotation maneuver will convert the scoliosis curve in the coronal plane into a lordotic curve in the sagittal plane.

Sagittal imbalance associated with stenosis is seen with a hypolordotic fusion mass, junctional kyphosis, and junctional stenosis. If the deformity is flexible, it can be treated with anterior and posterior fusion with anterior structural grafting. (13, 14). Often this requires instrumented fusion from T10 to pelvis. If the deformity is fixed, which it usually is, then a pedicle subtraction procedure with decompression and extension of the fusion usually is the most suitable operative approach. (12-14).

The surgical principles are:

In short segment fusion for a Type I degenerative curve. The superior endplate of the most cephalad vertebral body should be made as horizontal as possible to maintain spinal balance.
Avoid ending the instrumentation at an area of junctional kyphosis or at a level of a retrospondylolisthesis or spondylolisthesis.
An interbody fusion, either by ALIF or PLIF approach should be performed at the lumbosacral junction, in combination with the posterolateral instrumentation due to high risk for pseudarthrosis such as in patients with long fusions to the sacrum.
One stage posterior instrumentation alone is preferable, and is usually adequate in most cases with degenerated scoliosis. (22). Anterior surgery may be necessary in Type II curves involving a long segment, where there is considerable loss of sagittal balance due to rotation of the segment.
In cases of fixed sagittal plane deformity, pedicle subtraction osteotomy is a preferable method to restore sagittal balance, which also decompresses the neural forearm by removal of the pedicle.
Restoration of sagittal balance is more important in the presence of equal sagittal and coronal plane deformity.

References:

Verbiest H.A. radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg 1954;36:230-7.
Dick W Widmer H. (Degenerative lumbar scoliosis and spinal stenosis). Orthopade 1993;22 (4):232-42.
Fellrath RF, Jr., Hanley EN, Jr. Causes and management of unstable degenerative spinal stenosis. J South Orthop Assoc 1996; 5(3):221-8.
Frazier DD, Lipson SJ, Fossel AH, Katz JN, Associations between spinal deformity and outcomes after decompression for spinal stenosis. Spine 1997;22 (17):2025-9.
Garfin SR, Herkowitz HN, Mirkovic S. Spinal stenosis. Instr Course Lect 2000; 49:361-74.
Marwalder TM. Surgical management of neurogenic claudication in 100 patients with lumbar spinal stenosis due to degenerative spondylolisthesis. Acta Neurochir (Wien) 1993;120(3-4):136-42.
Nasca RJ. Rationale for spinal fusion in lumbar spinal stenosis. Spine 1989;14(4):451-4.
Simmons ED. Surgical treatment of patients with lumbar spinal stenosis with associated scoliosis. Clin Orthop 2001(384):45-53.
Gelalis ID, Kang JD. Thoracic and lumbar fusions for degenerative disorders: rationale for selecting the appropriate fusion techniques. Orthop Clin North Am 1998;29(4):829-42.
Simmons ED, Jr., Simmons EH. Spinal stenosis with scoliosis. Spine 1992;17(6 Suppl):S117-20.
Kostuik JP, Maurais GR, Richardson WJ, Okajima Y. Combined single stage anterior and posterior osteotomy for correction of iatrogenic lumbar kyphosis. Spine 1988;13(3):257-66.
Thomasen E. Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. Clin Orthop 1985 (194):142-52.
Bridwell KH, Lenke LG, Lewis SJ. Treatment of spinal stenosis and fixed sagittal imbalance. Clin Orthop 2001(384):35-44.
Bradford DS, Tribus CB. Current concepts and management of patients with fixed decompensated spinal deformity. Clin Orthop 1994(306):64-72.
Herkowitz HN, Sidhu KS. Lumbar Spine Fusion in the Treatment of Degenerative Conditions: Current Indications and Recommendations. J. Am Acad Orthop Surg 1995; 3(3):123-135
Herkowitz HN. Lumbar spinal stenosis: indications for arthrodesis and spinal instrumentation. Instr Course Lect 1994;43:425-33
Yoshizawa H, Kobayashi S, Morita T. Chronic nerve root compression. Pathophysiologic mechanism of nerve root dysfunction. Spine 1995;20(4):397-407.
Bassewitz H, Herkowitz H. Lumbar stenosis with spondylolisthesis: current concepts of surgical treatment. Clin Orthop 2001 (384):54-60.
Cohen MS, Wall EJ, Brown RA, Rydevik B, Garfin SR. 1990 AcroMed Award in basic science. Cauda equina anatomy. II: Extrathecal nerve roots and dorsal root ganglia. Spine 1990;15(12):1248-51.
Garfin SR, Cohen MS, Massie JB, Abitbol JJ, Swenson MR, Myers RR, et al. Nerve-roots of the cauda equina. The effect of hypotension and acute graded compression on function. J bone Joint Surg Am 1990; 72(8):1185-92.
Truumees E, Herkowitz HN. Lumbar spinal stenosis: treatment options, Instr Course Lect 2001;50:153-61.
Liew SM Simmons ED, Jr. Thoracic and lumbar deformity: rationale for selecting the appropriated fusion technique (Anterior, posterior and 360 degree). Orthop Clin North Am 1998;29(4):843-58

2. Early Mobilization Protocol After Surgical Treatment Of Femoral Shaft Fractures In Children – Innovative Policy And Results

Dr. Noam Bor, M.D., Dr. Yoseph Salameh, M.D. and Dr. Basil Kaufman, M.D.
Department of Orthopedics, Hemek Medical Center, Afula, Israel

Introduction:

Femoral shaft fracture is the most common major pediatric injury treated by orthopedic surgeons. Factors like early mobilization, minimization of hospital stay complications and other medical and social considerations endorsed orthopedic surgeons towards surgical treatment. Transverse fractures of the middle 60% of femoral diaphysis in skeletally immature children older than six years is the indication of choice for treatment with titanium elastic nails. Postoperative immobilization – knee immobilizer – with partial weight bearing is the protocol described in literature after fixation of stable transverse fractures. Immobilization is discontinued after callus is observed. Nail tip can cause soft tissue irritation. In our study a new strategy for postoperative early mobilization has been conducted in patients with titanium Nancy nailing of transverse stable femoral shaft fractures allowing early full weight bearing and knee and hip mobilization as much as can be tolerated by the patient. Results are evaluated.

Material and Methods:

Seventeen patients were operated upon during the past five years in our department. 10/17 patients who completed at least two years of follow up were included. They were within the age range of 8-12 years (average – nine). The ten patients were skeletally immature, two girls and eight boys, with ten stable femoral shaft fractures. Mechanism of injury was with low energy trauma – four bicycle falls, three pedestrian road accidents and three height falls. They were operated upon in our department by closed reduction and internal fixation using flexible titanium – Nancy nails. In five patients two opposing nails were used and in the other five – three nails were inserted. Weight bearing and joint and limb mobilization was conducted during admission.

Results:

A two year and four month’s follow up was conducted. Callus formation was seen within one month in a median value. No limb deformity or limb length discrepancy was observed. Also no joint contracture was observed. Later on all patients underwent removal of hardware because of impingement at an 11-month median period (range 6-8 months).

Discussion:

Internal splintage with intramedullary nail fixation maintains length and alignment and permits sufficient motion at the fracture site to generate callus formation, with excellent results reported over the past two decades. Flexible titanium nailing is the treatment of choice for stable fractures. Early mobilization protocol was found to be safe enough for maintaining alignment and thus constituting an innovative policy secured by stable fixation with all the benefits of early limb mobilization. This policy contributes more for reducing the length of admission with quick rehabilitation, allowing for a rapid return to normal life, including school.

3. Management Options In Congenital Scoliosis

Dr. Ashok N. Johari
M.S. Orth., F.C.P.S., D.N.B. Orth., M.A.M.S., M.Ch. Orth., England
Hon. Prof. Of Orthopaedics, Grant Medical College, Consultant Orthopaedic Surgeon
Sir J.J. Hospital, B.J. Wadia Hospital for Children, Mumbai
Lilavati and Nanavati Hospitals, Mumbai, India

Introduction:

The five major problems in congenital scoliosis are

Trunk deformation
Trunk decompensation
Truncal shortening
Altered neurology
Other congenital anomalies

The major target site for deformation in congenital scoliosis is the vertebral bone aaitself. It is truly a “bony” scoliosis and principles of bone growth do apply.

1. Trunk deformation:

Arises out of growth imbalance on the two sides of the spine. The reason for this growth imbalance is structural.

i. Presence of wedge or hemivertebrae on one side of the spine
ii. Presence of an unsegmented bony bar with or without contralateral hemivertebrae

The site of the bony anomaly is important as lower thoracic and thoracolumbar curves have a larger propensity to increase. Upper thoracic or cervical scoliosis has a highly visibility and becomes a cosmetic problem much earlier. The unsegmented bar in combination with contralateral hemivertebrae has the greatest potential for deformation followed by a unilateral unsegmented bar or double / single hemivertebra. Hence it is important to identify the structural defect responsible for the spinal deformity.

2. Truncal decompensation:

A solitary hemivertebra located strategically may give rise to truncal decompensation. This happens at the junctional zones e.g. the lumbosacral junction (oblique take off), the thoracolumbar or cervicothoracic junction. Large rigid curves may show poor compensation above or below the curve. Trunk balance is an important aspect to be considered in treatment planning.

3. Truncal shortening:

Due to reduced growth potential truncal shortening may be visible. Secondarily due to early spinal fusion the truncal height may be reduced. However, a short straight trunk is better than a deformed one. We have currently no means available to increase truncal height and this remains a research area.

4. Altered neurology:

Congenital scoliosis is characterized by a high incidence of intraspinal problems ranging upto 30% in some series. These comprise pathologies like those of diastematomyelia, fibrous splitting of the cord, low filum terminal, cord or root tethering etc. These may be responsible for altered neurological treatment signs prior to treatment. They also have important implications for surgical treatment e.g. distraction instrumentation. This may demand rectification of the intraspinal pathology prior or along with the definitive surgical treatment.

5. Other congenital anomalies:

The VATER association and presence of other anomalies e.g. cardiac or genitourinary may have a bearing on treatment and all congenital scoliosis need to be evaluated for presence of other congenital problems.

Treatment Options:

Age, remaining growth, presence of other congenital defects and neurological status are important in clinical examination. A thorough clinical and radiological evaluation should include analysis of the type and site of vertebral anomaly, trunk balance, presence of laminar defects and signs of occult dysraphism etc. The treatment options when faced with a patient of congenital scoliosis are either non operative or operative.

1. Non Operative Treatment:

i. Observation
Small curves
Initially to determine progression
ii. Bracing
Curve < 400 with flexibility of 50%
Where better trunk balance can be obtained by bracing
Post operative management of curves where localized apical fusion is carried out.
Bracing has limited role in congenital scoliosis.

2. Operative Treatment:

Operative management is indicated for congenital scoliosis in the following situations
i. Progressive increase in deformity
ii. Trunk decompensation
iii. Neural deficit
The types of surgeries carried out for congenital scoliosis are as follows:
i. Prophylactic to prevent progression
ii. To improve trunk balance
iii. Salvage- correction of deformity
iv. Neurosurgery

Preventing Progression:

i. Combined anterior + posterior convex epiphysiodesis
This is a growth arrest procedure which effectively stops growth on the convex side. When growth potential exists on the concave side, some curve correction may be obtained. This is best done for small curves < 600 preferable by five years of age.
ii. Posterior /anterior + posterior convex apical fusion increasing curve in an immature patient demands a convex anterior + posterior fusion. This is a limited fusion and requires post operative support and bracing. The option of subcutaneous rodding of the curve and apical fusion seems largely unacceptable in developing countries because of the frequent surgery required. Growth rods may have a role to play in such a situation.
iii. A progressive deformity in a nearly skeletally mature patient would need correction, posterior fusion and instrumentation to support the fusion. Different options of instrumentation are available with their merits and demerits.
In a similar situation where the deformity is severe and rigid, anterior release needs to be combined with posterior instrumentation and fusion.

Improve trunk balance:

The aims of these procedures is to restore spinal balance and not to achieve maximal curve correction.
i. Hemivertebra resection with or without instrumentation. This is indicated where the cause of truncal imbalance is the hemivertebra. This occurs at the junctional zones. The Hemivertebra needs anterior and posterior resection. Where suitable a posterior compression assembly can be used. This surgery can occasionally be carried out by a single posterior approach in which the hemivertebra is exicised from the posterior approach. The procedure of hemivertebra resection is associated with risks especially in the thoracic region and must be undertaken by an experienced surgeon.
ii. Total vertebrectomy, correction, instrumentation and fusion. This is reserved for rigid decompensated curves to improve spinal balance and gain correction. It is technically a demanding procedure and should be used for cases which have marked decompensation. The procedure involves anterior resection or decancellation, corresponding posterior resection, instrumentation and fusion.

Salvage – correction of deformity:

Correction of the deformity will most often involve the above procedures. In severe curves, anterior surgery is combined with posterior surgery, instrumentation and fusion.

Neurosurgery in congenital scoliosis:

In congenital scoliosis the incidence of intraspinal pathology tethering the cord is high. All intraspinal problems do not need active intervention. This is necessary where a spinal dysraphism is symptomatic or likely to become symptomatic or where distraction instrumentation is planned. Rapidly increasing scoliosis should entail a search for intraspinal pathology. Such problems can be dealt with as an isolated procedure or combined with posterior surgery for scoliosis.

Technical Notes:

All cases of congenital scoliosis should have a MRI to know the cord status, canal diameter and narrowing, intraspinal pathology etc.
In the thoracic region, limited anterior + posterior surgery e.g. epiphysiodesis or apical fusion can be carried out via a single sloping thoracotomy incision. The incision can be retracted to the mid line for the posterior fusion. I have been using this approach for many years now.
Instrumentation should be used with caution in cases of congenital scoliosis. A proper assessment of the vertebral size, canal size and age of the patient has to be made. The highest incidence of neural complications of instrumentation exists in this group, Instrumentation can be used without distraction to support the spine. Alternative to this is cast support, wedging and cast correction of the spine.
Laminar defects may make exposure and instrumentation difficult and alternative sites of purchase like the pedicle and transverse process should be sought in these cases.
Anterior instrumentation should be avoided in a severely rotated spine.

In Conclusion:

The biggest error in the management of congenital scoliosis is procrastination in offering surgical management. Prophylactic fusion should be considered for curves which are known for rapid progression e.g. those with unsegmented bar and contralateral hemivertebrae. Progressive curves should be fused regardless of age. Neurosurgical aspects of scoliosis management should not be neglected. Management options should be weighed and considered in each situation.

4. PEDFP: Iatric Fractures

Dr. Noam Bo, M.D.
Head Pediatric Orthopedic Unit, Haemek Medical Center, Afula, Israel

Trauma is the leading cause of death of children and second to infection as cause of morbidity. Fractures in children are different from those in adults, but they also very depending on the age of the child. Boys are injured more often than girls particularly in adolescence, and the percentage of fractures that occur through the physis increases with age. Fractures become more common as sport activities increase. Fractures in children less than 18 months old are rare, and any long-bone fractures, should raise the question of non-accidental trauma due to child abuse.

Multiple injuries occur in about 10% of children admitted to hospital for trauma. The child with the multiple injuries must first be resuscitated, very similar to an adult, except that instrumentation and therapy must be tailored in accordance with variable patient size, and injury response. Head trauma in young children is the prevalent, followed in decreasing frequency by limb fracture and trauma to the torso.

Fractures of the distal forearm are the most common in children; the clavicle is the next most commonly injured site. The majority of pediatric fractures of the lower extremity can and should be treated with closed reduction, and immobilization.

The capacity of bone to remodel significantly influences the management of fractures; remodeling potential is greatest in children less than 10 years old, fractures near the physis, and in deformities in the plane of joint motion. As a general guideline, at union, a varus or angulation up to 15 degrees, anterior or posterior angulation up to 20 degrees and up to 30 degrees of mal-rotation are acceptable femoral alignment in children who are two to ten years old.

Reduction and internal fixation of fractures in children have become more widely practiced than in previous decades. In the last two decades, there has been a strong trend towards methods that allow rapid immobilization of the child, whereby reducing hospitalization time also for cost reasons, and letting the children rapidly return to their normal pre-fracture life. This attitude is classically emphasized in the treatment of femoral shaft fractures. Following conservative treatment with a spica cast, the majority heals without long term sequelae, however, the most frequent and expensive complications in the field of orthopedics result from closed treatment of pediatric femoral fractures. Currently, flexible intramedullary nailing is the pediatric orthopedist’s treatment of choice for skeletally immature children older than six years of age with a transverse fracture in the middle 60%o the femoral diaphysis. This fixation is adequate, safe, relatively easy to apply and remove, and associated with few complications. Diaphyseal fractures of the tibia are the most common lower-extremity fractures in children. As opposed to the femoral fractures, most tibial fractures should be treated conservatively with a walking cast, the child is not restricted to bed, and can return very quickly to school. However, since the tibia has little soft tissue cover and the leg is exposed to view with normal clothing, malunion is more obvious, than for most long bone fractures, the limits f acceptable reduction are more limited, less than 10 degrees of varus, valgus or recurvatum angulation, and no malrotation. The vast majority of pediatric fractures of the upper extremity can and should be treated conservatively with closed reduction and cast immobilization.

Diaphyseal fractures of the forearm are most common in girls ages 10 to 12 years and in boys ages 12 to 14 years. Distal forearm fractures are the most common, and those involving the metaphysis usually involve both bones. Although some authorities have used 20 degrees of angulation as a guideline for closed reduction of diaphyseal fractures, it is generally believed that any acute fracture that limits forearm rotation should be reduced. Unstable transverse fractures are ideally treated surgically by intramedullary devices or plate and screw fixation. In principle, patients with less than one year of skeletal growth remaining have limited growth potential and thus should be treated as adults. Only 10 degrees of angulation should be accepted in older children.

Supracondylar fractures are the most common elbow injuries. Serious neurovascular injuries and residual cubitus varus deformities are common. All the complete and displaced fractures should be treated in the operative room with closed reduction, percutaneous pinning and cast immobilization. Indications for open reduction are vascular injuries and fractures that cannot be reduced adequately for percutaneous pins.

Physeal injuries represent 15 to 30 percent of all fractures in children. Fortunately, although these injuries are common, growth deformity is a rare occurrence, occurring in only 1 to 10 percent of all physeal injuries. The most utilized classification system is that of Salter and Harris. Because of the intraarticular component, displaced type 3 and 4 injuries must be reduced anatomically, to prevent late arthritic changes, physeal bridge formation and reduced the risk of bar formation. Therefore, most of these fractures should be treated by open reduction and internal fixation.

Spine injuries are relative uncommon in children, accounting for only about 2-3% of spinal trauma cases. Spinal cord injury without radiographic abnormality (SCIWORA) is one of the unique spinal injuries of childhood, and therefore merits a special high risk of suspicion from the pediatric orthopedic surgeon. The condition occurs in children under the age of 8 years.

Pelvic fractures in children are relatively unusual and pelvic ring disruptions are even more rare. Treatment is mostly conservative since exsanguinating hemorrhage is unusual in children so operative pelvic stabilization to control bleeding rarely is necessary, and healing is excellent with significant remodeling.

Open fractures in children most commonly involve the tibia, but they may also complicate supracondylar fractures of the forearm, femur and other bones. The same adult classification of Gustilo is used, however, the overall prognosis for a given grade is better in children, especially infants and young children. Treatment is very similar to that of adults and included antibiotic prophylaxis, debridement, irrigation and immobilization, generally by external devices.

References:

The operative management of pediatric fractures of the lower extremity. John M Flynn. JBJS 84A 2288-2300 2002
The operative management of pediatric fractures of the upper extremity. John M Flynn. JBJS 84A 2078-2089 2002
Symposium on Children’s fractures. Clin Orthop Related Res, 376:2000
Fractures in children. Rockwood and Green, Lippincott 2001, 5th edition
Tachdjian Pediatric Orthopedics. 3rd edition, Saunders Company. Volume 3 2000
Practice of pediatric orthopedics. Lynn T. Staheli. Lippincott Williams and Wilkins 2001

5. Physeal Injuries

Dr. K. Vinodh
G.K.N.M. Hospital, Coimbatore

Physeal injuries are common in children. Though growth disturbance resulting from these injuries is a rare complication, when it occurs, it is difficult to treat. Physeal damage can also occur due to infection, irradiation, frostbite, burns vascular damage and iatrogenic damage. The hypertrophic zone of the physis is the weakest zone and is most vulnerable during growth spurt to injuries.

Several classification systems are present to classify these injuries. The traditional Salter-Harris and the recent classifications of Ogden and Peterson are popular classifications. The basic principle of treatment is to obtain accurate reduction to maintain growth and function. This should be achieved either by closed or open means. Salter-Harris type I and II injuries can usually be reduced by closed means and maintained in a plaster cast as they have low risk of causing joint disturbance. Type II and IV injuries require accurate reduction to restore articular congruity and to prevent formation of physeal bars.

The most important complication is partial or complete physeal arrest resulting in angular deformity or leg length discrepancy. The type IV injury has the greatest potential for formation of bar. The size, location and duration of growth left in the child determine the extent of deformity. For complete arrest in older children no treatment is required. In younger children, treatment depends on the specific physis injured and the amount of LLD anticipated. Partial arrests are classified as central, peripheral or linear based on the relationships of the arrest to the healthy physis. The treatment options are resection of bar, physeal distraction, arrest of remaining growth on injured physis, corrective osteotomy or a combination of these depending on various factors.

References:

Fractures in children. 4th edition, Editors: Rockwood, Wilkins, Beaty. Lippincott-Ravenpress-1996.
Langenskiold A.: Surgical treatment of partial closure of the growth plate. JPO 1:31981.
Ogden J: The evaluation and treatment of partial physeal arrest. JBJS 69A: 1297, 1987.
Tachdjian’s Pediatric Orthopaedics, 3rd edition. Herring. (ed). W.B. Saunders. 2001.

6. Physeal Injuries

Dr. K. Vinodh
G.K.N.M. Hospital, Coimbatore

References:

Fractures in children. 4th edition, Editors: Rockwood, Wilkins, Beaty. Lippincott-Ravenpress-1996.
Langenskiold A.: Surgical treatment of partial closure of the growth plate. JPO 1:31981.
Ogden J: The evaluation and treatment of partial physeal arrest. JBJS 69A: 1297, 1987.
Tachdjian’s Pediatric Orthopaedics, 3rd edition. Herring. (ed). W.B. Saunders. 2001.

6. Post Infective Long Bones Defects

Dr. S.K. Saraf
Department of Orthopaedics, Institute of Medical Sciences
Banaras Hindu University, Varanasi-India

A gap non-union in the diaphysis of long bones resulting after osteomyelitis or open fracture is a difficult problem to manage. Surgeon has to face three problems at one time i.e. non-union, infection and shortening of the limb. Late presentation, long standing immobilization, joint stiffness soft tissue contractures, deformities segmental loss of bone, multiple previous surgeries are some of the factors contributing to the difficulties faced by the patient as well as by the treating surgeon. Considerable judgment is required to treat these cases and to provide optimum in the prevailing situation. The management ranges from osteosynthetic procedures to amputation. A variety of treatment modalities like single bone forearm, fibular by pass surgery, bridging of gap by massive allograft, autograft, cancellous insert graft, vascular graft, various osteosynthesis procedures using nails, plate wires, external fixator etc have been tried conventionally. Bone transportation techniques using Ilizarov ring fixator system have revolutionized the management in the recent past.

The treatment modality must be individualized. The same principle cannot be applied blindly to all. In the present time, with better technical skill assisted by modern equipments and potent antibiotics, the surgeon must make all possible affords to achieve union with single surgery and make the limb functional as early as possible.

References:

Dell, PC and Sheppard, JE. Vascularized bone grafts in the treatment of infected forearm non-unions. J. Hand Surg.9;653:1984.
Gill, AB. Treatment of ununited fracture of the bones of the forearms. Surg Clin North Am12; 1535:1932.
Krempen, JF, Silver, RA, and Sotelo, A. The use of the Vidal Andry external fixation system; Part 2. The treatment of infected and previously infected pseudarthrosis. Clin Orthop 140;122:1979.
Meyer, S, Weiland, AJ and Willeneggar, H. The treatment of infected non-union fractures of long bones: study of 64 cases with a 5 to 21 year follow-up. J Bone Joint Surg. 57-A;836:1975.
Reckling, RW and Waters CH. Treatment of non-unions of fractures of the tibial diaphysis by posterolateral cortico cancellous bone grafting. J Bone Joint Surg 62-A; 936:1980.
Shelton, W.E. and Sage, F.P.: Modified Nicoll graft treatment of gap non-union in the upper extremity. J. Bone Joint Surg. 63-A, 226, 1981.
Paley, D, Catagni M, Argnani, F et al. Ilizarov treatment of tibial non-unions with bone loss. Clin Orthop 241;146-165:198900

7. POTENTFP : IAL Applications Of Stem Cell Therapy In PAEDFP: Iatric Orthopedis

Dr. James HP HUI
New University of Singapore

Congenital and developmental conditions in the musculoskeletal system of children are chronic and disabling. Investigations were performed on a wide range of topics aiming to obtain knowledge and understanding of the etiology of diseases and what emerges would have the potential to revolutionalize the treatment of patients suffering from loss of tissue function and treatment of such conditions. Current research involves the most updates research strategies and approaches and is carried out at multiple levels of experimentation such as cell and molecular biology, biomaterials, biomechanics, and advances imaging and computation.

One of the most exciting areas of research involving cell-based therapy is tissue engineering using embryonal stem cells and mesenchymal stem cells. Embryonal stem cells are totipotent cells cultured from human fetal tissues which has the capacity to differentiate into virtually every tissues/organ of the body. However, the undesirable tendency to form teratomas and its ethical controversy has limited its clinical application.

The more promising mesenchymal stem cells (MSCs) can be derived from various sources such as bone marrow, periosteum and fat. These pluripotent MSCs have the liability to self-renew at a high proliferation rate, yet they can differentiate along osteogenic, chondrogenic, tenogenic or marrow stromal lineages, and show identical phenotype when grown from a single cell clone. In addition, some studies have demonstrated that the adherent stromal cells can be transduced with genes for reporter molecules which secrete circulating cytokines. These genes can be inserted into the genomes of MSCs without affecting their stem cell capacity, thus making MSCs an excellent curative agent in genetic disorders. In animal models, MSCs had been transfected using retroviruses and were able to achieve high level of gene expression in vitro and in vivo.

Research is being carried out in the identification of cellular and molecular mechanisms of osteogenesis; analysis of mediators of bone resorption and bone formation that may play important roles in osteolysis and osteoporosis such as in the report of the successful transplantation of bone marrow derived mesenchymal stem cell in children with osteogeneis imperfecta.

The chondrogenic potential of stem cells had been validated in experimental studies whereby lesion of osteochondritis dissican and physeal arrest were repaired with transplantation of MSCs.

Other studies have investigated the tenogenic potential of MSCs in the clinical application of tendon healing/transfer. Mesenchymal stem cells had also been shown to enhance osteointegration of donor graft in ligamentous reconstruction in adolescent sports injury.

Given the right regulatory signal, it has the ability to be transformed into cardiomyocytes. Tissue engineers are manipulating its right lineage to differentiate into myoblasts and myocytes thus offering hope to patients inflicted with muscular dystrophies.

However, stem cell therapies are not without its challenges; namely the characterization of mesenchymal stem cell owing to the lack of specific surface marker. Successful application of generated musculoskeletal tissues depends on sufficient cells and the delivery vehicles to enhance differentiation. Appropriate biocompatible scaffolds would enhance mechanical stability ad transplanted tissue.

8. The Human Genome Project And Its Impact On Clinical Practice

Madhulika Kabra, Associate Professor,
Genetics Unit, Department of Pediatrics,
All India Institute of Medical Sciences, New Delhi – 110 029, INDFP: IA

The Human Genome Project (HGP) began formally in 1990 and is a 13 year effort coordinated by the US Department of Energy and the National Institute of Health (NIH). It finalized almost two years earlier than expected. It was an enormous task as the aim was to sequence 3 billion base pairs and identity approximately 30,000 genes.

What is the genome? The genome is defined as the total genetic material contained within the chromosomes of an organism. It can be said to be the total genetic information which is carried by the DNA. From the functional point of view it is also necessary to define the ‘transcriptome’ and the ‘proteome’. Transcriptome is the transcribed messenger RNA (mRNA) complement and the Proteome is the translated protein constitution. Transcriptome and proteome may vary considerable in different tissues or even within the same tissues. The advantages and disadvantages of screening using genome, proteome and transcriptome are given in Table I.

Table 1: Advantage and disadvantages of Genomic, Transcriptome, and Proteomic Screening for Disease Prediction

Advantage/Disadvantage	Genomic	Transcriptomic	Protenomic	Conventional Screening	Symptoms
Early detection and treatment	++++	+++	++	+	-
Predictive power for true future disease	++	+++	+++	++++	+++++
Lead time for intervention to prevent clinical onset	++++	+++	++	+	-
Likely effectiveness of gene-based or other individualized therapy	++++	++++	+++	++	++++
Length of potential social, economic, or health care discrimination prior to clinical disease onset	++++	+++	++	+	+

The Goals:

Human Genome Sequence: Complete the human genome sequence by the end of 2003 while emphasizing the establishment of a working draft version for at least 90% of the genome by 2000, the development of a sustainable capacity for large-scale sequencing, the generation of large contiguous stretches of high-quality sequence, and the provision of ready access to the data.

Sequencing Technology: Continue incremental improvements in current sequencing methods so as to increase the throughout and reduce the cost of sequencing, with emphasis on automation, miniaturization, and process integration. In parallel, support interdisciplinary research for developing novel sequencing technologies and the means for implementing such technologies into established sequence producing operations.

Human Sequence Variation: Develop the technology for rapid, large-scale identification and scoring of single-nucleotide polymorphism (SNPs), with aims of identifying and cataloging the common variants in the coding regions of the majority of human genes and creating a human SNP map of at least. 1,00,000 markers. In addition, establish the intellectual foundations and requisite public resources of DNA samples and cell lines for studying human variation.

Technology for Functional Genomics: Generate complete sets of full-length cDNA clones for humans and model organisms, develop the technology for defining the spatial and temporal patterns of gene expression, design new strategies for the global study of noncoding sequences, design new approaches for systematic mutagenesis of genes, and advance the understanding of protein function on a genome-wide basis.

Ethical, Legal and Social Implications: Examine the issues surrounding the completion of the human genome sequence and the study of human genetic variation, study the issues raised by the integration, of genetic technologies and information into health care, public health activities, and non-clinical settings, and explore how the new genetic information will influence various societal issues related to genetics.

Bioinformatics and Computational Biology: Develop better tools for data generation and capture, improve the content and utility of databases, create mechanisms for sharing and disseminating exportable software, and construct appropriate tools and databases for dealing with comprehensive studies of gene expression and function as well as with sequences homology and variation.

Training and Personnel: Facilitate the training of new scientific specialists with expertise in genomics research (including the recruitment of non-biologic scientists from fields such as computer science, engineering, mathematics, physics, and chemistry) and aid in the establishment of academic career paths for genome scientists. Increase the number of scholars who are knowledgeable both in genetics and in ethics, law and social sciences.

Impact of human disease and clinical practice:

Isolation of disease genes by positional cloning
Comparative study of the biology of humans and other organisms
Advances in molecular diagnostics
- Identification of new genes & mutations
- Newer equipments and techniques
Therapeutic benefits
Ethical legal and social implications

1. Isolation of disease genes: many genes are known to cause human diseases when mutated, but there are others which may have an indirect influence. The major effort of modern molecular medicine is to identify association of genes with human diseases. Isolation of diseased genes can be done by two major strategies: functional cloning and positional cloning. In functional cloning there is knowledge about the function of the gene product (protein) and the identification of gene follows. In positional cloning identification of the gene follows the establishment of its position on the genome. The various makers identified all over the genome on different chromosomes help in gene identification. Positional cloning is used in majority of disorders as the function of gene products is seldom known. The isolation of the gene is followed by identification of disease causing mutations.

2. Comparative biology of humans and other organisms: Study of comparative biology was a major component of HGP. It helps in developing strategies, techniques and infrastructure for studying human DNA. This is based on the fundamental knowledge that all organisms are related and share general type of DNA blueprint and there is significant conversation. This approach helps in understanding gene structure and function.

3. Advances in molecular diagnostics: Molecular diagnostics has a tremendous scope and usefulness in clinical practice. The disorders which can be tested are of wide range which include hereditary, neoplastic and infectious diseases. The HGP has and will help in development of molecular diagnostics in two major ways. Firstly by identification of disease genes and disease causing mutations and secondly use of wider range of moral refined technologies in clinical practice. PCR is being extensively used in clinical practice already. With the availability of high-through put PCR testing hundreds / thousands of PCRs can be performed in a day. An important discovery is this area is DNA chips or micro arrays.

4. Therapeutic benefits: The therapeutic benefits encompass pre-symptomatic diagnosis and use of preventive measures (like life style alterations and surveillances), prenatal diagnosis in lethal or chronic disabling disorders and actual therapeutics. The therapeutic advances would include gene therapy, development of better pharmacological agents. An interesting area in Pharmacogenomics is studying the genetic basis of drug, responsiveness and resistance.

5. Ethical, legal and social implications: There are various issues which need serious thought and discussion. Some of the important ones are as follows:

Who should have access to this data.
Use of genetic information to discriminate people like carriers being stigmatized or problem in health insurance.
Pre-symptomatic diagnosis and susceptibility to disease (e.g. late onset neurological disorders and malignancy pre-disposition).
Misuse in parental testing.
Interpretation of tests and pre and post test counseling issues.

Conclusions:

HGP is one of the most important and ambitious project in biomedical research. It is changing the way and has hastened the speed of genetic research and will open several names for understanding and treating genetic and non-genetic disease.

Suggested readings:

The Human Genome Projects and its impact on the study of human disease. Green ED in the metabolic and molecular bases of inherited disease. Eds. Scriver, Beaudet, Valle, Sly, Childs, Kinzler, Vogeslstein. 8th Edition. McGrawhill 2001 pp 259-298.

Gerling IC, Solomon SS, Bryer-Ash M. Genomes, transcriptomes and proteomes, molecular medicine and its impact on medical practice. Arch Intern Med 2003; 163:190 – 198.
Guyer MS, Collins FS. The Human Genome Project and the future of medicine. Am J Dis Child1993; 147: 1145-,
Sachs BP, Korf B. The Human Genome Project: Implications for the practicing obstetrician. Obstet Gynecol 1993; 81: 458-.

9. The Ilizarov Treatment Of Hypertrophic Nonunion And Mal-Union Of Fractures With A Retained Intramedullary Nail – Report Of 5 Cases

Dr. Noam Bor M.D.,
Head, Pediatric Orthopedic Unit, Haemek Medical Center, Afula, Israel

Introduction:

Hypertrophic nonunions are well vascularized, but union is prevented by the lack of stability. It is largely a mechanical problem of inadequate fixation or reduction. Distraction or compression forces applied to the site of the nonunion lead to new bone formation and healing of the nonunion. During this process, limb deformity and shortening can be addressed. In cases of mal-union, corrective osteotomy, followed by adequate fixation, are required. We report our experience in treating five patients who previously suffered from tibial or femoral fractures who had primarily undergone internal fixation of the fractures with an intramedullary (IM) device. Two patients ended up with malunion and the other three with hypertrophic nonunion of the fractures. We prove that the IM device should not be removed during treatment.

Material and Methods:

Four males and one female are included in the study. The average patient age was 34 years (range, 20-48 years). Two patients had hypertrophic nonunion of tibial fracture, one of the femur, and other two patients had mal-union of tibial fractures. The average interval from the IM fixation of the fresh fractures to the treatment with the Ilizarov device was 11 months (range, 8-12 months). The three patients with the hypertrophic nonunion were simply treated with an application of the Ilizarov device over the retained IM nails, in no case was the nonunion site opened, nor was any bone grafting used. All the wires and pins were carefully positioned to avoid contact with IM nail. For these patients, treatment was followed by alternate distraction and compression of the Ilizarov frame for an average of 3.3 months (range 3-4 months), complete union was achieved, and the frames removed. In the two patients with the mal-united tibial fractures, part of the IM device was found to be broken, was surgically extracted, and an osteotomy through minimal skin incision was performed proximal to the retained nail. An Ilizarov device was applied over the nail, correction of 14 degrees of varus in one patient, 10 degrees of varus, 10 degrees of external rotation and two centimeters of shortening in the other patient were performed gradually in course of three and four months respectively. All rules of deformity correction according to Paley were carefully followed, including, positioning of the frame hinges exactly at the CORA level (Center of rotation and angulation), performing an opening wedge osteotomy in one patient at the CORA level, and translation angulation osteotomy proximal to the CORA level in the other patient as required form the preoperative planning. All nonunions and mal-unions healed uneventfully. Besides pin site infection experienced by all patients, no complications were noticed.

Discussion:

Hypertrophic nonunions often are the sequelae of fractures lacking a sound healing environment with instability being the primary determinant in their development. Treatment should concentrate on creating a stable environment to optimize healing potential. In our three patients who suffered from hpertrophic nonunion, using the Ilizarov external fixation and leaving the IM device had two main advantages: 1) additional stability during treatment is achieved, and 2) they all were saved from unnecessary surgery to remove the nail itself. Removal of a broken IM nails is an often a serious challenge for the surgeon, with significant surgical exposure by invasive, technically demanding procedures, various osteotomies being required in order to access and remove the broken nails. All this was avoided in our two patients with the fracture mal-union and broken nails. The technique of applying an Ilizarov frame over IM nails was found to be favorable in all of our patients, and should be considered by the orthopedic surgeon. In our patients the technique of tibial and femoral lengthening over nail, as was described by Paley and Herzenberg, was adopted.

References:

1. Femoral lengthening over an intramedullary nail, Dror Paley. John E. Herzenberg J.B.J.S. 79-A; 1464-1480. 1997.
2. Tibial lengthening over nails. (LON), John E. Herzenberg. Dror Paley, Techniques in Orthopedics 12(4): 250-259. 1997.

10. Stabilization Of Neuromuscular Scoliosis In Duchenne Muscular Dystrophy – Pelvic Vs Lumbar Fixation And Mong-Term Follow-Up

Dr. Dilip K. Sengupta, MD, Dr. S Hossain Mehdian, FRCS
Department of Orthopaedic Surgery, William Beaumount Hospital, Royal Oak, MI 48073, USA.

The caudal extent of spinal instrumentation remains a matter of considerable debate, in the surgical treatment of scoliosis in Duchenne Muscular Dystrophy (DMD). Traditionally, the recommendation was to extend the stabilization to the sacrum or pelvis to correct pelvic obliquity, and to restore sitting balance of the trunk. It has been well recognized that pelvic fixation is technically demanding and associated with higher complication rate.

Two major changes in the recent decades affected the surgery for scoliosis in DMD cases earlier spinal intervention as soon as the patient is wheel chair bound, and improvement in the implants and instrumentation technique. The authors hypothesizes that the distal fixation using pedicle screw instead of sublaminar wire may provide better stability and avoid the need for extending the stabilization to sacrum or pelvis. This may be particularly true when surgery was performed early, before fixed obliquity of the pelvis has taken place.

To examine the above hypothesis the authors reviewed their experience with surgical stabilization in neuromuscular scoliosis in a series of studies. The first study 1 compared the effect of pelvic vs. lumbar fixation in 50 patients of DMD in two different centers. The second study reviewed the 4-5 year follow-up after lumbar fixation in the 19 cases of DMD from the previous study and 8 more cases of the Spinal Muscular Atrophy (SMA) from the same center."

Study I. Pelvic vs Lumbar fixation in the surgical management of scoliosis in Duchenne Muscular Dystrophy (DMD)1
Purpose:

This retrospective study evaluates whether fixation to sacrum or pelvis is always indicated, in the surgical treatment of scoliosis in Duchenne muscular dystrophy (DMD).

Method:

50 cases of DMD, operated in two different centers, and followed-up for a minimum three years, were reviewed. In the first group (Oswestry), 31 patients had fixation down to the pelvis, using Standard Luque instrumentation and pelvic fixation. The Galveston technique was used in 9 cases and L-rod configuration in 22 cases. In the second group (Nottingham), 19 patients had fixation down to the L-5 vertebra using pedicular screws in the lumbar spine and sublaminar wires in the thoracic spine. These cases were operated early, shortly after becoming wheelchair dependent.

Results:

In the pelvic fixation group, the mean age at the time of surgery was 14 years and forced vital capacity (FVC) was 44%. The mean Cobb angle and pelvic obliquity were 48° and 19.8° respectively. Immediately after surgery the Cobb angle and pelvic obliquity measured 16.7° and 7.2° and at the final follow-up (mean 4.6 years) was 22° and 11.6°. The mean blood loss was 4.1litre and the average hospital stay was 17 days. There were four complications including a deep wound infection in one case, trimming of the rod in two cases and reinsertion of the rod in one case.

In the lumbar fixation group, the mean age at the time of surgery was 11.7 years, and FVC was 58%. The mean Cobb angle and pelvic obliquity were 19.8° and 9° respectively at the time of surgery. Immediately after surgery the Cobb angle and pelvic obliquity were 3.2° and 2.2° and the final follow up (mean 3.5 years) these were 5.2° and 2.9° respectively. The mean estimated blood loss (3.3 litre) and average hospital stay (7.7 days) were significantly less (p(<)0.05) compared to the pelvic fixation group. One patient had loosening of instrumentation and one other had a deep wound infection. Pelvic obliquity was corrected and maintained below 100 in all but two cases who had an initial pelvic obliquity exceeding 20°.

Conclusions:

Pelvic fixation may be necessary in presence of larger curve and significant pelvic obliquity, in older children. In presence of deteriorating lung function this is associated with greater morbidity and higher complication rate. Lumbar fixation to L-5 is adequate if the surgery is performed early, soon after being wheel chair bound, due to the smaller curves and minimal pelvic obliquity. Use of pedicle screws in lumbar spine provides a solid foundation to maintain the correction over the period of short life expectancy of these children.

A concern is raised regarding the adequacy of the lumbar fixation in preventing progression of the pelvic tilt and low back pain in the long run. The follow-up in the previous study for the lumbar fixation group was short. In the second study2 the authors evaluated the results of scoliosis surgery with lumbar fixation using pedicle screws in DMD and SMA cases, with particular interest to pelvic tilt and low back pain.

Study II. Lumbar fixation in scoliosis surgery for progressive neuromuscular diseases and low back pain2
Material and methods:

Twenty-seven cases of scoliosis in DMD(19) and SMA (8) were treated surgically between 1990 and 1998. All had fixation to the L-5 vertebra using pedicle screws in the lumbar spine and sublaminar wire in the thoracic spine. These cases were operated early, shortly after becoming wheelchair dependent.

Results:

The mean age at the time of surgery was 9.2 years, and FVC was 58%. The mean Cobb angle and pelvic obliquity were 250 and 7.50 respectively at the time of surgery. Immediately after surgery the Cobb angle and pelvic obliquity were 60 and 2.20 and at final follow-up (mean 4.6 years, range 2-8 years) these were 8.50 and 3.60 respectively. The mean estimated blood loss was (3.5 litres) and mean hospital stay was (7.5 days). Complications included deep infection in three, loosening of instrumentation in one, and pulmonary infection in two patients.

Pelvic obliquity was corrected and maintained below 100 in all but three cases who had an initial pelvic obliquity exceeding 200. The lumbo-sacral disc height remained well maintained in all the patients and there was no incidence of low back pain in any patient at the time of last follow-up.

Conclusion:

Lumbar fixation to L-5 has a low operative morbidity, and is adequate to prevent progression and correct smaller pelvic obliquity. The open lumbo-sacral disc does not degenerate early or lead to low back pain. Unlike sublaminar wires, used of pedicle screws in the lumbar spine prevents rotation of the spine around the rods, and provides a solid foundation to maintain the correction. Fixed pelvic obliquity exceeding 20 degrees may be a relative contraindication to lumbar fixation.

The above two studies clearly established that the use of pedicle screw fixation in the lumbar spine can successfully stabilize the long fusion of the rest of the spine over the pelvis, and restores the sitting balance, as long the stabilization is done early, before the pelvis rotates into a fixed obliquity. It further shows that the long fused segment of the spine above the open lumbo-sacral disc does not cause its degenerate over time to cause back pain. Short life expectancy and less physical demand of these wheel chair bound children may prevent the failure of the lumbo-sacral disc in these children. The morbidity and complications of pelvic fixation my safely be avoided in these children.

However, lumbar fixation may not be adequate in other forms of neuromuscular scoliosis. This is particularly true when the life expectancy is near normal, or when spasm of the trunk muscles may produce unusual strain on the lumbar fixation to cause failure at the lumbo-sacral junction. In a subsequent review of different forms of neuromuscular scoliosis, treated surgically, either by pelvic or lumbar fixation, with a minimum five-year follow-up, the authors seen that lumbar fixation failed in cerebral palsy cases and also when the initial pelvic obliquity exceeded 20°.

Study III Pelvic obliquity and surgical stabilization in neuromuscular scoliosis – a minimum 5 years follow-up
Purpose:

This retrospective study evaluates the effect of lumbar and pelvic fixation on pelvic obliquity in surgical stabilization of neuromuscular scoliosis.

Method:

27 cases of Neuromuscular scoliosis [Cerebral Palsy (CP) 9, Fredrick’s Ataxia1, Duchenne Muscular Dystrophy (DMD) 14, and Spinal Muscular Atrophy (SMA) 3] surgically treated with Luque rods and sublaminar wire, with minimum 5 year follow-up (mean 8.5 years) were reviewed. Pelvic fixation with ‘L’ rod configuration was used in 10 cases. The remaining cases had lumbar fixation to L5 vertebra using pedicle screws in the lower 3-5 lumbar vertebrae.

Results:

Pelvic fixation was used in 7 cases with CP, 2 cases with MDM and one case with Fredrick’s Ataxia. The mean age at operation was 17.5 years (range, 10-22 years). The mean Cobb angle was 820 (range, 480 – 1120) at operation, 450 (range, 180-520) direct postoperative, and 560 (range, 180-510) at final follow-up. The mean pelvic obliquity was 280, at the time of operation, 16.50 direct postoperative and 18.50 at final follow-up. Complications included three cases of loosening of sacral fixation, one case of deep infection requiring removal of implants. The mean blood loss was 4.2 L and mean hospital stay was 17 days.

Lumbar fixation was used in 12 DMD cases, 2 CP cases and all the three SMA cases. The mean age at operation was 11.5 years (range, 9-13 years). The mean Cobb angle was 19.80 (range, 120-280) at operation, 3.20 (range, 00-80) direct postoperative, and 10.60(range, 00-160) at final follow-up. The mean pelvic obliquity was 90 at the time of operation, 2.20 direct postoperative and 4.50 at final follow-up. Mean blood loss was 3.2 L and mean hospital stay was 7.5 days. Two cases had deep infections, and two cases had loosening of implants. None developed low back pain. Significant loss of pelvic obliquity was noted in both the CP cases and two DMD cases who had initial pelvic obliquity exceeding 200.

Conclusions:

Lumbar fixation group had significantly less morbidity and may be adequate to prevent the pelvic obliquity when operation is performed early. However pelvic fixation desirable in all cases with CP, and cases with established pelvic obliquity exceeding 200. Low back pain at the lumbo-sacral junction was not experienced in the lumbar fixation group at medium term follow up.

With increased awareness among the parents and the primary care physicians, more and more children with progressive is short, but with the availability of the modern medical facilities, they live into their second or even third decade of their life. Almost all these patients are destined to develop scoliosis in course of time, as the trunk muscles are progressively involved. It may be pertinent to stabilize the spine early, as soon as they become wheel chair bound this may prevent loss of sitting balance, and offer these children a reasonably comfortable active life within the confines of the wheel chair. It is possible to avoid pelvic fixation, which has a higher morbidity and complication rate than lumbar fixation. The apprehension of progressive loss of sitting balance or lumbo-sacral disc degeneration in the long-term follow-up with lumbar fixation has been overestimated On the contrary, these children may enjoy the mobility of the open lumbo-sacral disc for their activity I the wheel chair for a long time. However, one must remember that lumbar fixation may not be adequate in other forms of neuromuscular scoliosis like cerebral palsy, where longer life expectancy and muscle spasm may complicate the issue and a fixation to the pelvis becomes a better option. The same is also true when DMD or SMA cases are operated late, after developing a fixed pelvic obliquity exceeding 20 degrees.

References:

Sengupta DK, Mehdian SH, McConnell JR, Eisenstein SM, Webb JK: Pelvic or lumbar fixation for the surgical management of scoliosis in Duchenne muscular dystrophy. Spine 2002;27:2072-9.
Sengupta DK, Mehdian SH, Webb JK; Pelvic fixation for scoliosis in progressive neuromuscular diseases and low back pain, ISSLS Annual conference. Cleveland, 2002.

Congenital / Development

1. A New Appraoch To Congenital Pseudarthrosis Of TIBFP : IA (CPT)

Dr. R.A. Agrawal, (M.S. Orth), Dr. Anuj Kr. Jain (D. Ortho)
Agrawal Orthopaedic Hospital, Jubilee Road, Gorakhpur, U.P., India
Phone – 0551-2333102, Email – agrawalram@hotmail.com

Congenital Pseudarthrosis of Tibia (CPT) present surgeons one of most challenging of all Orthopaedic problems. Various surgical treatments have succeeded only rarely. There is a failure of normal bone formation in distal half of Tibia, resulting in segmental defect of bone, anterolateral angulation and pathological fracture. The tibial ends are radiographically atrophic, often appearing thin and pointed. Histologically the tissue interface is composed of fibrofatty hamartoma that intends into modalities of treatment of CPT

1. Ilizrov External Fixator
2. Vascularised Fibular Graft
3. Electrical Stimulation
There is various method of treatment of CPT by Ilizarov Technique –
1. Compression of Pseudarthrosis alone.
2. Compression with metaphyseal/diaphyseal lengthening.
3. Resection of pseudarthrosis site with compression by gradual lengthening.
4. Resection of the pseudarthrosis area with acute compression followed by metaphyseal lengthening.
We have adopted a new principle in which nonunion site is not excised and union is made between two new fresh surfaces made by percutaneous double osteotomy proximal and distal to pseudarthrosis site and lengthening by metaphyseal corticotomy.
In the present work Ilizarov ring fixator controls osteotomized fragment. We have treated fifteen cases of CPT by adopting different techniques of Ilizarov method since 1994. Five cases have been treated by this new technique.
In this new technique the proximal osteotomy and corticotomy is done in single stage. The site of proximal Osteotomy is above the nonunion site where the medullary cavity is open. The whole fragment (middle) from corticotomy site to proximal osteotomy site is bring downward it reaches below the nonunion site. In second stage second osteotomy is done distal nonunion site where the medullary cavity is open. Now distal fragment is rotated at the osteotomy in such a way that it unites with the new surfaces made by proximal osteotomy. It is very necessary to make the proper angle of two osteotomy so that the new surfaces should coincide with each other. As union is made between two new fresh surfaces thus union is not a problem, and lot of exuberant callus is formed around the nonunion site. So there will be no chances of refracture as all the associated deformity are corrected usually during treatment.
All the five cases are excellently united and the average union time is 6 to 7 months with 3 years follow up. Refracture and any complication are not reported yet.

2. A RELFP: Iable & Valid Method Of Assessing The Amount Of Deformity In The Congenital Clubfoot Deformity

Dr. Shafique Pirani, Dr David Hodges, Dr Flyod Sekeramayi
The Department of Orthopaedics and Radiology, University of British Columbia

This paper outlines a method of assessing the amount of deformity in the congenital clubfoot deformity using 6 well-described simple clinical signs that has been tested & found to be both valid and reliable.

Method:

A clinical clubfoot scoring system was created (Clinical total Score/CTS; Clinical Hindfoot Score/CHS; Clinical Midfoot Score/CMS). 100 consecutive congenital clubfeet were scored for clinical deformity each week during Ponseti treatment by 3 independent observers & Inter-observer reliability evaluated by the Kappa Statistics.

A MRI scoring system was developed to visualize & score osteo-chondral pathology (MRI Total Score/MTS; MRI Hindfoot Score / MHS; MRI Midfoot Score / MMS). 19 clubfeet were evaluated with 38 MRI exams during treatment. Validity was evaluated by correlating the MRI and clinical scores (Pearson Correlation)

Results:

The Kappa values for inter-observer reliability were CTS –0.92, CMS- 0.91, and CHS-0.86. All scores showed almost perfect inter-observer reliability. The Pearson Correlations between clinical & MRI scores were CTS: MTS=0.786 (P(<)0.01), CHS: MHS=0.712 (P(<)0.01) & CMS: MMS=0.651 (P(<)0.01). All correlations were highly significant confirming validity of the clinical scores.

Conclusions:

We have developed a clinical scoring system for clubfeet that is reliable and valid.

Significance:

A valid and reliable method of assessing deformity allows meaningful comparison of results between different investigators.

3. Changes In Tarsal Anlages During Manipulation & Casting Of Clubfoot With The Ponseti Method: A Mri Study

Dr. Shafique Pirani, Dr. David Hodges
Department of Orthopaedics and Radiology, University of British Columbia

Purpose:

Little information exists about how manipulation and casting corrects the pathology of the virgin clubfoot deformity. The steps in the correction of the displacements and anomalies of the skeletal components have never been visualized. The purpose of this presentation is to firstly see if MRI can visualize osteochondral pathology in newborn clubfoot, and secondly to see the effect of Ponseti Rx on this osteochondral pathology. The skeletal anomalies of the congenital clubfoot that we wish to image with MRI are well demonstrated in Dr. Ponseti’s dissection from the 1960s. (1. Severe tibio-talar plantar flexion, 2. Medial talar neck inclination. 3. Sever medial displacement of navicular, 4. Wedge shapes navicular, 5 Medially displaced cuboid, 6. Wedge shaped distal calcaneal articular surface, 7. Adducted and inverted calcaneus, 8.Wedged shaped head of talus.

Method:

A MRI protocol was devised to image the described chondro-osseous abnormalities of the virgin clubfoot deformity. 19 infants undergoing Ponseti Treatment of their clubfeet had their feet sequentially examined by 38 MRI to illustrate the changes that occur with the Ponseti treatment. Using this MRI protocol, with an adult wrist coil, we imaged 4 standard planes aiming to have 3 scans 2 weeks apart during Ponseti treatment. All the abnormal skeletal elements could be imaged.

Results:

The MR images showed correction of; wedge shaped talar head, medial talar neck inclination, medial navicular displacement, medially displaced cuboid, wedge shaped medially inclined distal calcaneal articular surface, inverted calcaneus, tibio-talar plantar flexion & inferior talo-navicular subluxation. The change in the shape of the tarsals occurs mostly by cartilage remodeling without much alteration in shape and orientation of the underlying ossification centers. All the abnormalities seen on the initial scans either improved markedly or corrected completely by Ponseti treatment.

Conclusion:

MRI can readily image all major chondro-osseus pathology of the clubfoot. Ponseti manipulation and cast treatment of clubfeet corrects abnormal relationships of the tarsal bones & corrects abnormal shapes of the individual tarsal bones.

4. Clubfoot Correction In Infants – Exeprience With The Ponseti Technique

Dr. S Sarup MS Orth, MCh Orth, FRCS
Paediatric Consultant, Max Healthcare & Children’s Bone & Joint Centre, Delhi

Abstract:

36 patients with 43 clubfeet were treated in the Children’s Bone & Joint Clinic as per the Ponseti methodology. Early results show a very satisfactory cosmetic and functional outcome in 41 feet. 6 children (7 feet) have developed a mild forefoot varus and 1 foot relapsed after treatment. Careful attention to technique including over correction of the forefoot ensures a low recurrence and a good cosmetic appearance in the short term. A detailed discussion on the Ponseti principles is included.

5. Complete Talar Mobilazation In Surgery Of Rigid Clubffet – Our Experience

Dr. Rajeev Thakural, Registrar, Ortho. Surgery,
Dr Ramani Narasimhan, Sr Consultant Indraprastha Apollo Hospitals, New Delhi

We present our experience in the surgical management of 21 rigid CTEV in 19 children (2 bilateral), and subsequent follow-up of 2 years at least.

All feet were rigid (equinus inversion and adduction, persisting after possible passive manipulation) to start with and were subjected to initial manipulations and castings for at least 3 months, before surgery was performed. Subtalar releases were done in all feet between 6 months and 13 months of age and talo-navicular and talo-calcaneal joints were fixed in all. There were 15 good results, 3 fair results and 1 poor result after 24 months of follow-up, as per a subjective (pain) & objective assessment (gait and radiological criteria). Our study, although not being a comparative one, was compared with similar studies in literature. We feel that talus needs to be completely mobilized through sub-talar releases in order to achieve satisfactory talo-navicular and talo-calcaneal relationships, thus helping towards good results in future.

6. Congenital Dislocation Of Knee – Facts And Myths

Dr. Premal V Naik MS, DNB [Orth.]
Associate Professor of Orthopaedics, NLH Municipal Medical College, Ahmedabad, India

Introduction:

Congenital dislocation of knee is not very common but grotesque deformity. There appears to be lack of awareness about this condition amongst obstetrician, paediatrician and even orthopaedic surgeons.

Material and Methods:

There were total 18 patients with 28 knees with this problem. There were 9 females and 9 males with 10 patients having bilateral problems. Ten patients had recurvatum, 9 patients had subluxation and 9 patients had dislocation. Age of presentation was from day of birth to 10 years. Five patients had arthrogryposis with multiple contractures, one had hip dysplasia and one patient had bilateral radio ulnar synotstosis. Two patients who had manipulations and plastering done elsewhere came with plastic deformation and bowing of upper tibia on both sides.

Results:

Fourteen knees were successfully managed with plastering while fourteen knees required surgery [operated or posted for surgery]. All patients with recurvatum required single plaster, those with recurvatum and arthrogryposis needed serial plastering. All patients with complete dislocations needed surgery. Good per operative flexion was achieved with minimal difficulty in patients presenting before one year and older patients required serial plastering after surgery to achieve flexion.

Discussion and Conclusions:

Patients with recurvatum can be managed with plastering while patients with subluxation if present within first six months can be managed with plastering but those presenting late may need surgery. Patients operated within first year had good functional outcome compared to patients presenting late who had restriction of movements.

7. Congenital Muscular Torticollis

Dr. S. Sengupta, Dr Saw Aik
University Hospital, Kuala Lumpur

Introduction:

In most centers conservative management of congenital muscular torticollis has 10% to 20% failure rates. Surgery done before the age of six has excellent prospect of correcting the neck deformity and also resolving the associated facial asymmetry. Open tenotomy of lower attachments of the sternomastoid is the standard procedure. This achieves the correction of deformity but may result in ugly scar, lateral fascial bands and the conspicuous loss of sternomstoid column. Authors have devised a method of elongating the muscle, thus retaining the column.

Material and Methods:

Forty-nine patients from one and a half to twenty years have been operated since 1986. The sternal head of stenocliedomastoid muscle is tendinous and cord like specially in patients with torticollis but becomes muscular proximally. The broad clavicular head is muscular and passes proximally deep to the sternal head to be attached to occiput and mastoid process. The accessory nerve passes laterally between the two heads just below the mastoid process.

Through a three centimeter supra-clavicular incision along with the skin crease, both the heads of the muscle are exposed. The sternal head is followed proximally upto the muscle attachment and divided. The fleshy clavicular head is detached from the clavicle. Patient’s head is not rotated fully towards the operating side by anaesthetist. The two ends of the muscle are now sutured together as a tube to maximally lengthen the muscle. Fibrous bands, fascia and strap muscles are released as necessary to obtain complete range of motion. All the dissection is done by careful blunt dissection to minimize soft tissue injury. Meticulous haemostasis is mandatory to avoid haematoma formation which may later form fibrous bands. Drains were not used to avoid scarring. Skin is closed with absorbable sub-cuticular stitches. Halter’s traction with pillow support is applied for three days. Usually by this time pain will have minimized and stretching exercises are begun by the therapist. Mother is taught how to turn the face towards the operated side and bend towards the opposite side with slight vertical traction. Children were allowed home when parents have learnt to perform the exercises.

Results:

All the 39 patients who had undergone the procedure successfully were followed up for over two years. Excellent to good results were obtained in 30 cases with correction of head tilt and restoration of neck movements. Scar has been inconspicuous in all cases. Lateral fibrous brands have however appeared in 5 cases. Most importantly the sternomastoid column has been maintained improving significantly the cosmetic result.

Conclusion:

A new method of correction of muscular torticollis by elongation of sternomastoid is described. Deformity can be fully corrected with restoration of neck movements. Cosmetic appearance is improved by the retention of sternomastoid column as compared with the sternomastoid release.

8. Corelation Between Forefoot Addcution & Hidnfoot Varus In Children With Clufeet Treated With Ponseti’s Method

Dr. Taral Nagda, Dr. Shailendra Telang, Dr. Vikas Trivedi
Department of Orthopaedics KEM Hospital Parel Mumbai India

Introduction:

Ponseti’s method for correction of clubfoot is based on the assumption that correction of forefoot adduction & manipulation of forefoot into abducted position with fulcrum on talus causes derotation of calcaneum along the transverse axis & corrects calcaneal varus. Although he demonstrated this with foot models & fluoroscopy, there is no documentation of this fact in literature. We conducted a study to clinically correlate the correction of forefoot adduction & its relation to passive correction of heel varus in children with clubfeet treated by Ponseti method.

Materials & Methods:

15 children with 19 feet were included in this study, over a period of 6 months, using the Dimeglio’s & Pirani’s methods for assessing the clubfoot deformity while treating the children with Ponseti method of clubfoot correction. FFA (forefoot adduction) was measured by forefoot score of Pirani’s method & by forefoot adduction score in Dimeglio’s method. All the readings were taken independently by 2 examiners & each reading was taken twice to reduce the inter & intra observer variability. The measurements were done at the beginning of treatment & before each plaster session.

Results:

Out of the 19 feet which underwent total midfoot correction, the varus deformity was corrected in the same sitting of plaster as total midfoot correction in 10 feet i.e. 52% & within one sitting of each other in 7 feet i.e. 37%. Our statistical analysis shows that the Pearson correlation coefficient is 0.84 & there is positive correlation between these two parameters.

Conclusions:

There was significant correlation between correlation of FFA & heel varus as demonstrated by Dimeglio scoring method.
There was significant correlation between correction of FFA & heel varus as demonstrated by forefoot score of Pirani’s method & heel varus score of Dimegio score
Thus we can conclude that with the Ponseti technique of clubfoot correction, the varus deformity corrects itself while the FFA is being gradually corrected by manipulation.

9. Correction Of Foot Deformities In Dysplastic Syndroms

Dr. Renjit A Verghese, Dr Benjamin Joseph.
Paediatric Orthopaedic Service, Kasturba Medical College, MANIPAL

Introduction:

Unusual and sometimes severe deformities of the foot and ankle occur in association with skeletal dysplasias and other syndromes. Very little information is available in the literature on how to deal with some of these problems. One has to often improvise in these situations. We describe foot and ankle deformities encountered in Reinhardt-Pfeiffer’s mesomelic dysplasia, Larsen’s syndrome, Grebe’s chondrodysplasia and Furhmann’s type of multiple synostoses syndrome. The outcome of surgery to deal with each of these cases is presented.

Material & Methods:

A girl with Reinhardt-Pfeiffer dysplasia had severe ankle valgus. This was treated by a combination of a supramalleolar osteotomy and screw epiphyseodesis of the distal tibial growth plate.
A girl with Larsen’s syndrome had severe valgus of the ankle in association with a ball-and –socket ankle joint and fibular hypoplasia. This was treated by fibular lengthening, supramalleolar osteotomy and screw epiphyseodesis of the distal tibial growth plate.
A boy with Grebe’s chondrodysplasia had bilateral fibular hemimelia and valgus deformities of the ankles. Postero-lateral soft tissue release was performed to improve the ankle alignment.
A boy with Furhamann’s type of multiple synostoses syndrome had a ball-and-socket ankle joint with hindfoot varus and marked forefoot inversion. This was treated by a lateral displacement osteotomy of the calcaneum and a mid-tarsal lateral rotation osteotomy.

Results:

In all these cases the deformities improved and a plantigrade tread was restored.

10. Dysplastic Diseases Hip Treated By Open Reduction And Capsular Re-Inforcement – An Overview

Prof. N.K. Das
The Institute of Child Health, Kolkata

Dysplastic diseases of hip is relatively rare in our country. Detection of unstable hip at birth very often missed due to inadequate infractureal facilities. Therefore late presentation with frank (location we have to encounter in our practice which need surgical intervention. In this paper dysplastic diseases of hip treated by open reduction and capsular reinforcement using slivers of bone graft taken from dorsal aspect of ilium keeping its distal attachment intact is discussed. During the period between 1996 and 2002, altogether 32 patients were treated by this technique. Age of institution of treatment varied between 11 months to 4 years 6 months. 23 patients were female and 8 had intrinsic variety. 22 patients properly followed for more than 2 years is included in this study with average follow up of 3 years 2 months.

In 18 cases stable reduction w~: achieved and maintained. Increases reduction partially failed but roofing effect of graft used provided support to the femoral head from slipping out of the acetabular socket. In some cases external rotation was restricted in terminal paJ1 and m2 case fragmentation of femoral head was noticed.

As graft taken dorsal aspect of ilium keeping its distal attachment intact and placed over the repaired capsule following open reduction of hip, the capable became reinforced augmentation of acetabular roof was there increasing the depth of acetabular socket and better graft incorporation is expected due to its intact distal attachment. For the reasons is technical easier procedure provides satisfactory end result.

11. Easy Approach To Mild / Moderate CTEV

Dr. HS Verma, MS, PhD, Associate Professor
NSCB Medical College, Jabalpur

Management if CTEV, has always been a topic of lively debates in orthopaedic circles. In order to get long term results the treating surgeon must have thorough understanding of the pathophysiology of the disorder and ‘should be conversant with array of operative and nonoperative treatment modalities available’.

We managed 84 cases of “mild to moderate CTEV by P.M.S.T.R. using a new simple twin incision. Residual forefoot adduction was corrected by cuboid enucleation in 8 patients. The results were accessed, by clinical ~ radiological and patient satisfaction criteria.

There were 61 excellent results, 22 good results and 4 failure cases at a follow-up of 24 to 60 months. The incision provides excellent exposure, through which all vital structures can be identified and good deformity correction achieved. The neurovascular structure are not at pevil, anytime during surgery. Moreover the incidence of wound dehiscence is almost nil, the scar cosmetically excellent and the procedure is short.

We recommend this procedure in mild to moderate cases of CTEV not responding to conservative treatment.

12. Modified Miyaki Procedure For Open Reduction Of The Hip – A Preliminary Report

Dr. Sivaramakrishna, Dr Risha Madhuri
Department of Orthopaedics Unit 2, Christian Medical College and Hospital, Vellore, India

Miyaki procedure is described in Japanese literature and consists of a circumferential release of the hip capsule and muscle through an extended Bikini incision. The described advantages of this are good postoperative stability, avoiding shortening and varus osteotomy of the femur and less need for the secondary acetabular procedure. Modification of this procedure involved modification of the incision, and the extent of muscular release.

We have carried out 12 modified Miyaki procedures in 10 children without additional bony procedures in the late presenting DDH between 1.5 to 3 years. The minimum duration of follow up is one year. The most significant change noticed in this in contrast to the standard technique is the ease of reduction and marked improvement in stability after reduction obviation the need to consider a secondary femoral or acetabular procedure. There was no avascular necrosis in this age group.

The preliminary results suggest that modified Miyaki procedure appears to be a better technique for open reduction in this age group.

13. Non-Union In Osteogenesis Imperfecta

Dr. Vineet Agarwal, Dr. Benjamin Joseph
Paediatric Orthopaedic Service, Kasturba Medical College, MANIPAL

Introduction:

It is often assumed that healing of fractures in osteogenesis imperfecta (OI) proceeds normally. However, we have encountered delayed and non-union of fractures in children with OI. This prompted us to undertake this study to 1) identify the frequency and pattern of non-union of long bone fractures in OI and 2) to analyse the results of our attempts at obtaining union in three cases of non-union.

Methods:

Case records and radiographs of 44 patients with OI treated over the last 15 years were analysed. Cases presenting with established non-union and hose who had delayed healing of osteotomies were identified. The nature of the non-union and the variables that may have contributed to delayed fracture healing were analysed. The methods adopted to achieve union of long-standing gap non-union of the humerus, in three children, were recorded and the outcomes of these procedures were analysed.

Results:

We identified eight nonunions in seven patients from a population of forty four patients with OI. There were five humeral, one femoral, one tibial and one ulnar nonunion in these seven patients. Six of these non-unions were atrophic, and two were hypertrophic non-unions. Four of these non-unions, (1 femur, 1 tibia, 1 ulna, 1 humerus) developed as a result of osteotomies performed for intramedullary rodding. The other four were established cases of non-union noted at the time of presentation.

We attempted to restore bone continuity in three patients with humeral non- unions. In one patient, autogenous bone grafting failed to achieve union. A second attempt with maternal bone graft supplemented with external and internal fixation again failed. In another child, two unsuccessful operations were performed and in the third child one attempt at obtaining union failed.

The non-unions noted following osteotomies are all asymptomatic and the intramedullary rod appears to have provided sufficient stability. None of these were re-operated.

Conclusions:

Non-unions following spontaneous fractures of long bones in OI appear to be most common in the humerus. One an atrophic non-union develops in OI it is difficult to achieve union. Hence every effort must be made to prevent them by adequate immobilization once a fracture occurs. Non-unions following osteotomies appear to be more innocuous provided an intramedullary rod is retained in the bone.

14. Outcome Evaluation In Clubfoot

Dr Sandeep Munsi, Dr Renjit A Verghese, Dr Benjamin Joseph
Paediatric Orthopaedic Service, Kasturba Medical College, MANIPAL

Introduction:

Several scoring systems have been used to evaluate the results of treatment of congenital clubfoot. Each of these scoring systems gives weightage to different aspects of the deformity and function of the foot. As a consequence, is it possible to compare results? This study was undertaken to compare the different scoring systems reported in the literature.

Methods:

34 feet in children who had been treated for clubfoot either surgically or by non-operative treatment and who had a minimum follow-up for two years were included in the study. Each foot was evaluated by the following scoring systems by the same investigator. The scoring systems used were those of McKay, Magone, Laaveg and Ponseti, Ghanem and a system developed at our center. The scores of each of the scoring systems were then compared. Spearman’s rank correlation coefficients were calculated to compare the scores of each system. The feet were then classified as excellent, good fair and poor based on the criteria of each system. The grading of each system was then compared by computing the Kappa statistic.

Results:

There was good, significant correlation between all the scoring systems with Spearman’s correlation coefficients ranging between 0.7 and 0.9. However, when the Kappa statistics were compared, very poor agreement was noted between some of the scoring systems. In particular, Laaveg & Ponseti scores did not tally with the score of other systems. The reason for discordance was on account of the disproportionate weight being given to some variables in different systems. A closer look at the relationship between functional outcome, deformity correction and radiological outcome revealed that there was poor correlation between them.

Conclusion:

Valid comparison of outcome of treatment of clubfoot of different series cannot be made unless the same scoring system is used.

15. Outcome Evaluation Of Clubfoot Treatment Using Internatinal Clubfoot Study Group (Icfsg) Criterfp: Is

Dr Alaric Aroojis & International Clubfoot Study Group Holy Family Hospital & Children’s Orthopaedic Clinic, Mumbai, India.

Purpose:

To evaluate the medium-term results of surgically operated clubfeet using the Outcome Evaluation criteria of the International Clubfoot Study Group (ICFSG).

Patients And Methods:

37 consecutive children (53 feet) who underwent surgical release of clubfoot deformity by a single surgeon between 1996-97 were recalled for follow-up at an average duration of 68 years (range: 6.2 years – 7.6 years) post-surgery. There were 14 unilateral and 12 bilaterally operated feet. Patients underwent a variety of soft-tissue and / or bony procedures including posterior release, posteromedial lateral release lateral column shortening procedures etc as per the pre-operative requirements. All feet were scored by a single observer using the newly established Outcome Evaluation criteria of the International Clubfoot Study Group (ICFSG). Feet were scored on Morphology (12 points); Passive joint motion (6 points); Muscle function (16 points); Dynamic function (11 points); Pain (3 points) and X ray evaluation (12 points) for a total score of 60 points. Results were classified as Excellent (0 – 5 points); Good (6 – 15 points); Fair (16 – 30 points) or Poor (>30 points).

Results:

There were 3 excellent, 28 good, 6 fair and 2 poor results. On analysis of results, it was evident that feet which were operated earlier ((<)1 year of age) scored better on final evaluation, especially with regard to foot morphology and supple joint motion. However, even surgery at a later age did not preclude a good result. Mild to moderate forefoot adduction was the commonest residual deformity seen in 12 of 38 feet. Detailed analysis of results will be presented.

Conclusion:

The Outcome Evaluation criteria established by the International Clubfoot Study Group (ICFSG) is a comprehensive method for evaluating medium–term results of surgical treatment of clubfoot. Emphasis is given not only to foot morphology but also to functional evaluation of joint motion, muscle function, gait and radiological evaluation. Our medium-term results indicate that surgical treatment of clubfoot can yield excellent to good scores using this evaluation system. Further follow-up till skeletal maturity will be necessary to ensure maintenance of these results.

16. Role Of MRI As a Preoperative DFP: Iagnostic Tol In DDH

Dr. Harsimran Sing, Dr Shuvendu Prosad Roy, Dr Paramjeet Sing, Dr SS Gill
Dept. of Orthopaedics and Dept. of Radio diagnosis, PGIMER Chandigarh

Eleven cases of unilateral DDH who attended the Department of Orthopedics, PGIMER, Chandigarh during July 2002 to December 2003, included in this prospective study. Mean age of these patients was 24 months during presentation. We did: MRI with T 2 coronal and transverse section and evaluated the changes of capsule, labrum, ligamentous teres, pulvinar, psoas tendon, femoral head and acetabular cartilage, which are the major parameter predicting reduction. These patients were subsequently operated on the next day. And the same parameters as predicted in: MRI are particularly noted during surgery.

We found that the MRI finding regarding the soft tissue and cartilage of dysplastic hip were nearly 90% correlating with preoperative finding and very helpful regarding decision making during surgery so as to what structure surgeon should give more attention for reducing the hip.

Though MRI is a expensive procedure it has potential to enhance proper soft tissue details of dysplastic hip. In addition it is noninvasive and non-ionizing procedure.

We conclude that: MRI could be very informative preoperative diagnostic modality in the management of DDH, particularly when the cases are considering for open reduction.

Key word: DDH, MRI

17. Rotation Fasciocutaneous Flap For Neglected Clubfeet – A New Technique

Dr Vikas Trivedi, Dr Alaric Aroojis, Dr Harold D’Souza, Dr MG Yagnik
Bai Jerbai Wadia Hospital for Children, Mumbai, India

Introduction:

Skin necrosis and wound problems are dreaded complications after the surgical release of severe, neglected and recurrent clubfeet. This is primarily due to excessive tension on the skin edges and a poor understanding of the abnormal vascular anatomy in clubfoot. We report a technique of primary skin closure using a local rotation fasciocutaneous flap.

Technique & Results:

The incision used is similar to the posteromedial incision described by Turco. The posterior tibial artery perforators supplying the medial skin flap and the long saphenous vein are carefully preserved. A posteromedial release is carried out in the conventional manner. One the deformity is fully corrected, a defect appears in the incision and the entire medial fasciocutaneous flap is rotated inferiorly to cover the defect. The triangular defect appearing proximally is sutured lightly or covered with a skin graft. This technique was used in 60 feet (44 patients) with severe, rigid clubfeet. Primary uncomplicated wound healing was achieved within 2 weeks in all 60 feet.

Discussion:

The success and validity of this flap is based on a combination of factors: using a full-thickness local fasciocutaneous flap which preserves the suprafascial and subdermal arterial plexuses, preservation of the septocutaneous perforators of the posterior tibial artery which supply the flap, preservation of the saphenous vein and accompanying perivenous capillary network, and respect for the angiosome areas of the foot. This flap is scientifically logical, technically easy and ensures primary wound healing after correction of severe, rigid and neglected clubfeet.

18. Significance Of Radiographic Angle Measuremens In Evaluation Of Congenital Club Foot Treated With Postero-MEDFP: IAL Soft - Tissue Release

Prof. SS Gill, Dr Ramesh K Sen, Dr Prabhudev Prasad AP.
PGIMR, Chandigarh

Postero-medial soft-tissue release is a common surgery performed for the correction of clubfoot. The results of this surgery are usually good. The results of PMSTR during follow-up are assessed by various methods like clinical (Functional) and radiological. Numerous formal, positional and angular foot skeleton deviations have been described in radiographic evaluation of congenital clubfoot.

We in our study to correlate the functional outcome with the radiological findings after a minimum of 1 year after the surgery. Our study involved 32 cases of congenital clubfoot in 20 patients of which 18 were male and 2 were female patients. Twelve of the cases were bilateral and 8 were unilateral and the age group of the patients varied from 2 to 17 years. Only the type II clubfoot according to Lehman’s classification i.e. the congenital clubfoot without any associated anomalies were considered for the study. Clinical follow-up examinations followed the functional rating system of Laaveg and

19. The Mirror Foot – Management Of Five Cases

Dr Vineet Agarwal, Dr Glesson Rebello, Dr Narasimha Rao KL, Dr Renjit A Verghese, Dr Benjamin Joseph
Paediatric Orthopaedic Service, Kasturba Medical College, MANIPAL

Introduction:

The mirror foot is a distinctly uncommon form of polydactyly. Most reports of mirror foot deal with the genetics of the deformity and its association with other congenital anomalies. There are very few treatment recommendations for this uncommon anomaly, which has both aesthetic and functional implications. In the majority of instances the limb was amputated. Reconstructive procedures with limb preservation were reported infrequently. We present our experience with limb-sparing reconstructive surgery in five children with mirror feet and associated major limb anomalies.

Materials & Methods:

Associate skeletal and visceral anomalies were identified in each child. The stability of the hip, knee and ankle on the affected side was assessed. The level of function of the quadriceps mechanism was evaluated. The technique of reconstruction varied according to the nature of anomalies encountered. In general, centralization of the available bone in the leg was achieved and the ankle was fused. Post-operatively an orthotic appliance was used while walking.

Results:

Each of these patients had different patterns of associated skeletal anomalies. The skeletal anomalies of the lower limb included congenital dislocation of the hip in two children, tibial agenesis in all five children, fibular dimelia in three. In one child the hands had complex syndactyly very similar to that seen in Apert’s syndrome. All five children are now ambulant with orthotic support.Based on our experience and excerpts from the literature we present algorithm of treatment of mirror foot and its associated anomalies.

20. Treamtment Of Congenital Pseudoarthrosis Of TIBFP: IA By Ilizarov Technique

Dr. Rutam Kulkarni
PGI Swathyayog Pratisthan, Miraj

Keyword: Periosteum And Bone Grafting, Intramedullary Fixation

Introduction:

CPT remains one of the least understood, most complex & most difficult to treat of all orthopaedic problems. Purpose of this study is to assess the results of Ilizarov method and to study the various factors affecting the outcome. We also analyzed our failures and studied the etiology of complications like re-fracture.

Material:

We have treated 32 cases of CPT by Ilizarov technique since 1992 to 2003. The age group varies from 9 months to 35 years. Follow up ranges from 3 months to 1 year. Mean follow up is 5.8 years. 16 cases were of dysplastic type, 6 were cystic, 2 late onset, 5 anterolateral bowing and one club foot type. 28 cases were multiply operated.

Method:

In multiply operated patient and when bony ends are dysplastic, we resects the pseudoarthrosis and required length of fibula. Then we apply the fixator and do acute docking at fracture site and corticotomy in proximal metaphysis. We also do bone grafting and grafting of periosteum from iliac bone. We fix the tibia by intramedullary wire & fix the fibula as well.

Results:

We have analysed our results according to Morrissy rating. We have had 2 excellent 15 good 9 fare and 4 poor results. One is still under treatment and in one patient treatment was abandoned. We had 14 re-fractures. All but one united with re-application of fixator.

Conclusion:

Results are better above 4 years of age. Bone grafting, periosteal grafting and intramedullary fixation improve the outcome. Re-fractures are higher in dysplastic type. Main cause is residual deformity. It should be treated by re-application of the fixator.

21. Trends In The Management Of Idopathic Clubfoot – Analysis Of A Survery Of 40 POS

Dr Benjamin Joseph, Dr Gleeson Rebello
Paediatric Orthopaedic Service, Kasturba Medical College, Manipal

Introduction:

While observing different orthopaedic surgeons deal with clubfoot, we have had the impression that no two surgeons have identical approaches to the management of clubfoot. This study was undertaken to verify this impression.

Methods:

A questionnaire was designed to solicit information regarding specific approaches to non-operative and operative management of idiopathic clubfoot. There were 21 questions related to non-operative management and 31 questions related to surgical treatment. The questionnaire was administered to 40 paediatric orthopaedic surgeons. 18 responders were members of POSI to whom the questionnaire was mailed. The remaining responses were obtained from those who attended the annual meeting of the Australian Paediatric Orthopaedic Society and the New Zealand Paediatric Orthopaedic Society. The responses of all 40 surgeons were then analyzed to identify trends in management of clubfoot.

Results:

The approach to both non-operative and operative treatment of clubfoot varied profoundly. Absolute agreement of all respondents was noted only in one single issue related to operative treatment. Discordant views were noted for all other 51 variables.

Conclusion:

In view of such divergence in approaches to treatment, any report of outcome of management of clubfoot must be interpreted in the light of the exact procedures followed.

22. Triple Arthrodesis – A Retrospective Assessment / For Eequnino Varus Deformity In Neglected Club Foot / Paralytic Deformity

Dr Manishi Bansal, Dr Bhasker Banerji
Bhasker Orthopaedic Centre, (Gaurav Clinic), 4 Bandh Road, Allahabad

Aims & Objectives:

A retrospective analysis of Triple Arthrodesis in the management of Equino Cavo Varus in Neglected Club foot and Paralytic Deformity has been done and analysed.

Material and Method:

A total of 16 cases were selected of which 8 were of neglected club foot and 8 were of paralytic equinovarus foot, was operated on after failure of conservative treatment either in the form of pop correction or surgery. They were followed up to a period between 36 to 48 months. The results were analysed.

Observation:

Of total, 2 cases were lost to follow. 16 cases were followed of which 8 were post paralytic and 8 were neglected clubfoot with equal proportion of male and female with average age group between 6 to 8 years of age. Pts were analysed subjectively on the basis of pain and gait and objectively on the basis of correction. In 1 patient there was pain at the talonavicular joint because of improper fusion of talonavicular joint.

Summary and Conclusion:

It seems to be an effective method of treatment of the neglected and paralytic failed treated cases of club foots.

Infection & Arthropathy

1. Arthritis Of Largetreatment Of Inadequately Treated Septic A Joints In Infants – Our Experience.

Dr Ramani Narasimhan, Senior Consultant,
Pediatric Orthopaedic Surgery, Indraprastha Apollo Hospitals, New Delhi.

Fourteen infants presented to us with long standing (> 4 weeks) large joint infection affecting hip, knee or shoulder (Ac Chronic Septic Arthritis). All had been managed outside surgically or without, and had been empirically treated with IV antibiotics for = 7 days, followed by oral antibiotics.

All presented with symptoms to us, with their latest blood work-up showing evidence of active infection. After documenting persistence of infection in the joint, all patients underwent arthrotomy and a thorough joint debridement, along with decompression of the adjacent long bone metaphysis. Materials for pus culture / sensitivity was sent in all, from 3 places, namely joint cavity, joint capsule & synovium and adjacent long bone metaphysis. The offending organism was isolated through culture in all patients and appropriate antibiotics were administered IV for 4-6 weeks, followed by oral antibiotic for 2 weeks. At the end of a year of follow-up, none had any evidence of active infection and ROM of the affected joint was comparable to the normal side. Twelve out of 14 patients were asymptomatic. Out of the two affected, one had osteomyelitis of the whole humerus which has affected the ROM of shoulder and elbow. The other presented with a pathological hip dislocation (post septic arthritis) which was reduced, but its ROM is affected.

2. Changing Epidemiology Of Neonatal Septic Arthritis

Dr Sanjay Yadav, Dr Shantanu Deshpande, Dr Taral Nagda
Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai

Introduction:

Septic arthritis is one of the diseases, which can have crippling sequalae. These sequelae can be prevented by early identification of suspects and prompt initiation of definitive treatment. Initial diagnosis and treatment depends of clinical suspicion, hematological and radiological findings. The factors affecting the prognosis are age, time duration between onset of symptoms and surgical intervention, and type of microorganisms. The microbiological spectrum of neonatal septic arthritis has been typically dominated by gram-positive cocci. There have been reports of a shit in the microbiological spectrum and epidemiology of this condition. We did this prospective study conducted at a single institution to assess the changing spectrum of bacteria, the associated risk factors, time between onset surgical intervention and relationships of these factors to the outcome.

Aim:

To study the changing epidemiological pattern of microorganisms as etiology of septic arthritis and to correlate it with the outcome of septic arthritis in terms of function of joint and morphology of joint.

Materials And Methods:

We have done a prospective study of septic arthritis of hip joint in 15 consecutive patients in neonatal age group (1 to 31 days) at our hospital admitted in neonatal intensive care unit between periods of 1999 to 2003. These patients have been primarily admitted for their associated clinical condition like neonatal asphyxia, sepsis, premature and low birth weight babies. These 15 children presented with very subtle signs of septic arthritis of hip initially. We did haematological investigations like CRP, ESR. Leukocyte count, Blood culture, Urine culture. Ultrasonography of hip was done in all patients of septic arthritis. The diagnosis of septic arthritis was made on the basis of clinical criteria of Morrey and associates, supported by raised CRP values, USG of hip and aspiration of joint fluid sent for bacterial and fungal culture. All 15 in our series were treated by arthrotomy by anterolateral approach after aspiration of purulent joint fluid. Postoperative drain was kept for 24 hours. All patients were protected in hip spica. All of these were followed over a period of time with a maximum follow-up of 4 years and assessed clinically for Range of motion of joint, Pain associated with function, Instability & Shortening of lower limb and radiologically for morphological changes in capital femoral epiphysis & acetabulum.

Results:

Mean age of neonates was 20.35 days. Out of 15 neonates 13 (87%) patients had primary septic arthritis while 2 patients had associated bony lesions in femoral metaphysis suggestive of probable osteomyelitis. We had 11 (73%) patients with prematurity and low birth weight.

All 15 patients were hospital-acquired infections. 86% patients had leukocytosis with increased polymorphs. 100% patient showed raised C-reactive protein (mean 86) and erythrocyte sedimentation rate (mean 56). Positive blood culture was seen in 7 (46%). The distribution of organisms was Gram-negative 4 (57%), Pseudomonas One (14%), Gram-positive 2 (29%). Joint culture was positive in 9(60%) and 6 patients had pus cells positive but no organisms grown at culture. The causative organisms were Staphylococcus aureus 3, Klebsiella 2, One each of Enterococcus, Proteus, Escherichia coli and Candida. Thus percentage of infection was Gram-positive 20%, Gram negative were 34%, 6% were Fungal and 40% were Culture Negative. Joint fluid culture and Blood culture correlated well only in 42.8% patients. Out of 15 in our series 3 patients were operated after 72 hrs due to late presentation to us. Rest 80% was operated as early as possible mostly within 48 hr. All 15 patients were followed at frequent intervals over a period of time, with maximum follow-up of 4 yrs (mean 2.4yrs). Clinically 80% had better outcome after early arthrotomy i.e. within 48 hours. 12 patients showed excellent joint function without any pain, instability & shortening. These patients had radiological normal joint. The radiological sequalae were seen in 3 patients who had arthrotomy after 72 hours. The sequalae being delayed calcification of head of femur, fragmentation of head, lateral avascular necrosis but there were no acetabular changes. Clinically these 3 patients had restricted range of motion especially rotations, associated with pain at extremes of flexion and internal rotation range but without any instability or shortening.

Discussion:

The septic arthritis of hip in neonate is a disease with severe long- term disability if not treated urgently. Prematurity and low birth weight predisposes child to frequent bacteraemia and hence septic arthritis. The epidemiology and natural history of neonatal septic arthritis is changing now due to early recognition & intervention.

The primary septic arthritis is on rise than secondary to osteomyelitis. We had only 2 patients with osteomyelitic lesion in femoral metaphysis. But as per literature septic arthritis is often associated with osteomyelitis. This is change is possibly because of early attention given to child and picking up of subtle signs. In our series 73% patients were premature and low birth weight and this is also a changing pattern. As more and more premature children are surviving with special care, multitude of procedures is required to help them grow. These children with underdeveloped hemato-lymophoreticular system development, gets bacteraemia often during hospital acquired infection. The chronic indwelling catheters, intravenous accesses and long hospital stay plays a significant role in causing bacteraemia. C –reactive protein and erythrocyte sedimentation rate were raised in 100% patients. CRP is time sensitive and is disease process indicator. It is raised immediately after infection and also reduces in value as the infection responds to antibiotic and settles down. It shows the downfall as early as 3rd day after arthrotomy whereas ESR takes 6 to 7 days to show a downfall and is reduced over a long period of time. So CRP helps to monitor patient regarding benefit of treatment & this is well supported by literature.

As per literature 40% patients had blood culture positivity except Lyon who has reported 21% positivity. We had 46% patients. The microbiology had gram-negative septicaemia most, followed by gram-positive sepsis. The joint fluid culture had shown different organisms that blood culture in 4 patients. But it is correlating well with type of infection in 3 patients. Hence in patients with no growth seen at culture from joint fluid, the blood culture organism and antibiotics sensitivity has definite role of probable aetiology.

Literature has reported the dominance of gram-positive cocci in causing infection. Tachdjian says Staphylococcus is second most common. Lyon has reported 80% of gram-positive infection. Edwards reported that prior to 1940 to 1970 staphylococcus aureus was major cause. After 1970, Group B streptococcus is the significant cause of neonatal septicaemia and meningitis and osetomyelitis.

But this microbial epidemiology is changing. In our series, joint fluid culture had shown 34% gram negative, 20% gram positive and 6% fungal. We had different gram-negative organism like Klebsiella, Proteus, and Eneterobactor, Escherichia coli. One should always try to remember the current epidemiological trends as this etiological shift has significant importance for antibiotic selection & early empirical coverage of spectrum. As early effective antibiotic therapy will be of help in prevention of further damage and maximum preservation of morphology of joint

In our series 3 patients has significant radiological sequalae following late arthrotomy. Out of 3, two had gram-negative organism in blood culture and in joint fluid culture. One had gram-positive organism in joint culture. Though literature has reported gram-positive cocci are more destructive because of kinases13 and proteases enzymes, the gram-negative organism are also capable of significant long-term sequalae as seen our series. So one should cover Gram-negative organisms in antibiotics and also try to search for them in culture. As per the literature the culture negative septic arthritis is between 18 to 48%. In our series it was 40%. But Lyon has reported 70% patients. We think that indiscriminate use of antibiotic before taking a sample for culture may mask the result.

In our series, 3 patients were operated after 72 of due to late presentation and all 3 had radiological changes and restriction of joint function. This is in contrast to literature by Paterson & Wilson who says that one can wait till 4 days with intravenous antibiotics and aspiration before deciding about arthrotomy. Hence we suggest Time of arthrotomy should be as early as possible on emergency basis.

Conclusion:

The disastrous consequences of septic arthritis in neonates can be prevented by early recognition and immediate arthrotomy of hip joint. The changing epidemiology of septic arthritis should be kept in mind to reduce the rate of disability. The changing patterns are:

More of primary septic arthritis than secondary and hence to identify septic process even in the absence of bony lesion on x-ray.
The aetiology shift to gram-negative organism in addition to fungal and gram positive should be always kept in mind for antibiotic selection and culture methods.
Immediate arthrotomy to drain pus from joint and not to wait fro more than 72 hours in view of strong clinical suspicion.
Better long term results with early surgical drainage and immediate antibiotic coverage.

3. Neonatal Bone And Joint Infections: Analysis Of Rsk Factors

Dr Atul Bhaskar, Paediatric Orthopaedic Surgeon
KJ Somaiya Hospital, Ayurvihar, Mumbai 22, India

Introduction:

Musculoskeletal infection in the neonates can have devastating sequalae. Establishing the diagnosis in this vulnerable age group poses the greatest challenge to all treating physician. A study of 20 children was carried out to analyse the risk factors, the causative organism and treatment received.

Patients & Methods:

20 children with established infection were reviewed. The mean age at infection was 25 months (7 days – 6 months) and there were 14 girls and 6 boys. 12 children were born premature and had prolonged hospitalization. The mean birth weight was 1.4 kg in the premature group. Eight children were born at term and the mean birth weight was 2.4kg(1.9-4.2) Three children in the premature group had exchange transfusion for neonatal hyperbilirubiunaemia 5 premature children had respiratory infection and neonatal septicaemia. Joints involved were as follows in the premature group 4 children had bilateral hip infection, 4 children had unilateral hip infection, 1 had knee sepsis had shoulder involvement respectively, and two children had multifocal (hip, knee, elbow) infection. In the term group 4 children had unilateral hip infection; two each had shoulder and knee sepsis respectively.

Results:

Six hips, two knees and one shoulder needed open drainage. Blood cultures were positive in 7 cases. In 6 cases the infection was diagnosed late with bone changes already established, four of these were premature children of the nine operative cases, pus culture revealed staphylococcus in 3 cases, Klebsiella in 2 cases, Pseudomonas in 1 case, E coli in 2 cases and streptococcus in one case. Blood culture was positive in 4 of the nine cases. C-Reactive Protein was positive in all cases and ESR was positive in 7 of the 13 cases.

Discussion:

Risk factors for neonatal infection include prematurity, low birth weight, duration of hospitalization, female sex and septicaemia. In the premature group there is more severe infection, with multiple joint involvement and higher chance for missed infection. CRP is a very sensitive indicator of infection in this age group.

Conclusion:

A high index of suspicion with routine examination of all joints should decrease incidence of neonatal infection. An elevated CRP must alert the treating physician of covert bone and joint infection.

Spine

1. Acute Traumatic Fp: Spinal Cord Injury In Children (Premiminary Report Of 29 Cases)

Dr Navnendra Mathur
H.O.D., Dept. of Physical Medicine & Rehabilitation & Rehabilitation Research Centre
S.M.S. Medical College, Jaipur

Acute traumatic spinal cord injury is uncommon. A retrospective study of acute 702 cases of acute traumatic spinal cord injury, who are admitted in the Department of Physical Medicine & rehabilitation between Jan. 2000 to Aug. 2003 are analysed for incidence, cause, type and paten of injury in childrens below the age of 15 years. In all there are 29 childrens, 15 in with cervical spinal cord injury and 14 with dorsolumber spinal cord injury. The incidence is 4% of all acute spinal cord trauma. Majority of them were male in cervical group and fall from height is the major cause of injury in both groups. Cervical 4-5 and T12-L, is the commonest site of injury resulting in complete neurological deficite below the site of injury in 33% cervical & 64% cases of dorsolumber group. The fall from height is the commonest cause of injury and it is difficult to identify the site and type of bony injury in children.

2. C1 C2 Facet Screws In Paedfp : Iatric Patients

Mulpuri K2, Reilly CW1,2, Tredwell SJ 1,2, Choit RL2
1. University of British Columbia, Vancouver, British Columbai, Canada
2. British Columbia’s Children’s Hospital, Vancouver, British Columbia, Canada

Introduction:

The aim of this paper is to review C1-C2 facet screw use in paediatric patients and to demonstrate that the technique plays an important role in patients with underlying anatomic abnormalities, which are common in children with cervical instability.

Material and Method:

A chart review was conducted of all patients managed with C1-C2 facets screws from Jan1, 1996 until July 30, 2003 present in the base database. All radiographs were obtained and reviewed. Post-operative and follow-up films were assessed for acceptable screw position and evidence of fusion.

Results:

C1-C2 facet screws were utilized in nine patients at British Columbia’s Children Hospital. The youngest patient treated was five years of age with a mean age for the group of 12. The group consisted of three Down syndrome patients and six with Os Odontoidium, two of which failed previous C1-C2 fusion. Two patients presented with an acute spinal cord injury. Pre-operative CT or MR imaging was used in all patients. Screw placement was unacceptable in one case. Post-operative Halo immobilization was used in seven patients. Post-operative complications included one wound infection and four halo pin infections requiring treatment. No patients have required surgery at a mean follow-up of four years. C1-C2 facet screws are an important adjunct in a paediatric spine practice. This technique has a great advantage in Down syndrome patients who have a high rate of pseudoarthrosis because of: ligamentous laxity, non-compliance with immobilization and a high incidence of congenital deformities such as os odontoidium and incomplete posterior arch of C1.

Discussion:

C1-C2 facet screws are an important adjunct in a paediatric spine practice. This technique has a great advantage in Down syndrome patients who have a high rate of pseudoarthrosis because of: ligamentous laxity, non-compliance with immobilization and a high incidence of congenital deformities such as os odontoidium and incomplete posterior arch of C1. This technique can be safely used in young patients and results in a high fusion rate.

Conclusion:

C1-C2 facet screws can be safely used for young children, promote fusion, and allow for fixation in the absence of an intact posterior arch.

3. Improved Survival In Patients With Scoliosis Secondary To Duchenne Muscular Dystrophy : The Role Of Fp: Spinal Surgery And Nocturnal Ventilation

J.S. Mehta, M. Eagle, M J Gibson, K.M. Bushby, J P Bourke, R Bullock
Freeman and Newcastle General Hospitals, Newcastle upon Tyne

Objective:

To assess the effect of spinal surgery and nocturnal ventilation on lung function and survival in patients with scoliosis secondary to Duchenne Muscular Dystrophy.

Study Design:

Prospective, observation study by a single observer.

Subjects:

91 patients with Duchenne Muscular Dystrophy were treated for spinal deformity between 1986 and 2002. During this period 39 patients underwent a spinal fusion at a mean age of 14.05y (95% CI 13.6 – 14.6) Nocturnal ventilation was commenced when symptoms and signs of respiratory failure were evident. The mean FVC at commencement of nocturnal ventilation was 0.4 liters. The patients were divided into 4 groups based on whether they received spinal fusion and / or nocturnal ventilation. In Group 1 were patients who had spinal surgery and were later ventilated (n-15). In Group 2 (n = 14) were patients who were ventilated but had not undergone spinal stabilization. Patients in Group 3 received neither ventilation nor spinal stabilization (n = 38). In Group 4 were patients who had spinal stabilization but were not ventilated (n=24).

Outcomes:

Serial forced vital capacity (FVC) measurements and survival measured by Kaplan Meir survival analysis.

Results:

The mean vital capacity dropped from 1.41 litre (95% CI 1.21 – 1.61) to 1.13 liters (95% CI 0.893-1.37), a year post-operatively. This was not associated with the development of respiratory compromise. The vital capacity improved gradually, reaching the pre-operative level before it declined again. The shortest survival was seen in patients who received neither surgery nor ventilation (median survival 17.1 y). The patients who received surgery but no ventilatory support (median survival 19.5y) were not as good as the patients that were ventilated but did not have surgery (median survival 22.2 y). The best results were seen in the patients who had both surgery and ventilation (median survival 27.6y). The worst prognosis was in patients with early onset symptomatic cardiomyopathy (6 patients, with a median survival of 16.3y).

Conclusion:

Nocturnal ventilation is the most important factor in the improvement in survival of patients with Duchennes muscular dystrophy. Spinal surgery is also beneficial and the best results are in those patients who have both.

4. Osteblastoma Of The FP: Spine In Children – A Report Of Three Cases

Dr Vijay Sriram, M.S.Orth, Dr K Sriram, F.R.C.S. Orth.
Kanchi Kamakoti Childs Trust Hospital, Chennai, India

Abstract:

Osteoblastoma of the spine is a rare primary bone tumor. We present three cases of histopathology proven Osteoblastoma occurring in the posterior elements of the spine in children. Two patients had involvement in the lumbar spine and in the third patient the dorsal spine was involved. All three patients had a painful scoliosis on presentation. All patients had relief of symptoms and spontaneous correction of the scoliosis following tumor removal. One of the patients had a recurrence and had to be operated upon again. An intra-lesional curettage is usually sufficient to cure this condition. Osteoblastoma is a benign tumor but can be locally aggressive. The recurrence seen in one of the cases is probably due to inadequate clearance during the first surgery. The clinical history, investigations, management and results are presented.

5. Sternal Split Approach To Cervical Thoracic Junciton

Mulpuri K2, Tredwell SJ1,2, LeBlanc JG1,2, Reilly CW1,2, Sajahal V1 , Choit RL2
1. University of British Columbia, Vancouver, British Columbai, Canada
2. British Columbia’s Children’s Hospital, Vancouver, British Columbia, Canada

Introduction:

The anterior approach to dealing with complex spinal deformities around cervical thoracic junction presents a surgical challenge. With the help of a cardiothoracic surgeon, a sternal splitting technique was utilized in six paediatric patients to resolve the difficulty and gain access to spinal deformities around the cervical thoracic junction.

Material and Method:

A longitudinal incision is made parallel to the sternocleido muscle and extended across the strernum for a median sternotomy. The sternocleido muscles are retracted to the lateral aspect of the incision. The carotid and jugular vein are dissected out. To continue with the dissection and exposure of the upper thoracic spine, a full sternotomy is done. The sternum is opened. The dissection of the right carotid is extended over the innominate artery including the bifurcation of the right subclavian artery. The jugular vein is dissected out coming down to the superior vena cava. The innominate vein is isolated. The lower end of the anterior scalenus muscle is divided up.

Discussion:

This approach was invaluable in gaining access to the cervical thoracic junction to address complex spinal deformities. Access to the lower cervical and the upper thoracic spine is granted. No significant complications occurred. The aid of a cardiothoracic surgeon is advised.

Results:

This technique was employed in 6 paediatric patients, aged 3-15 years, at the author’s institution. Diagnosis included Klippel-Feil Syndrome (2 patients), Proteus syndrome, Larsen Syndrome and, Neurofibromatosis type I (2 patients). All patients had severe cervical thoracic kyphosis requiring surgical instrumentation. This technique resulted in a range of access from C5 to T6 being granted. In one patient, a separate thorocotemy was performed in order to gain access to the lower thoracic spine.

Conclusion:

This sternal splitting technique resolves the surgical challenge of the anterior approach to dealing with spinal deformities around the cervical thoracic junction and provides good access to the lower cervical and upper thoracic spine.

Trauma

1. A New Design Of Stainless Stell Flexible Nails (N – Nails) For Femoral Shaft Fractures Of Children

Dr Navin N. Thakkar
Pragna Orthopedic Hospital, National Highway No.8,
Odhav, Ahmedabad, Gujarat, 382415

Introduction:

Intramedullary flexible nailing has become a preferred method for fracture of shaft of femur in children above the age of 5 years. Presently used flexible nailing systems of Enders and Titanium Elastic Nails have their own disadvantages. A new type of nail was designed in 1998 to overcome these disadvantages. This paper discusses the results achieved with this nail.

Methods:

28 children with fracture of shaft of Femur were admitted at author’ hospital from January 1998 to December 2002. All children were treated by stainless steel flexible nails (N- Nails). Age ranges from 6 to 15 years. This nail is a straight stainless steel nail. They are given special treatment to increase their flexibility. Nails are available in 2, 2.5, 3, 3.5 mm diameter. Nails are prepared only in one length (50 cm). Both ends have conical tip. All nails were introduced retrograde from lateral side under IITV control. Nails are bent near tip and general curve is given to get c or lazy s shape Two to four nails are passed depending on the size of medullary canal. Portion of the nail remaining outside the entry point was trimmed keeping 1 cm and is given knurling effect by small multiple cuts for easy removal later on. Average operating time was 45 minutes with c-arm exposure of 90 seconds. Patients were followed up at an average period of 12 months (range from 6 months to 18 months). They were assessed clinically for range of movement, pain, and deformity and radiologically for union.

Results:

Rate of union was 100%. Range of movements and functional results were flexible nailing of Enders and Titanium Elastic Nails and also offer other advantages.

More flexibility with stability.
Intra-operative surgical latitude of bending, diameter, length
Path finder conical tip at both ends glides easily in canal-can make two out of one
Cost effective for average Indian patient as one nail costs Rs.150
So this is recommended as economical alternate method with more advantages of flexible nailing for treatment of diaphyseal fractures of femur in children.

2. Review Of Comparative Analysis Of Close Reduction With Cross Pin Fixation And Manual Reduction With Pop In TT of SIC # Humerus In Children

Dr SK Singh
Orthopaedic, Spine & Joint Replacement Surgeons
APEX Hospital, DLW Hydel Road, Varanasi

Supracondylar # of humerus is most common # around the elbow joint in children. Supracondylar # of distal humerus accounts for >60% of all the # about Joint. Immobilization in cast as conventional method of managing the undisplaced # is good but there is controversy regarding the best treatment for displaced fracture. The preferred treatment for this is closed reduction and perautaneous pinning. The challenge therefore in treating SIC # is not only in achieving good reduction but in maintaining the reduction in position while the # heals. The Close Reduction under IITV and Pin fixation is the present example of modifications in the surgical technique and exhibitation of craftism which now should be practiced more frequently not truly for better result in term of union but for early recovery and comfortability of patient.

Materials and Methods:

From December 1999 to December 2003, 96 Pt. Were studied prospectively. There were 75 male and 21 female mean age 7 years (3-13). There where 92 extension type and 2 flexion type R. Elbow was involved in 68 cases and left elbow in 28 cases. Closed reduction under general anesthesia and percutaneous cross k-wire fixation under C-Arm control taking care of nerve, patient were discharged other 6 hr. of observation while in MR and POP patient were discharged on next day but with observation other 7-10 days & POP off at 3-6 week as per age of patient.

Results:

Assessment was done on the basis of FL YNNS CRITERLA out of 96 cases –09% cases had excellent results 28% cases had good result the overall good to excellent results in our study suggest that maintenance of anatomical reduction is more important that other factors. Good anatomical reduction results in good functional outcome on comparing the effected arm with control arm objectively and subjectively showed excellent results. In remaining 3% minor problem of Blister, temporary ulna neuroproxia & Pin site infection seen which had no permanent problem.

Discussion:

Extension SIC # Humerus are the most common # around the elbow in children. Different methods of treatment for displaced SIC # have been practiced. Skin or skeletal traction requires a longer period in hospital at and does not provide any advantage over immediate manual reduction with POP cast which deprives the patient for movements around the elbow joint for 3-6 week and neither pre disposes for ma union. Primary CR and precentaneous k-wiring is the preferred treatment for displaced# humerus as it is less invasive, holds the fragment, cost effective, less hospital stay, early mobilization and minimal chances of mol union, non unio and angular deformity, which is very common in the conventional method of MR with POP Cast.

3. Closed Intramedullary K-Wire Fixation Of Femoral Shaft Fractures In Children

Dr Rakesh Chandra, Dr O.P. Vishwakarma, Dr S.C. Gaur
Allahabad

Fifty cases of Fracture Shaft femur in children were treated by closed reduction. under image intensifier and fixation with intramedullary cross K-wire placed from lower and of femur, children were in age group of 5-12 years with twenty five transverse, fifteen short oblique, four long oblique and six communited fractures. All fracture united, but 8 cases had shorting of 0.5 to 1.5 cm, 10 cases had angulations of 50 – 100. 10 cases had mal-rotation of 50-120, 2 cases had local infection. No case had a vascular necrosis of head of femur in follow up of 6 month to 5 years.

4. Closed Reduction And Percutaneous Kirschner – Wire Fixation Of Difp: Splacedsupracondylar Fractures Of The Humerus In Children

Dr. C.M. Badole, Dr Rahul Singh
Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha 442102 Maharashtra, India

Introduction:

Displaced types of Supracondylar fractures of humerus have always presented a challenge in their management. Different lines of treatment have been reported.

Material & Method:

Clinical material consists of 29 cases of displaced supracondylar fractures in children reported, between July 1998 to March 2001 in Department of Orthopaedics, MGIMS, Sewagram.

Result:

Common age group 6 to 9 years, Left elbow involved commonly, Male were predominant, 4 children had nerve injury, Extension type of fracture seen commonly, minimum of 2 and maximum of 3 K-wire used for fixation, All fractures had radiological union within 3 to 6 weeks after which K-wire were removed and physiotherapy advised. Result were graded as per Flynn’s Criteria & 96. 15% had satisfactory and 3.85% had unsatisfactory.

Discussion:

Present study results were compared with the result of other studies and found comparable results. Considering the final carrying angle & range of motion which were considered for the follow up for the final result 24 (85.72%) children had excellent, 3 (10.71%) had good and 1 (3.57%) had poor result.

Conclusion:

This method is safe even in presence of swelling with shorter hospital stay with consistently satisfactory result considering cosmetic and functional result for those who are willing to become proficient in the technique this method will be nearly ideal for management of displaced supracondylar fracture in children.

5. Comparative Study On Two Methods Of Percutaneous Pin Fixation In Difp : Splaced Supracondylar Fractures Of Humerus In Children

Dr Agus Iwan Foead (Masters Ortho, U Malaya), Dr Robert Penafort (Masters Ortho, U Malaya), Dr Saw Aik FRCS (Edin.), Dr Subir Sengupta (FRCS Edin.)
Deptt. Of Ortho. Surgery, University Malaya Medical Centre, 59100 Kuala Lumpur, Malaysia.

Introduction:

Complications in the treatment of displaced supracondylar fractures of humerus in children by percutaneous pin fixation are still a problem. Medial-lateral pin fixation is stable but ulnar nerve may be injured by the medial pin. Two lateral pin-fixation poses less risk to ulnar nerve but is mechanically less stable.

Material and Method:

a prospective randomized controlled study between the 2 methods of fixation was conducted on 66 children. None weeks postoperatively, radiograph examinations were taken to measure the Baumann angle, Medial Epicondylar Epitrochlear (MEE angle. Clinical measurement of carrying angle, degree of flexion and extension were made when the range of elbow motion is comparable with that of the opposite side.

Results:

The mean period of follow up was 7.7 months. Postoperatively, there were seven ulnar nerves and one radial nerve injuries. Five of these ulnar nerves injuries were approached by medial – lateral pin fixation; Two ulnar nerve and one radial nerve injuries were approached by two lateral pin fixation. Difference in Baumann angle, MEE angle, carrying angle, degree of flexion and extension between the affected elbow and normal opposite side showed no significant difference.

Conclusion:

Both methods of fixations provide adequate stability for bone healing in the treatment of supracondylar fracture of humerus in children. Although there were more ulnar nerve injuries in medial-lateral pin fixation group, it was not satisfactory significant.

6. Delayed Open Reduction Internal Fixation Of Supracondylar Fracture In Children

Dr Ebrahim Chaem Hasankhani

Objective:

To determine The Clinic and radcagraphic out come (Specially range of motion of elbow joint and myositis assifican) Following delaied (8-18 days after fracture time) open reduction and internul foxation of Supracondylar Fracture of humerus in children.

Design:

Prospective Study Setting: The Orthopaedic department of shahid Kamiab University hospital.

Patients:

Ninety–eight consecutive patients with supracondylar Fractures of humerus seen between 199-2002.

Interventions:

Early and late open reduction and internal Fixation of Fractures, Followed up by radiographs and clinic. Main out come.

Measures:

Range of motion of elbow joint, deformity, myositis ossifican, neuro vascular disorder and infection.

Results:

In patients with early O.RI.F. the results were as follows: movement Disorder of elbow joint (Gruber & Healy score) (Excellent 48/7%, Good 31/6%, Fair 13/45%, poor 6/6% Deformities 5/2%, infection (superficial) 7.9% , Neurovascular disorder and myositis ossification not seen in patients with late O.R.I.F. The results were as follows: Movement disorder in elbow joint (Gruber & Healy score) (Excellent 45/5%, good 31/8%, Fair 13/6%, poor 9/1%), deformities 4.5%, infection (Superficial 13/6%, Neuro vascular disorder and myositis ossification not seen.

Conclusion:

By taking into consideration of results specially this Fact that in patients with late O.R.I.F., Myositis ossifican has not been seen, it is believed that supracondylar fracture of humerus in children can be treated surgically after one week (Late O.R.I.F.)

7. Femoral Neck Fracture In Children

Dr Protyush Chatterjee, DORTH, MS (ORTH), Consultant
Dr Suhas Bala, Ms (Orth), Consultant, Dr Sailendra Bhattacharya, FRCS, Director BORRC, Kolkata

Femoral neck fracture in children is a rate injury. One surgeon in his life time, may not treat many cases. Yet the challenges are formidable. Non union, late coxa vara, osteonecrosis, leg length discrepancies are to mention a few of the complications. Another unique complication is that the initial good result deteriorates in adulthood. Thus, collective wisdom and sharing of knowledge is essential which will act as a guiding force for satisfactory outcome in future.

At Bhattacharya Orthopaedic & Related Research Centre in Kolkata (BORRC), five paediatric femoral neck fractures were treated from January, 1999 to December 2002. Another five cases were collected from different surgeons in Kolkata who treated such patients during this period Only two of them were girls, the age varied from 11 years to 17 years (mean 14.8 years). According to Delbet classification, one was Type I, four Type II, two Type III and three Type IV. All were treated by internal fixation. In all but one case, hip spica plaster cast was applied post operatively and kept for 6 – 8 weeks. We present our results of these ten cases.

8. Long Arm Cast In Extension For Forearm Fractures In Children

Dr Alaric Aroojis, Dr Manoj Singrakhia, Dr Shantanu Deshpande, Prof. Kaye Wilkins
King Edward VII Memorial Hospital & Children’s Orthopaedic Clinic, Mumbai, India

Purpose:

To study the efficacy of long arm cast with elbow in extension for treatment of unstable forearm fractures in children.

Patients and Methods:

60 consecutive children of age < 16 years, presenting to the Trauma Center of a tertiary care Trauma Level I teaching hospital, with displaced or angulated forearm fractures were randomly assigned, after closed reduction under anaesthesia / sedation, to either of 2 groups. Group I: Long arm cast with elbow in flexion; Group II: Long arm cast with elbow in extension. All children were followed up at 1-, 2-, 4-, 8-, 12- weeks, 6- and 12 months, clinically and radiologically to note for re-displacement or re-angulation within the cast. Limits of acceptability were set at (<)10-150 of angulation and (<)30-450 of malrotation. Elbow ROM and forearm rotations were measured after cast removal and on follow-up.

Results:

There were 30 patients in each group and both groups were matched for age, type of fracture and pre-reduction angulation / displacement. After reduction, unacceptable angulation persisted in 3 patients in Group I but non in Group II. At 2- week follow-up, 3 more patients in Group I angulated within the cast and had to be re-manipulated and treated in extension cast till union. A statistically significant number (p(<)0.05) of fractures in Group I developed unacceptable angulation as compared to Group II. All patients had full elbow and forearm motion at 6 month’s follow-up. Complications included cast slippage in 3 patients in Group I and superficial plaster sore in 1 patient in each group.

Conclusion:

The conventional method of treating unstable forearm fractures with the elbow flexion results in an unacceptable degree of angulation within the cast. As the cast slips distally, the bend at the elbow may actually cause the fracture fragments to angulate further (Rang, Wilkins). Casting with the elbow in extension using the proper technique is an effective and innovative method to avoid angulation during the period of cast immobilization, as has been show in this pilot study. This technique is superior to alternative methods such as percutaneous intramedullary fixation, plating, or pins and plaster for management of unstable forearm fractures in children.

9. Neglected Posterior Dislocatio Of Elbow In Children

Dr Veeramanjunath, Dr Vrisha Madhuri and Dr Sivaramakrishna P
Department of Orthopaedics Unit 2, Christian Medical College and Hospital, Vellore, India

Posterior dislocation of elbow in children is an uncommon injury. A significant proportion of these injuries are associated with bony injuries around the elbow. We describe the results of 10 such injuries seen by us as late presentations varying from 1-12 months. 10 neglected posterior dislocations were seen in children aged 8 to 18 years (mean 11 years). There were 5 males and 5 females. 5 children had associated malunited injuries of the elbow. The associated injuries were flexion supracondylar fractures, lateral condylar fractures, flexion physeal injury of the distal humerus and, lecranon fractures. 5 patients had myositis ossifications.

The surgery consisted of reduction through a posterior approach. An extensive lateral medial and posterior release was required. Triceps lengthening was required in all cases. Postoperative mobilization was started between 2 to 6 weeks depending on other injuries. Postoperative arc of motion varied from 20 to 105 degree. There was no instability of elbow in any cases. This paper highlights the importance of recognition of associated injuries and management of this rare injury in children.

10. Neglected Supracondylar Fractrures, “What To Do”

Dr Manoj Mittal
Aligarh

Key Word : Trauma, Elbow, Supracondylar

Supracondylar fractures are the commonest fractures around elbow among children. The best treatment of Gartland grade iii fracture is close reduction and K wire fixation. But this treatment is only possible when the patient comes son after the injury or at the most within first week of injury. In our country majority of patients from village don’t come within this period, rather the first seek some sort of treatment at the local osteopath level and only then they approach to a good center. Now what to do of such patients? Either, leave them as such to remodel or do some thing. So the purpose of this study was to evolve some method to tackle such group of patients.

Since 1994 to 2002 total 122 patients of supracondylar fractures were treated. 44 patients reported within first week of injury were not included in this study; rest 78 patients were those who reported within second to fourth week o injury. They were further divided into three categories i.e. 36 reporting time with second week, 30 patients within third week, and the rest 12 patients reported within fourth week of injury. All cases were assessed radiologically and clinically, especially to exclude any sign and symptoms of myositis ossifications. All cases were operated by minimal invasive method innovated by me (Video clipping) under image intensifier with crossed K wire fixation and a posterior slab for three week, followed by removal of slab but K wire fixation continued for another three weeks with physiotherapy of elbow.

The overall results were good 66 patients (84.61%) according to FLYNN criteria. The recovery of elbow movements were significantly delayed as compared to fresh fractures cubitus varus deformity was observed in 12 cases (15.40%), Pin-tract infection – 8 cases (10.25%), Latrogenic ulnar nerve injury (neuropraxia) – 4 (5.10%), median nerve injury – 1 case only. In none of our cases neither compartment syndrome nor heterotropic bone formulation was observed.

So we concluded that such neglected cases can be dealt successfully if treated judiciously, carefully, and noninvasively rather leaving them for a long time to remodel the malunion and then to correct the residual deformity after 1-2 years. By this method patients as well as parents psychological and economical trauma could be averted.

11. Outcomes MEDFP: Ial Approach To Cubitus Varus Resulting From Malunited Supracondylar Fractures

Dr Anirban Chatterji

Cubitus Varus causes cosmetic deformity and late onset instability. Osteotomies described previously include lateral closing wedge, French, dome and step cut osteotomy. Most of these are inherently unstable and often associated with unsatisfactory results such as prominence of lateral condyle, a lateral scar, and injury to the triceps. The objective of this study was to valuate the results of a new approach using the medial incision for the corrective osteotomy of cubitus varus.

The outcomes of this medial approach was evaluated on Twelve consecutive children with cubitus varus deformity resulting from supracondylar fractures. The mean age of the patients at osteotomy was 7 yrs 8 months (range between 5 to 11). The mean duration of follow up was 3 years. The mean angle of deformity of cubitus varus was 220 off the contralateral normal elbow. The mean degree of hyperextension of elbow was 190 compared to the contralateral side. The average operating time was 1 hour 20 minutes (range 55 minutes to 1 hour 34 minutes). The incision was made medially and the ulnar nerve was identified and protected. Intraoperatively, image intensification was used to identify the wedge. Lateral close wedge osteotomy was performed and secured with cross K-sires. After the osteotomy was performed the distal fragment was translated medially to reduce the lateral prominence. Both the distal fragment was translated medially to reduce the lateral prominence. Both hyperextension and internal rotation deformity could be corrected with the osteotomy. Postoperatively the patients were immobilized in a cast for 3-4 weeks. The K-wires were maintained for 3-4 weeks post operatively.

At the mean follow up period of 3 years, all 12 patients were satisfied with the correction of their deformity and the scar. The average degree of post operative varus was within 30 to 50 of the contralateral elbow. The post operative carrying angle averaged 7.20 (range -). The range of elbow movement had improved to correct the hyperextension. No patient had a prominence of the lateral condyle and the operative scars were well concealed along the medial aspect of the elbow. There was no case of non union, one case of transient ulnar nerve paresis, and 2 cases of superficial pin tract infections. With careful intraoperative protection of the ulnar nerve and the use of image – intensification, the medial approach for the supracondylar osteotomy is a good and safe procedure and avoids an uncosmetic scar and a lateral prominence.

12. Percutaneous Osteotomy For Correction Of Cubitus Varus In Children

Dr Taral Nagda, Associated Professor
Department of Orthopaedics KEM Hospital Parel Mumbai

Introduction:

We present a percutaneous dome osteotomy for correction of Cubitus Varus Osteotomy in children.

Preoperative Planning:

CORA is marked at intersection of humeral and ulnar axis. It usually corresponds to center of olectanon fossa. A dome is drawn facing down (SAD osteotomy) concentric to CORA with diameter 1.5 times of width of humerus at level of CORA.

Operative Technique:

Position of patient is lateral with elbow supported on radiolucent L top. This facilitates us of C RAM and allows to check the carrying angle when elbow is extended. After draping a reference K wire is passed at CORA posterior to anterior perpendicular to the coronal plane of humerus. With a dome osteotomy jig appropriate hole to match the planned site of osteotomy is selected. A small stab incision is made at the hole. With the drill sleeve in place multiple drill holes are made along the dome using the jig. The position of drill holes are confirmed on image intensifier. The drill jig is replaced with osteotomy jig and the dome osteotomy is completed. The osteotomy is translated under image intensifier control, necessary derotation, flexion achieved and fixed with cross K wires. Additional fixation is with wires in proximal humerus passed from lateral to medial and fixed with lateral cross K wires with mini external fixator as a lateral tension band.

Post Operative Protocol:

Patient is placed in a sling and elbow mobilization started once the patient is pain free. The fixator and K wires are removed at 4-5 weeks post op.

Results:

We have done 11 osteotomies in children with cubitus varus with age group 8 years to 12 years. All the children at follow up of 3 months to 1 year have full range of elbow movement with satisfactory correction of deformity. There were no neurovascular complications. Mild pin tract infections occurred in 4 patients. The procedure was well tolerated by the patients and accepted by the parents as suggested by the questionnaire.

Advantages:

Cosmetically superior. Minimally invasive one stitch surgery.
No lateral bump seen in French Osteotomy
No translation of humero ulnar axis
Early mobilization

13. Preoperative Planning & Modified Fremch Osteotomy In Cubitus Varus Deformities

Dr D C Srivastava, Dr S C Gaur MS
47 B Hamilton Road, George Town, Allahabad (211006) U.P., INDFP: IA

Abstract:

We have operated 10 cases between 1995 & 2003 by modify the basic technique of French osteotomy. We have used the K wires for the fixation which take care of the both axial loading & rotational forces at the site of the fracture where as in the French osteotomy used screws & wires take care of the only axial loading force. We have achieved 94.5% results by comparing the normal contra lateral limb.The details of the preoperative planning will be discussed & the different minor details of the procedures will be taken in to account at the time of presentation.

14. Safety And Cost Managment Of Forearm Trauma Care – An Overview

Dr G Kanagaraj and Dr A Vimaladithan
Research and Development, MGRM Medicare Limited, New Delhi, INDFP : IA

Introduction:

The ultimate rehabilitation of mankind, especially the traumatized paediatric population demands not only the updated medical knowledge and technologically sound diagnostic as well as surgical equipments, but also needs close and carefully evaluation of safety and cost of the overall management of trauma care.

Materials and Methods:

Original research papers that studied extensively the trauma care management of paediatric population were included.

Results:

Medical audit report showed 12.1% readmission rate in case of closed reduction of distal radial, forearm shaft and distal humerus fractures due to 16% loss of position achieved. Internal fixation procedure was employed (24%) as salvage.

Discussion:

In the human lifecycle, the risk of trauma in the paediatric group (4 – 14 years) is about 0.5%. Nature of injuries that required hospital admission were fractures (87.3%), soft tissue injuries (8.5%) and joint injuries (2.2%). Of the total emergency admissions, 1.5% was hand and arm fractures which included 44% of radius – ulna fractures.

Conclusion:

Early diagnosis and selective, primary treatment by internal fixation or cast splinting with per cutaneus pinning after closed reduction were shown to be safe and cost effective in terms of minimum hospital stay, avoidance of readmission of reduction failure minimized medical errors and related cascading effects of Catastrophe.

15. Supracondylar Fractures – Crossed Or Parallel Wires?

Dr Saw Aik, Dr S Sengupta, Dr Agus Iwan Foead
University of Malaya Medical Centre, Kuala Lumpur

Abstract:

Closed manipulation followed by K-wire fixation has become the standard method of management of displaced supracondylar fractures of the humerus (SF). Usually two K-wires are used. However complications such as nerve injuries, pintract infections and stability of fixation are still a problem. A prospective randomized controlled study was carried out between two methods of fixation viz., cross K-wire and two wires introduced from lateral side, was conducted on 101 children admitted in UMMC during a three year period from May1, 2000 to 30th April 2003. All grade 3 (Gartland) and grade 2 fractures needing manipulation under general anaesthesia were reduced under X-ray control and fixed with K-wires in one of the two methods. The upper limb was supported in a plaster cast. Three weeks later cast and wires were removed and the child was encouraged to mobilize the elbow. End point of mobilization was reached when full range of elbow and forearm movements have returned or nerve injury, if any, has resolved. This was usually achieved in six months (mean 8.9 months). Anteroposterior and lateral X-rays were taken at this time and clinical carrying angle and radiological Baumann’s angle and humor-radial angle were compared with contra-lateral side.

There were two each of ulnar and median and one radial nerve injuries and one with palsy of all three nerves on presentation. Post operatively nine more children were found to have sustained ulnar nerve and one radial nerve injuries. Three of the ulnar and the single radial nerve injuries occurred with lateral wires while in the other six cases ulnar nerves were injured with cross K-wire fixation. All the nerve injuries recovered spontaneously.

The difference in carrying angle when compared with the normal side was 3.55 degrees in cross-wire fixation and 3.70 degrees in lateral pin fixations. The Baumann’s angle difference between the two sides was 5.90 in cross K-wire fixation and 6.93 in lateral pin fixations. The humero-radial angle difference were 4.05 degrees in cross K-wires and 4.55 degrees in lateral wire fixations. None of these differences were of statistical significance. As all the fixation were carried out by senior trainees under the guidance of an academic staff, the standard of reduction and fixation are considerable to be equal. Therefore there is no significant differences between these two methods of fixation. In terms of risk of nerve injury and stability of fixation.

16. Treatment Of Dfp: Iaphyseal Femoral Shaft Fracture In Children By Stapping

Prof R.C. Gupta, Dr K.K. Gupta
Kushul Hospital, Allahabad

Most of diaphyseal femoral shaft fractures in children are closed and are mainly treated by closed methods. Many methods have been employed successfully like Gallow’s traction, 900 – 900 traction on Bohler Brown splint, balanced traction on Thomas splint or even simple skin traction without any splint. Recently a number of pins, wires are being used, less on biology fracture healing but more frequently because of market compulsions. All these methods give good result due to good muscle mass, vascular supply and elastic periosteum, but they require longer period of hospitalization or increased costs and radiation. We have been treating these fractures by strapping of thigh with leg for last 25 years (Gupta R.C. Verma, A.N. and Mittal, K.K.; Treatment of diaphyseal fractures in children by strapping, Injury 12,:234, 1980) for age group from day 1 to 7 years. So far we have treated; 86 cases. The patient is sedated with promethazine syrup, affected thigh is lifted up, fracture aligned, knee flexed and strapping of thigh with leg is done with adhesive plaster. Anteriorly quadriceps give good support and posteriorly calf muscles do the same work. In addition the strapping does not permit any rotational movement at fracture site. The patient is ambulatory, can be taken on lap. The shortening if nay, mostly radiological is easily compensated in few months to a year.

Tool and Technology

1. Antenatal MRI

Dr Sona A Pungavkar, DNB, DMRD., Consultant, Dr Deepak Patkar MD
MRI Centre, Nanavati Hospital, Vile Parle, Mumbai

Introduction:

Magnetic resonance imaging (MRI) was first used in prenatal diagnosis in the early 1980’s. It became obvious that, MRI allowed for greater resolution of the fetus as compared to the commonly used ultrasound. MRI is the ideal choice because of lack of ionizing effect, multiplanar capability and inherent soft tissue contrast. Although seen as a promising technique, fetal MR studies were limited by long image acquisition times that necessitated sedation of the otherwise moving fetus. Technical advances of the early 1990’s produced fast MR techniques, better coils and gradients. This paved the way for meaningful imaging of a fetus without the need for sedation. Single-shot fast spin echo (ss FSE) sequences provide evaluation of the fetal organs, especially of the brain in a detailed fashion.

Aim: This study was performed

1. To establish the efficacy of antenatal MRI.
2. To ascertain if antenatal MRI could provide additional information compared to ultrasound

Material:

In a prospective study, we performed antenatal MRI in 60 abnormal pregnancies of which, 04 were multifetal pregnancies. The fetal gestational age ranged from 15 to 37 weeks. We highlight the cases of abnormal fetal spine and limbs. These are five in number.

Method:

MRI was performed on a 1.5 T Signa, Echospeed machine (GE Medical Systems, Milwaukee, USA). A torso-phased array or body coil was used depending on the age of the scanned in the supine position. 2 patients in the third trimester were uncomfortable in the supine position and were scanned in the left lateral decubitus position. The entire gravid uterus was first scanned in three planes orthogonal through the fetal organ of interest. Each sequence was then used a scout for the subsequent sequence, depending on the indication and the target organ. ssFSE sequence was used. The scan time per sequence was ranging between 15 to 23 sec. Minimum slice thickness obtained was 2 mm and the maximum was 6mm. The sequence was repeated in cases where fatal motion caused artifacts. 3D reconstructions were also obtained in few patients.

Results:

The MRI study was well tolerated by all patients and no patient experienced significant discomfort, so as to abandon the study. In all the patients, satisfactory images could be obtained in multiple planes. The anatomy was displayed and interpreted with respect to the fetal orientation. In all the cases, MRI provided as much information as the ultrasound. Additional information was obtained in 3 patients, while better delineation was provided in 2 patients. Of these, significant contribution to the prenatal counselling and pregnancy management was observed in all 5 cases. There were no contradictory findings between the two imaging modalities.

2. Biomechanical & Biophysiological Interpretitions Of The Cubitus Varus Deformity Following Supracondylar Fractures

(A cadaveric experimental study & follow up of the 412 cases of supracondylar fractures between 1990 & 2003)
Dr DC Srivastava MS, Dr SC Gaur MS
George Town Allahabad

Abstract:

We have conducted an experimental study on a right upper limb of a 15year old cadaver. We have denuded the muscles from the humerus, radius & ulna. We have preserved the elbow joint complex with their capsules & ligaments. We produced an artificial fracture at supracondylar level by transverse osteotomy. We passed a K wire through the medullary canal of the humerus & a K wire through the medullary canal of the ulna. The third K wire was passed in the distal fragment of the humerus parallel to the fracture line & perpendicular to the humeral K wire. We used the specially designed goneometre to measure the angles when the fracture site is subjected to the r~ different a type of angulation & rotations.

We are of the opinion that the cubitus varus deformity following supracondylar fractures are produced due to medial angulation or medial rotation or due to the combination of the both immediately after the fracture unites & we are capable of measuring the carrying angle when the full extension & full supination is possible following the physiotherapy. The change in the growth of the medial or lateral condylar epiphysis does not play an important role at that time because that time period is so short that the growth changes can not produce any significant impact.

The 412 cases attended our clinic between 1990 & 2003. The 390 cases were treated conservatively by close reduction followed by POP cast & 22 cases were treated by open reduction & fixation with K wire. The 320 cases showed no change in the carrying angle but 71 cases showed cubitus varus deformity ranging from 1 to 11 degree with an average of 5.4 o immediately after the treatment with return of the full supination & full extension.

The 200 cases with normal carrying angle, 21 cases with cubitus varus & 6 cases with the cubitus valgus deformity were lost in the follow up. But 120 cases with normal carrying angle, 50 cases with cubitus varus deformity & 15 cases with cubitus valgus deformity were followed from 6 months to 13 years with an average of 5.7 years.

In the 120 cases with normal carrying angle showed changes in the angle with development of cubitus Vanls deformity in 13 cases ranging from 1 to 13 degree with an average of 4.4 degree & cubitus valus deformity in 2 cases with 50 in one case & 80 in second case. In the 50 cases with cubitus varus deformity, 40 showed no change but 10 cases showed increase in the angle ranging from 3 to 11 degree with an average of 4.8 degree. In 15 cases with the cubitus valgus deformity 11 showed no change but 4 cases showed in increase by 2 to 8 degrees.

The follow up findings indicates the growth variation in the medial or lateral epiphysis is also an important cause for the production of the change in the carrying angle & it plays it role only over a long period of time in the later phase of the growth after the treatment but no immediately during the phase of treatment.

3. Clinico Radiological Evaluation Of Perthes Disease – Is Surgery Needed In All Cases?

Dr. Harsimran MR, Prof. SS gill, Dr. MS Dhillon, Dr (Mrs.) Katariya
Deptt. Of Orthopaedics & Radio-diagnosis, PGIMER Chandigarh

30 cases of Perthes were studied to compare the ultimate range of movement and sphericity of the femoral head in patients managed conservatively and those undergoing surgery. The mean age of the patients was 6.34 years, male to female ratio, 10.6: 1 and 70% belonged to low socio economic group. 21 cases had Rt. Hip involvement, one bilateral and 8 cases had Lt. Hip affected. The diagnosis was made by classical clinical presentation and radiological features on plain X-rays (MRI & Bone scan being done in the doubtful cases). Out of 24 patients whose aged was less than 9 years, 8 had Caterall stage 1 & 11 and 16 had staged III & IV disease. 6 patients had disease onset after 9 years of age and all had stage III & IV disease. All stage I & II patients underwent conservative treatment consisting of traction, analgesics and calipers. Subtrochanteric derotation varus osteotomy was done in six patients with stage III & IV disease. All these patients were less than 9 years of age. Rest of the patients of stage III and IV disease received conservative treatment. The results were assessed at two year; from one of symptoms. Itangc of movement of hip in flexion, abduction and internal rotation was measured with a goniometer. The sphericity of the femoral head was measured with a Mose template using X-rays in AP and Frog lateral view. We did not find any statistically significant difference in the result in patient of stage III/IV Caterall, treated conservatively or by surgery. All patients with age >9 yrs at presentation had poor ultimate outcome.

4. Efficacy Of Botulinum Toxin – A In Cerebral Palsy

Dr Harsharan Singh Oberio MS, Dr Raju Shamla MSPT
Basant Memorial Trust, Oberio Hospital, Jalandhar, Punjab

Introduction:

The use of Botulinum toxin type A has gained widespread acceptance in clinical management of focal muscle spasticity seen in patients with Cerebral Palsy, Stroke and Traumatic Brain Injury. Purpose of study was to register the effects of BTX-A in reducing the spasticity and improvement in overall motor function.

Material and Method:

23 children (average age 5 years) were given BTX-A injections (6 to 8 units/Kg.). Children were assessed before and after 3 months of injection for spasticity level, more function, range of motion and gait by MAS, GMFM, Goniometry and Observational Gait analysis respectively. Statistical analysis done using paired t test. Follow up was done at 6 months.

Results:

78 percent children showed significant improvement (t at P<.001) in their spasticity level, motor function and range. On follow up only those who continued therapy, maintained their functional level.

Conclusion:

BTX-A proved both safe and effective in management of focal muscle spasticity in C.P. However to maintain functional level continuing regular physiotherapy and parental support are very important.

Key-words:

Spasticity, BTX-A, C.P., neuromuscular block

5. Management Of Tibfp: Ial Lenthening Using Ilizarov Apparatus And Botox To Prevent Equinus Contracture

Dr Sandip Vyas, MS (Orth.); D.N.B. (Orth.); Ilizarov Fellow (USA)
Purnima Hospital, Road No. 8, Daulatnagar, Borivli (E), Mumbai 400 066.

Material & Method:

Seven patients underwent Tibial Lengthening with Ilizarov Apparatus without a Foot-frame. All patients were given Botox Injection (Sub Type 4). Two to Four units / kg. of Botox per muscle Belly of Gastrocnemius was used, and Ilizarov Apparatus applied.

Results:

Mean Lengthening achieved was 4.5cms. Patients were on the regular Physiotherapy Protocol Post-Operatively. After frame removal, there was no equinus contracture in any patient. All patients underwent lengthening without significant pain and were walking comfortably without Foot-Frame.

Discussions & Conclusions:

Botulinum Toxin Binds to Motor nerve terminals and blocks release of Acetylcholine. The action lasts for 4-6 months with reversibility of action due to sprouting of nerve terminals. This feature helps us to complete Lengthening with a Paralysed Gastrocnemius and prevention of Equinus contracture in spite of no Foot-Frame, without significant pain.

6. Non Factor Transfusion Management Of Hemophilic Synovitis Knee In Children

Dr SK Saraf, Dr OP Singh
Department of Orthopaedics, Institute of Medical Sciences
Banaras Hindu University, Varanasi, India

Introduction:

Complications of musculo skeletal bleed like synovitis usually present late. The repeated factor transfusions recommended, as gold standard for the prophylactic as well as for the management is not possible in developing countries like India due to shortage and high cost of factor transfusion. Due to these constrains, we used Pulse Ultra Sound Therapy and muscle stimulation along with exercises to manage our patients of Hemophilic synovitis of the knee to observe if it can be used as an alternative therapy.

Material & Method:

Forty patients with 52 synovitis of knee selected at random and followed for minimum six months were considered as subject for the present study. Synovitis was classified as per Cavilgia (1997) classification. A total of 16-20 sittings of low frequency pulse ultrasound of six minutes duration five days a week were given. The results were assessed by observing the changes in the swelling, range of movement in the joint, frequency of joint bleed during the observation period and joint tenderness and classified as Good, Fair and Poor.

Results:

The age of patients ranged from 5 – 15 yrs. Six knee belonged to Grade I, 24 to Grade II and 22 were classified as Grade III. In grade I, there was significant improvement in swelling and range of movements with decrease in pain and frequency of bleeds. In grade II also there was improvement in swelling, pain and range of movements. In grade II also there was improvement in range of movements, but no difference was observed in swelling and frequency of bleed. Overall results were assessed as Good in 16, fair in 22 and poor in 14.

Discussions & Conclusions:

Pulse Ultrasound acting by its fibrinolytic effect and by enhancing the rate of absorption of hematoma helps in early recovery in synovitis of the knee. The results were better when the therapy was started earlier in the phase of synovitis. In long standing cases without arthropathy, the results were still encouraging. In developing countries, where patients present late and factor transfusion not always possible, PUSA with muscle stimulation can give the comparative results.

7. Partial Transfer Of Hamstrings For Crouch Gait In Cerebral Palsy

Dr Kunjabasi Wanhjam
HOD, PMR, RIMS, Imphal, Manipur

Abstract:

Crouch gait or posture is one of the most resistant conditions to treat in I cerebral palsy with spastic diplegia. Twenty nine such patients (19 males, 10 females); aged between 3 to 16 years (mean 8.9 years) were treated at the Department of Physical Medicine & Rehabilitation, Regional Institute of Medical Sciences, Imphal from Jan 1992 to December 2001 by partial transfer of distal hamstrings to correct croutch gait. Some tendinous and biceps by partial transfer of distal hamstrings to correct croutch gait. Some tendinous and biceps femoris tendons were transferred to lower femoral condyles by fixing to tendinous origins of corresponding gastrochemi. Semi-membranosus tendon was not transferred; but lengthened and it was left to serve as knee flexor. Results were assessed at 6 weeks, 3 months, 12 months after operation based on reduction of popliteal angle, increase of hip extensor power, improvement in balance and gait. Accordingly, 6 cases were graded as excellent; 16 as good; 2 as fair and there was no patient in poor grade. Genu-recurvatum occurred in 2 cases. Patients were followed up for a period ranging from 1 to 10 years (mean 5.5 years). This method of partial transfer of distal hamstrings is effective in relieving crouch gait, in spastic diplegic cerebral palsy.

8. Predicting Which Wlaking Aid Cerebral Palsied Child Will Need

Dr Dhiren Ganjwala
Ganjwala Orthopaedic Hospital, Ahmedabad, India

Introduction:

Spasticity and deficient equilibrium are two major problems of cerebral palsy child which case difficulty in ambulation. To overcome deficient balance child need some sort of supporting device. The aim of this study is to establish correlation with deficiency in equilibrium and supporting aid child needs.

Material & Method:

40 children with cerebral palsy were enrolled in the study. All the children were diplegic and ambulatory. 26 children had undergone some orthopedic surgery in the past. Children were tested for their capacity to maintain equilibrium in anterior, posterior and right and left direction. Their preferred device for support was asked. When they were using more than once device, they were asked to walk with each device and their energy consumption was measured by change in the heart rate and time taken to cover 30 feet distance. The device which gives lowest physiological cost index was considered as preferred device. From equilibrium deficiency, children were divided into five groups. Group A has adequate balance in all 4 directions. Group B has deficiency in one direction or has good balance in 3 directions and Group E has deficiency in all 4 directions. Children were either walking with the help of walker )4 point support) with two crutches, single crutch / stick or independently.

Results:

	4 point walker	2 crutches	Crutch/stick	Independent
Good in 4 directions				9
Good in 3 directions				6
Good in 2 directions		4	5
Good in 1 directions	12
Good in 0 directions	4

Conclusion:

Independent walker has good balance in 3 or 4 directions. While those who depend on 4 point walker have poor balance in all 4 directions or in 3 directions. The results indicate that simple test of checking equilibrium guides clinicians to select the best supporting aid for ambulatory cerebral palsied child.

9. Rectus Femoris Transfer For Childrenwith Cerebral Palsy – A Lng Term Outcome

Dr Aik Saw, FRCS (Edin), Dr Peter A Smith, MD, Dr Yuddasert Sirirungruan, MD, Dr Chen Shande, Ph.D., Dr Sahar Hassani, MS, Dr Gerald Harris, Ph. D., Dr Ken N Kuo, MD

Introduction:

The purpose of this study was to evaluate the long term results of Rectus Femoris Transfer (RFT) in cerebral palsy children with stiff knee gait by gait analysis and functional ambulatory assessment.

Materials and Methods:

Thirty-eight affected limbs in 24 children were evaluated by comparing preoperative and one year postoperative gait analysis. Also included were 26 limbs in 18 patients that were evaluated during a second gait analysis after an average of 4.6 years following surgery. Functional ambulatory status evaluation was based on level of ambulation as defined by Hoffer, 8 requirement of walking support and usage of ankle brace. Improvement or deterioration was documented at one year after surgery and at final clinical review at a mean of 5.6 years.

Results:

There was statistically significant improvements of 9.8 degrees in maximum swing phase knee flexion and 7.0 degrees in total range of knee motion at one year as measured by gait analysis, with a slight loss of knee extension in stance (3.70, p=.03). At long term gait analysis, the improvement in the swing phase knee flexion was maintained, but improvement in total range of knee motion was decreased due to further loss of knee extension (70, p=OOOI). There were no significant changes in temporal parameters either at one year or at the last gait analysis. Eight children showed improvement in functional status of their ambulation while five (not four) deteriorated at one year after surgery. At the final follow up, ten children showed clinical improvement while three deteriorated in their ambulatory status after surgery.

Conclusions:

Improvement in swing phase knee flexion and foot clearance after RFT was associated with loss of knee extension at long term follow-up. Hamstring lengthening in patients who develop excessive stance phase knee flexion, as well as careful attention to rotational abnormalities of the femur and tibia, and foot valgum may be necessary. There were more functional improvements than deteriorations in ambulatory status following RFT. Cerebral palsy children may require a longer period to recover from surgery and evaluation at times farther out than 12 months with gait analysis may be required.

10. Study Of Post Polio Residual Paralysis Around Ankle And Foot

Dr Preshit Gaddam, Dr OP Sharma, MS, Dr KR Patond, Professor & HOD Sewagram,
Wardha 442102 Maharashtra, India

Introduction:

Modern Orthopaedics deals with the study of the form and the function of the musculoskeletal system. Poliomyelitis which is known to be an oldest disease of mankind has been almost wiped off from the developed countries. However in developing countries poliomyelitis still continues to be one of the health problems of pediatric age group’.

Material and Methods:

62 patients suffering from post polio residual paralysis around the ankle and foot with lower limb involvement were examined and managed in the department of Orthopaedics, MGIMS, Sewagram. Muscle imbalance and deformities around the ankle and foot constituted the study. Thorough history clinical and neurological examination was carried out. Plan for management was laid down. All the surgeries were done under G.A., under tourniquet. Some patients with severe deformity were given traction before definitive surgical procedures.

Results:

Out of 62 patients, 53 (85.5%) were inpatients and 9 patients were treated on OPD basis. There were 24 males and 21 females. Majority of patients seen in were 7 to 9 years of age group with female predominance. Right lower involvement was common. Bilateral involvement was equally common (27 patients, 43.5%). Equinus deformity with its variant was the common deformity. Muscle wasting and shortening of lower limb was a constant feature. Tibialis anterior and posterior were the commonest muscles involved. 36 patients offering 38 feet (2 bilateral cases) were operated upon. 35 tendon transfers done Total 87 orthotic appliances were prescribed and supplied to the patient.

Discussion:

Study and its results were comparable with other series in India. The paper will highlight the same.

Conclusion:

Prevention is better than cure, stands very much in poliomyelitis. However, if a person has been affected by poliomyelitis, all the possible measures should be undertaken in preventing the severe deformities and definite treatment should be instituted at the earliest to provide reasonably useful limb.

Poster Presentation : Congenital / Developement

1. Accessory Soleus Muscle – Presenting With Rigid Club Foot Deformity, A Report In 3 Feet

Dr. P. N. Gupta, Dr. Raj Bahadur
Department of Orthopedics, Govt. Medical College & Hospital, Chandigarh

Introduction:

Clubfoot is amongst the commonest of congenital skeletal anomalies. It usually presents as isolated deformity; the incidence of associated anomalies is about 6%. We came across 3 such clubfeet in 2 children with associated accessory soleus muscle. The purpose of presenting this study is to know the contribution of this muscle to the deformity and to propose treatment method for dealing with such abnormality.

Case Report: Case 1:

A one year male child presented with right sided rigid clubfoot and was planned for posteromedial release. During dissection, and accessory soleus muscle inserting on to posteromedial aspect of calcaneum was revealed (Fig.). To assess the contribution of the equinus persisted. Full correction was achieved only after tenotomizing the insertion of this muscle. At 1 year follow up; the patient is walking with a plantigrade foot.

Case 2:

A one year male child presented with bilateral rigid clubfeet. Bilateral soft tissue release was done using Cincinnati incision. Accessory soleus was present on both sides and in this patient also, full correction of deformity was achieved only after tenotomizing the insertion of this muscle.

Discussion:

An accessory muscle forms due to splitting of a muscle anlage during fetal life. Soleus muscle fuses with the Gastrocnemius at the middle and lower third junction of leg to form the tendoachilles; accessory soleus tendon inserts separate from tendoachilles on the calcaneum. The most common presentation of accessory soleus is by a swelling at the posteromedial aspect of the ankle in early adulthood; associated with clubfoot is less common. The accessory soleus muscle contributes to a rigid deformity as was observed during surgery in both patients. When present, surgical division of this muscle along with posteromedial soft tissue release achieves full correction of the deformity.

Conclusion:

Accessory soleus muscle when present in clubfoot contributes to rigid deformity; though may not be sole cause of deformity. Full correction requires surgical division of the muscle in combination with a soft tissue release.

2. Assessment Of Clubfoot Deformity Using Dimeglo’s And Pirani’s Scoring System

Dr. Hailendra Telang, Dr. Taral Nagda, Dr. Vikas Trivedi
Department of Orthopaedics KEM Hospital Parel Mumbai

Introduction:

We conducted a study involving 22 idiopathic clubfeet in 15 pts over a period of 6 months, comparing DIMEGLO’S & PIRANI’S scoring systems for assessment of clubfoot deformity, while treating the children with the PONSETI’S method of clubfoot correction. The goal of study was to apply both these studies to practical use and to determine inter & intraobserver reliability of these systems and to study the co-relation between the different parameters of both these systems.

Materials & Methods:

Two designated observers evaluated 22 feet over a period of 6 months, a total of 144 examinations.

Results:

The children ranged in age from 1 to 6 months with mean age of 3.3. Both the scoring systems demonstrated excellent inter-observer reliability with correlation coefficients of 0.9915 (Pirani) & 0.9638 (Dimeglio). The 95% confidence intervals were within 2.3 points (Pirani) and 4 points (Dimeglio). Both the scoring system demonstrated excellent intra-observer reliability with the first examinee having p-values of 0.9658 (Pirani) & 0.9399 (Dimeglio). The three parameters of the hindfoot score in the Pirani systems went hand in hand throughout the course of the treatment out of 22 feet scored, 18 feet(82%) had the scan scoring of all 3 hindfoot parameters without any change.

Conclusions:

Both Dimeglio’s and Pirani’s classification systems have a good inter observer and intraobserver reliability. The three parameters in the Pirani’s hind foot score did not show any variation, thus the need to merge them into one single parameter to represent the hindfoot score and further simplify this scoring system should be considered.

3. Congenital Bilateral Pseudoarthrosis Of Hemerus

Dr Sanjay Yadav, Dr Shailendra Telang, Dr Taral Nagda
Seth GS Medical College & KEM Hospital, Parel, Mumbai

Congenital pseudarthrosis is a known common entity especially of tibia, studied in detail in the literature. These have been associated with a variety of multisystemic conditions like Neurofibromatosis. The age of presentation and the outcome of these states are well studied in Indian and western literature. We present a case of congenital Pseudarthrosis of humerus in a 3 year old male child who presented with bilateral deformities of the arm since birth. There were no sings of presented with bilateral deformities of the arm since birth. There were no signs of neurofibromatosis in the family or in the patient. Of his five siblings one sister was diagnosed as Beals congenital arachnodactyly. Other siblings were normal. Routine X-rays showed middle third and lower third pseudarthrosis in both arms and elbow was free and mobile with no stiffness whatsoever. Blood parameters were normal. Detailed paediatric research laboratory assessment was done to rule out any systemic involvement of subset of any multisystemic condition. These turned out to be negative. MRI was done to assess the status of the joint. It revealed synovial type of joint with presence of fluid in between.

Surgical intervention was done on one side through anterolateral approach and stabilized with plate and fibula on lay graft. Intra-operative there was true synovial lining the pseudarthrosis with pseudo capsule and true synovial fluid. The sample was sent for histopathological analysis including electron microscopy to find any hamartomatous tissue of neurofibromatosis. The report was negative with indication of true synovial joint. Immediate post-operative Shoulder spica was given and mainted for a period of 6 weeks. At six weeks there was good radiological and clinical union. The other side was operated at 2 ½ months after first surgery with predictable outcome. Congenital pseudarthrosis of humerus is not described in literature. Analogy is drawn to the post-infective or post-trauma pseudoarthrosis, both which were absent in this case. Out detailed investigations to rule out any underlying cause or pathology yielded no result, suggesting of its idiopathic nature. Our management produced predictable result with good outcome.

4. Cross-Leg Sitting Test In Tarsal Coalition

Dr Atul Bhaskar
Guru Nanak Hospital, Gandhinagar,
Bandra (East), Mumbai 52

We describe a new finding that can alert one to the presence of a tarsal coalition Cross-leg sitting test requires the subject to sit with his hips and knee flexed and feet inverted. An inability to sit in this position and, the knee of the affected leg at a higher level for comfort may be due to a presence of a stiff hindfoot.

Introduction:

Tarsal coalition is an uncommon condition seen in children and adolescents. Symptoms appear when there is loss of motion in the hindfoot due to ossification of the coalition. Some children may present with vague aching pains around the hindfoot for years and there may be history of recurrent ankle sprains. The classic findings of heel valgus, peroneal spasm and abducted forefoot clinches the diagnosis, but these characteristics take years to develop. We describe a simple clinical test that may alert one to the presence of a tarsal coalition before the above changes develop. Thus early management may help control the symptoms and prevent delay in surgical treatment.

Method:

The test comprises sitting cross-legged on a firm flat surface. Normal cross leg sitting requires good hip and knee motion and also a flexible hindfoot to invert the heels. In normal cross-leg sitting the knees are at the same with each other. As one attempts to sit cross-legged with a stiff hindfoot, the inability to invert the heel in the presence of normal hip and knee motion causes the knee of the affected leg to assume a higher level. This asymmetry in the sitting posture can provide a clue to restriction of hindfoot motion. Further clinical and radiological examination in a child can then be pursued to establish the diagnosis. In bilateral tarsal conditions, both the knees may be at a higher level and the asymmetry in the knee position may reflect the degree of hindfoot motion. We performed this test on six children complaining of hind foot pain. Four children demonstrated positive cross-leg sitting test and the subsequent radiograph confirmed a tarsal coalition – three had talocalcaneal and one had calcaneonavicular coalition. In the other two children the radiographs were normal.

Discussion:

Most tarsal coalitions are aymptomatic and they often remain so in adulthood. Children with alcaneonavicular coalitions become symptomatic earlier as compared to those with talocalcaneal coalition. The usual age for children to be symptomatic is between 8-12 years in the former and 12-16 year in the latter. The cross-leg sitting test should be performed in any child complaining of foot pain provided there is normal hip and knee motion. Imaging studies for evaluation of a patient suspected of having a coalition includes radiographs of the entire foot and oblique views of the subtalar joint. A CAT scan is usually required to confirm the diagnosis and map the area of the coalition. Early diagnosis and treatment of the coalition, before secondary changes occur in the hindfoot can lead to permanent resolution of symptoms and relief of pain.

5. Management Of Ctev By Ponseti Method

Dr B Leela Prasa, Dr M Murali Mohan, Dr KS Praveen Kumar

Background:

Idiopathic CTEV is one of the most common congenital deformities. Traditional methods of conservative management have yielded only fair results with considerable incidence of recurrence and surgery. Ponseti started his method of serial casting for CTEV in early 60’s and has reported 88% success rate in long term follow-up(Ponseti, 1980)

Aim:

To assess the effectiveness of Ponseti method of serial casting for correction of CTEV.

Materials and Methods:

20 patients with 34 feet, in the age group of 0 to 4 months were treated with serial casting during the period January 2003 to October 2003.

Results:

We assessed our results as per the CLINICAL CLUB FOOT SCORE devised by Royal Columbia Hospital, University of British Columbia. Our success rate was 91%.

Conclusion:

Ponseti method of serial casting is an easy effective and economical method for the management of CTEV. Even though our follow-up period is short ((<)one year), our success rate (91%) is definitely encouraging.

6. Ponseti’s Technique – A Noble Approach To Club Foot

Dr. R. A. Agrawal, (MS Ortho), Dr. Anuj Kr. Jain (D Ortho.)
Agarwal Orthopaedic Hospital, Jubilee Road, Gorakhpur, UP, India
Phone – 0551 – 233102, Email – agrawalram@hotmail.com

Introduction:

All Idiopathic club feet are treated with preliminary serial casting. However, 70-95 percent cases need Postero Medial Research (PMR) surgery, which leads to long-term stiffness and weakness. Ponseti stands for surgery only in 11 percent of patients.

Material and Method:

25 young children (33 feet) were treated by this method. Serial casting begins within first six months of life. Abduction applied to metatarsals, counter pressure on neck of talus not calcaneus, never pronate the foot. Weekly casting for 4 to 7 weeks, Percutaneous Achilles Tenotomy under local anesthesia in 90% cases, casting for three weeks followed by foot abduction arthrosis 23 hours a day for three months and night time for three years. Only 10% needs anterior tibialis tendon transfer at the age of 2 ½ to 4 years.

Result:

	PMR surgery required	Average duration of casting	Final Dorsiflexion	Final Plantar flexion
Ponseti Group	1/33 (3%)	2 months	32° (10-45°)	50° (25-70°)
Control Group	31/33 (94%)	3 months	80 (5-20°)	29° (10 –40°)

Conclusion:

Our study shows successful results in 25 cases.
Simple
Highly effective
Less expensive (less need for hospitalization)
Eliminates need for PMR in vast majority of patients)
Leads to stronger, more flexible feet and better long-term outcomes

Based on our success, we no longer think that PMR is required for most cases of idiopathic clubfoot. Longer follow-up will determine whether we can continue to match Ponseti’s reported outcomes.

7. Role Of Intraoperative Radiography In The Assessment Of Resmual Deformity In CTEV

Dr. Karanu Karan, Senthil Nathan S, Prof S.S. Gill
PGIMER, Chandigarh

In this study, 22 patients were subjected to intraoperative stress radiography using Simon’s standardized technique. Radiographic measurements were made for each of the deformities in hindfoot, midfoot and forefoot. Postoperatively, the foot was assessed using Demiglio score for residual deformity by a blinded experienced observer. The sensitivity, specificity, false positive and false negative values of each of the intraoperative radiological measurement were made. It was evident from our study that some of the radiological parameters like Beatson index for varus, talo-first metatarsal angle (AP) and calcaneofith metatarsal angle (AP) for forforehood adduction and calcaneo-fifth metatarsal angle (lateral) for cavus are highly sensitive and can be used routinely intraoperatively. However other radiological measurements for equinus, talonavicular dislocation should be used with caution.

8. Short Term Results Of Ponseti Method For Clubfoot

Dr Dhiren Ganjwala
Ganjwala Orthopedic Hospital, Ahmedabad, India

Introduction:

Clubfoot is very common congenital foot deformity. Various treatment methods like gentle manipulation, strapping, brace, repeated corrective cast and surgery have been described for this deformity. The aim of this paper is to study results of Ponseti method of plaster treatment.

Material & Method:

34 idiopathic clubfoot in 22 patients under the age of 6 months were treated with Ponseti method. Average age at the time of starting the treatment was 1.2 months (ranging from 1 day to 5 months). Three feet in three patients had taken plaster treatment elsewhere without achieving full correction. Severity of clubfoot was assessed by Pirani severity scoring before starting treatment. All patients were given plaster as per the standard technique of correction recommended by Ponseti. Average number of plaster were 4.3 (ranging from 3 to 7).

All patients completed the treatment. Full correction was achieved in all but one patient. In a child in whom full correction was not achieved, treatment was started at all age of 5 months and was treated by 6 plasters before staring Ponseti technique. Only cavus did not correct completely while other components of deformity got corrected. Not a single child required surgery other than percutaneous tenotomy of tendo Achilles. 4 feet in four patients showed early signs of recurrence and were managed with one plaster in a position of more than 50 degrees of forefoot abduction for 3 weeks. All feet were evaluated at average of 15 months after treatment (range from 6 months to 24 months).

Results:

Results were evaluated clinically and parents satisfaction at the time of latest follow up. On clinical examination, degree of correction (by Pirani severity scoring) and range of motion were tested. Parents were asked whether they are happy with the correction or not and whether they will suggest this treatment to some one. 33 feet out of 34 had complete correction of all component of clubfoot. Pirani severity score dropped from 4.9 before treatment to less that 0.5 at the time of latest follow up. All parents were happy with the treatment and said that they will like to recommend this treatment to someone with clubfoot.

Conclusions:

The results achieved in this study suggest that Ponseti treatment produces satisfactory correction in 97% of idiopathic clubfeet.

9. Spectrum Of Congenital Orthopaedic Anomalies In The Department Of Orthopaedics, M.G. I.M.S.

Dr Kiran Kumar Mallam, PG, Dr Balvinder Rana, MS, Dr KR Patond, Prof. & HOD
Department of Orthopaedics, Mahatma Gandhi Institute of Medical Sciences
Sewagram, Wardha 442102 Maharashtra, India

Introduction:

The musculoskeletal system is the one most prone to congenital anomalies, yet the full spectrum & anatomic variability of its anomalies is not well appreciated. Indeed the complicity of its growth and embryology make it unusually vulnerable to anatomic variability.

Material & Method:

This study was conducted in the Department of Orthopaedics, Mahatma Gandhi Institute of Medical Sciences. All patient reporting a out patient to the Department of Orthopaedics with congenital orthopaedic anomalies were included in the study. The details were described in a pre-designed proforma and thorough examination was done to exclude other congenital anomalies.

Observation & Results:

Among the 172 patients, 190 anomalies were observed (multiple anomalies in 18 patients). These 172 patients were among total 18006 new patients who reported to the department accounting for 0.98% of cases 31 different types of anomalies were observed. CTEV was common, i.e. 49.4% of cases. Rare anomalies in form of hemimelia, foot on knee were observed.

Discussion:

The magnitude of such anomalies may not be very great when considered in comparison to other affections of the musculoskeletal system. Still these are important. The study results are comparable to other studies but a single study insufficient to answer all the questions and more similar studies are required to substantiate any of the above statement.

Conclusion:

To have been born and grew up with anomalies is very frustrating for the child and become a stigma for the adult patient. Once the exact spectrum and burden of these anomalies well documented, efforts can be directed to their effective prevention and treatment.

Poster Presentation : Infection & Arthropathy

1. Body Mass Index In Infants: Predictor For Bow Legs?

Dr Atul Bhaskar –Paediatric Orthopaedic Surgeon
Children Orthopaedic Centre, Guru Nanak Hospital, Gandhinagar, Bandra E, Mumbai - 400 054

Introduction:

Minimal to moderate bowlegs is normal in infancy. These children present at the walking age with wide-spaced gait, toeing-in and occasionally repeated falls. An orthopaedics consultation is usually sought to allay parental anxiety. We looked at 10 infants before walking age and calculated their Body Mass Index (height / weight2) A low BMI can predict the excessive physiological varus (>16 degrees). Dietary modification can be helpful and fortunately all of these deformities correct spontaneously.

Patients and Methods:

20 patients before the walking age were evaluated. In 10 infants (Group A) the weight was more than 90th percentile at the time of birth and in the other 10 patients (control group) the weight was between 50th and 70th centile. In all children the height (length) and weight were recorded at 9 months and 12 months. BMI was calculated for both the groups at 9 months and one year. In both groups the mean tibio-femoral angles were measured clinically and radiologically.

Results:

The mean BMI in Group A at one year was 0.35 and in the control group was 0.74 in both groups. In Group A the mean tibio-femoral angle at 18 months was 20 degrees. (14 degrees to 24 degrees) and in Group B it was 12 degrees (8 – 16 degrees). Two patients in Group A had varus of 14 degrees and one patient in group B had tibio-femoral angle of 16 degrees. Six of the Group A children at 3.5 years had complete resolution of excessive varus while the remaining four are still under follow up. Radiographs in these patients were unremarkable and they also had a normal calcium profile.

Discussion:

Children with high birth weight continue to maintain their weight up to infancy and this may reflect as a low BMI. The mean birth weights at one year for Group A was 13.5 kg and for Group B was 9.8kgs. The two children in Group A who did not exhibit excessive varus had BMI of 0.44 and 0.48 respectively. Thus only weight may not predict the development of bow legs.

Conclusions:

Low BMI at one year can predict excessive bow legs (> 16 degrees) and treatment can be focused on dietary modifications and reassurance then advising braces or splints. Further studies are required to elucidate the role of BMI in the development of angular deformities in children.

Poster Presentation : Spine

1. Histology Study Of Nerve Endings In Flava Ligament In Patients With Discopathy

Dr Raisi, Sh. Dr Raj Behadur.Z. Ph.D. Mardani, M.PhD. MoinH. MD
Isfahan University of medical sciences and Health Services
Histology study of nerve endings in flava ligament in patients with discopathy

Introduction:

Flava ligament normally has neural ends so it has sensory role and help to protect vertebral column against different injuries. The aim in this study is to detect the neural ends in flava ligaments in patients with discopathy.

Method:

The samples were taken from flava ligaments of the patients with discopathy during surgery. One hundred samples were considered. Five Hundred sections were obtained and stained with H & E method and were studies with light microscope.

Results:

Nerve corpuscles were found in none of the sections of the patients.

Discussion:

It seems that flava ligaments in patients has a loss in the nerve ends that leads to a decrease in proprioceptive information to control nervous system and may injure tissues like cartilage, osseous and fascia.

Keywords:

Discopathy, Nerve ends, Flava Ligament.

Poster Presentation : Tool and Technology

1. Correction Of Flexion Deformity Knee In Polio By Ilizarov Technique

Dr RA Agrawal MS
Agrawal Orthopaedic Hospital, Jubilee Road, Gorakhpur, UP, India
Phone – 0551 – 2333102, Email – agrawalram@hotmail.com

Joint contractures are common sequelae in Polio. In Polio flexion contracture of knee is commonest problem. If contracture is mild, patient will walk with limp. If moderate with hand knee gait, if severe walk with stick provided opposite limb power is near normal. Many surgical procedures have been performed since long like hamstrings tenotomy followed by manipulation, release of tensor fascia latae as described by Yount’s posterior capsulotomy fixed with the plaster.

Principle of correction of deformity is to bring the center of gravity of tarso to G.R.V. (Ground reaction vector) that is perpendicular line drawn from T10 it should be within the foot area. Thus the line between G.R.V. and C.G. should be straight one. Between 1994 and 2003, 14 cases with knee flexion contracture were treated by supracondylar extension osteotomy of femur and lengthening fixed with Ilizarov ring fixator.

If there is associated, hip flexion deformity that is tested by moving the patient on both the knees. If they are not able to walk properly in kneel gait, it means hip is unstable and hip deformity should be corrected first. It foot and ankle are also associated with knee deformity it should be corrected in second stage. The femoral osteotomy is done after fixing the femur with two Ilizarov ring and one arch then percutaneous supracondylar extension osteotomy is done closed to condyles and desired angle deformity is corrected. Lengthening is started after two to three weeks.

The advantages of this technique are that correction of deformity & lengthening can be done simultaneously. As the patient is mobile through out the period any redisual deformity can be treated along with it.

2. Osteotomy Treatment For Spastic Limb Deformities

Dr RA Agrawal, MS (Ortho.)
Agrawal Orthopaedic Hospital, Jubilee Road, Buxipur, Gorakhpyr – 273 001, UP (India)
Ph.No. – 0091-551 – 2333102, Email: Agrawalram@hotmail.com

The incidence of Cerebral Palsy is increasing globally. No cerebral palsy child has a spasm or contracture before birth or in neonatal period and all these clinical phenomenon develop with the growth of the child. Of all the clinical manifestations of cerebral palsy spasticity remains most dominant and if left unabated it gradually leaves various contractures and further deformities. The principles of management of cerebral palsy can be considered as:

Wining over spasm: By pharmacological preparations and exercises.
Surgery: In Cerebral Palsy surgery is mainly performed on the followings:
- Peripheral nerves
- Tendons – Tenatomy, tendon transfers
- Bony procedures – Osteotomy plays a bigger role in correcting the fixed deformities. Various stabilization operative procedures on the joints definitely correct the deformities and improve stability.
Improving the power of muscles by proper scheduled physiotherapy.

The present work concerns mainly on the role of osteotomy in correcting the deformities in lower limb, mainly flexion, abduction, and internal rotation at hip; flexion deformity at knee and sever equinus, varus, cavus, abduction/adduction deformities at ankle foot. In the present work osteotomized fragments are controlled by Ilizarov Ring Fixator. The observation is based on 8 osteotomy in intertrochantric, 10 in region of femur, 1 at upper end of tibia and 10 in forearm (to correct pronation contracture). Due to some overlap at the osteotomy site little shortening is expected, which did not effect the ultimate results since problems are bilateral. Over all results have been quite encouraging.

3. Painful Hip In Children

Dr Anshuman Dutta
JNMC, AMU, Aligarh

Prospective study conducted on 56 children below age group of 15 years.
Non traumatic hip direction producing grain considered
Decease encountered. TSH, Septic Arthritic, SCFE, Perthes Disease, DDH, JRA, T.B., etc.
Managed conservatively or surgically according to A
Tools used in writing has diagnosis:
- Clinical
- Radiological
- Laboratory

4. Torticollis – Sternomastoid Release Or Lengthening?

Dr S Sengupta, Dr Saw Aik
University Hospital, Kuala Lumpur

Abstract:

Though conservative and expectant management for muscular torticollis often succeeds, there is 10% to 20% failure rate. If untreated an ugly deformity is produced with gross limitation of neck movements and facial asymmetry. Early surgical release of stemomastoid muscle is carried out to get neck movements back to normal and avoid permanent facial deformity. However, this may result in an ugly scar, lateral fibrous bands and conspicuous loss of the STM column. For many years authors have instead, devised a way to elongate the tendon which gives a better cosmetic result. Deformity can be fully corrected with retention of STM column and an inconspicuous scar. Through a 3cm skinfold incision just proximal to sterno-clavicular joint, both heads of STM are exposed. The tendinous sternal head is cut proximally at the musculo-tendinous junction and the fleshy clavicular head is detached from its insertion on clavicle. The two ends are sutured to each other. Halter’s neck traction is applied for a few days, followed by vigorous stretching exercises.

49 patients between one and a half years to 20 years, operated in our institution were followed up for a median period of 4.5 years. Excellent to good results were achieved in 39 patients. In 5 the two ends could not be sutured to avoid too much tension and in others restoration of neck movements were not adequate.

Poster Presentation : Trauma

1. BIL SCFE – RT. – LT.

Dr Anshuman Dutta
JNMC, AMU, Aligarh

11 year old male patient with CAD (21? Ud1) had B/L SCPE. R-severe slip, L-moderate slip, R-C/R – C-Arm, both hips pinned in sits with cumulated concelleon screws.

2. Ilizaro Hip Reconstruction In Children – Series Of 9 Cases

Dr Nikhil Prakash Agrawal, Dr GS Kulkarni, Dr Ruta M Kulkarni
Post Graduate Institute of Swasthiyog Pratisthan, Miraj (Maharashtra), India.

Introduction:

In the pediatric age, there are various pathological conditions affecting the hip joint leading to severe pain, limp, limb length discrepancy, instability and disturbed hip and knee biomechanics In such circumstances, where femoral head salvage procedures and total hip replacement are beyond limits, Ilizarov hip reconstruction procedure provides relatively stable, mobile, painless hip with restoration of hip and knee biomechanics.

Material:

In our institute at Swasthiyog Pratisthan, MIRAJ, we have performed Ilizarov hip reconstruction in 9 pediatric patients in the following hip pathologies.
1. Old infantile septic arthritis of hip - 4 cases. 2. Unreduced old hip dislocations – 3 cases. 3. Idiopathic Chondrolysis – 1 case. 4. Perthes disease – 1 case.
All patients were evaluated on basis of clinical symptoms – hip pain, limp, shortening etc. Clinical sings like hip and knee range of movements, trendelenburg lurch etc., and radiological sings. Age group ranged from 6 to 12 years.
Method: Ilizarov hip reconstruction is a Pelvic Support Osteotomy procedure with two level osteotomy. After Girdlestone excision of femoral head, proximally subtrochanteric valgus and extension osteotomy is done which supports against the pelvis. Distally corticotomy done at supracondylar level which permits lengthening and varusisation to correct proximal valgus and balance the mechanical axis of limb. Stabilization of the osteotomy is done with Ilizarov external fixator.

Results:

Results were evaluated on basis of residual pain in hip, ROM of hip and knee, trendelenburg lurch, shortening etc. We obtained excellent to good results in 7 cases and fair in 1 case, 1 case is under observation. All patients had significant relief of pain and lurch in hip decreased by almost 70%. All patients had good range of motion at hip and knee joints allowing them to suit cross-legged and to squat.

Discussion:

Conclusion:

We conclude that Ilizarov hip reconstruction procedure performed over pediatric hip offers a valuable and effective surgical modality preserving hip mobility, stability, correction of shortening, decrease of abductor lurch and well aligned knee.

3. Management of Grossly Displaced Compound Grade – Iii Surpacondylar Fracture Of Humerus In Children With Cross Pin Fixation – Lession Learnt

Dr Vipul Shah, Dr JK Jain, Dr UB Yadav, Prof. AN Vamla
Department of Orthopaedics, MLN Medical College, Ahmedabad

Introduction:

Displaced supracondylar fracture present varying arrays of complex problems in management, the addition of compounding adds yet another sinister dimension to the problem and bring in its wake multiple management dilemmas.

Material and Methods:

Twenty one cases of grossly displaced compound Grade iII supracondylar fractures in children were evaluated between Jan. 2002 – July 2003. The wounds were debrided and the neurovascular status assessed. Two brachial artery injuries with distal intact capillaries were pinned without repair. In one case repair with sephanous vein graft was performed. Cross pin fixation was performed in all cases. One preoperative radial (nerve) palsy, was observed, which recovered spontaneously.

Results:

The results were assessed according to the criteria of Flynn et al (1974). There were 18 excellent results (85.7%), two good results and one poor result (4.7%). There were no fair results.

Keywords:

Cross pin fixation, Internal fixation, compound supracondylar fracture.

4. Primary Management Of Idiopathic Clubfoot By Ponseti Technique

Dr Nikhil Prakash Agrawal, Dr GS Kulkarni, Dr Ruta M Kulkarni
Post Graduate Institute of Swasthiyog Pratisthan, Extension area, Miraj – 416 410 (MH)

Introduction:

In the early 1940s, Ignacio Ponseti developed non-surgical approach for the management of clubfoot and he is rightly considered as the “Living God” of clubfoot treatment. It consists of gradual gentle manipulation and serial plaster casts when the child presents very early, preferably in the first week of life. This allows relaxation of collagen and atraumatic remodeling of joint surfaces without fibrosis and scarring resulting from the surgical release.

Material:

Since 2001 in our series at Swasthiyog Pratisthan, Miraj, we have treated 36 dub feet in 29 patients. Bilateral deformity seen in 7 patients and unilateral deformity in 22 patients. 20 Boys and 9 girls were affected. Average age of presentation was 3 months (fn?»m five days of age till six months of age).

Method:

Caws, adductus, varus, equinus (CAVE) which are the components of clubfoot deformity are all corrected simultaneously, except equinus which is co~last. Elevation of first metatarsal and supination of forefoot corrects cavus. Simultaneously the whole foot is gently and gradually supinated and abducted under the talus while applying counterpressure against lateral aspect of head of talus correcting metatarsal adductus and heel varus. Equinus is corrected last by progressively dorsiflexing the foot after the varus and adduction have been corrected. However, to facilitate more rapid correction, a percutaneous tendoachilles tenotomy is done in 97 to 99% of patients. Correction is maintained by toe to groin plaster cast with knee in 90-dregee flexion. Usually 8 to 10 serial casts correct tile deformity. After that foot is splinted continuously – for three months and during night for three to four years to prevent relapse.

Results:

Full correction by Ponseti technique achieved in 32 cases. Percutaneous T A tenotomy performed in 99% of patients. Recurrence and secondary survey were required for following cases

For equinus, percutaneous tendoachilles Z plasty done in 1 case.
For adductus correction tibialis anterior transfer done in 2 cases.
Releapse occurred in 1 case (due to late presentation) for which RPMR was performed

Conclusion:

Ponseti’s non-surgical management of clubfoot deformity is the best. Safest and highly effective treatment modality, which has minimized the use of surgical management and the associated morbidity resulting from extensive release.

5. Remodeling Following Fracture Tibia And Fibula In Children

Dr B John, Dr Amitabh Dwyer

Spontaneous correction of residual angulation occurs after union. This is because the physis responds to malalignment by differential growth, which tends to align the diaphysis perpendicular to major joint reaction forces. However, remodeling of tibial fractures is often imcomplete. We attempted to define the critical acceptable deformity following fracture shaft of the tibia in children which remodels satisfactorily. Forty eight children in the 3 to 12 years age group were followed up clinico- radiologically over a period of 10 years to analyze the correction of deformities following fractures of the shaft of tibia.

Seventeen children with isolated fractures of the tibia had an average increase in limb length of 8.9mm, 23 children had an average shortening of 11.9 mm at final follow up. Anterior angular deformity corrected maximally (66.2%), followed by varus (53.2%) and valgus (35.8%) deformities. Posterior angular deformity were 120 and 60 respectively. Realignment of a maximum of 100 varus and 50 valgus to normal physiological configuration of the tibia was noted in the coronal plane. Up to 5 of rotational malalignment was noted initially which did not change at final follow up.

6. Secondary Treatment By Mcmurry’s Osteotomy (31-05-02) & Hip Spika (14-06-02) Which Also Failed

Dr. S K Singh
Ortho Spine & Joint Replacement Surgeon, Apex Hospital, DLW Hydil Road, Varanasi

Diagnosis?

7. Septic Arthritis Of Ankle With Distal Tibial Osteomyelitis Presenting With Calcaneovalgus Deformity

Dr PN Gupta
Department of Orthopedics, Govt. Medical College & Hospital, Chandigarh

Introduction:

Sequalae of septic arthritis and pyogenic osteomyelitis in children can be devastating if treated / detected late. Destruction of femoral head resulting, as a sequalae of Tom Smith arthritis is well known. Involvement of distal tibia is less common than proximal tibia or femoral involvement; the after effects can be equally serious. Unfortunately in India a lot of cases present late to the treating physician. One such case is presented.

Case Report:

An 8 years old girl from Himachal Pradesh presented with progressive deformity of left ankle region since 5 ½ years. This deformity followed pain in ankle region at 2 ½ years of age and the patient had an abscess drained at local hospital at the ankle region. At presentation at the author’s institute, patient had calcaneovalgus deformity and scarred puckered skin on lateral side (Figure1). Radiographs showed partial destruction of distal tibial epiphysis (Figure 2).

Management plan:

In the first stage the ankle is planned to be brought at the level of ankle mortise using distractors considering the poor skin on lateral side. In the second stage ankle fusion is planned. The patient may require further procedures for limb length equalization.

8. Surgical Management Of Displaced Supracondylar Fractures Of Humerus In Children: - A Prospective Study Of 33 Cases

Prof. Rajesh Kanojia, Dr Alok Sud, Dr Vivek, Dr Akshay
Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

Keywords: Displaced Supracondylar Fracture – Children – Surgical Management

Abstract:

We report the result of thirty three consecutive displaced supracondylar fractures of humerus in children (mean age 7 yrs) treated from Feb’ 2002 through June’2 03. Twenty cases of displaced supracondylar (simple) fractures were treated by closed reduction & percutaneous pinning under General Anesthesia & IITV. Thirteen cases were treated by open reduction and ‘K’ wire fixation (failed closed reduction and compound fractures). Open reduction was done by combined mediolateral incision to avoid scaring of intact posterior and / or anterior soft tissue. At the final follow up (avg 15 months) using FLYNN’S CRITERIA the clinical results were :

	Excellent	52%
Satisfactory	Good	21%
	Fair	15%
Unsatisfactory	Poor	12%

88% of cases treated by this protocol were free from deformity and regained good range of motion. The poor results were due to cubitus varus deformity (2 cases) and stiffness (2 cases). Majority of displaced supracondylar fractures have satisfactory outcome by this safe and efficient protocol.

9. Umex Fixature In Compounds #S Tibia In Paediatric Group

Dr KA Saindane, Dr NK Saindane
Suyog Hospital, Sakri Road, Dhule 424001 [MS]

Introduction:

Compound #s in children posses problems while treatment in the paediatric age group Implants are rarely used. Healing capacity is tremendous & remodeling is also boon for these patients, hence internal fixation is almost not required. Unique external fixation system called as umex is used in my study.

Material and Method:

Total 36 patients were studies. Male: 23 Female: 13. Age distribution is from 5 yrs to 12 yrs Classification grade 1:21 grade 2:8 grade 3a:5 grade 3b:2

Operative Procedure:

Debrided thoroughly removal of clots, foreign material, dead bone pieces, with ample normal saline, wound is washed. In safe corridor 2 mm k wires are introduced in uni planner fashion. # reduced and fixed with umex fixature. If possible wound is closed. Secondary debridement was done in three patients. Secondary procedures were done in three patients (partial thickness skin grafting was done in three patients) Removel of fixature was from 8 days to 21 days. AK cast was applied till bone heals.

Result:

All #s were healed. Average duration for healing was 56 days. Non non- union was seen. Superficial infection was seen in 8 patients at the # site. No pintract infection was seen.

Discussion:

This is novel method. It is light weight, easy to install, any peripheral ortho hospital# ends are realigned, compressed or distracted. Wounds are easily inspected local dressing can be done regularly. If required, secondary surgical procedures can be done easily. Limb elevation is easy. Early movements of adjacent joints are possible. Less trauma to tibia due to 2 mm k wires.

Conclusion:

It is novel method, easy to apply with all good results in comparison to only pop cast.

Posicon 2004 Abstracts

Abstracts